AHIP Coverage (May/June 2007)
Care That Maximizes Quality of Life
Patient-centered, interdisciplinary teams in an integrated health and long-term care plan foster independent living and dignity.
By Louise Kertesz
To understand how members are served at Community Health Partnership, consider the example of a couple in their 80s, identified by CHP as Frank and Elmira, who live at home. Frank has had two heart attacks and open heart surgery. Elmira had surgery to repair a brain aneurism, and she has symptoms of dementia including forgetfulness and confusion. Both have additional health problems. A registered nurse visits regularly to monitor their health and coordinate needed services with their CHP team.
Before becoming CHP members, the couple says they sold their house to pay off medical bills from 13 doctors and two hospitals. Frank is quoted as saying, “If it wasn’t for Community Health Partnership, we’d probably be living under a bridge somewhere.”
A fully integrated care management organization in Wisconsin that grew out of a demonstration project and is now a licensed HMO and Medicare Advantage Special Needs Plan, CHP is proving the effectiveness of a holistic approach in caring for some of the most vulnerable people in the nation’s health care system. Interdisciplinary teams provide comprehensive health and long-term care services for nearly 1,100 low-income frail elderly persons and adults with physical disabilities. It is the only such program in the nation that serves a rural population. Most members receive care in their homes or in non-institutional settings.
“It is a very intensive care management model” serving people who ordinarily would be placed in nursing homes, says CEO Karen Bullock. This private sector solution was developed to meet the needs of the unique population CHP serves.
While members typically keep their primary care physicians, when they become CHP members they “are connected to a team that is able to give them immediate attention, according to a detailed care plan,” Bullock explains. The plan is developed according to the member’s preferences—for example, whether the member wishes to receive assistance in order to remain at home or whether he or she wants to reside in an assisted living facility.
Other preferences may include nontraditional services such as acupuncture and massage; options for personal/supportive home care, including hiring family members; and home modification and adaptive devices.
The team is made up of the member, his or her physician, a registered nurse, a nurse practitioner, and a social services coordinator or social worker, as well as other CHP staff resources in partnership with the member’s family and other caregivers. “The member is considered the driving force of the team. The team involves the member in identifying his or her needs” and the activities and services required to meet those needs, Bullock explains. In addition to primary and acute health care services, a member’s needs can include a wide range of assistance like help with light house cleaning, personal hygiene, and transportation to the doctor’s office.
“The key to an individual’s success and to ours as an organization is making the member the center of the care team,” says Steve Landkamer, director of operations.
A Complex Weave of Conditions
CHP members are “high risk and high cost,” points out Brent Bauman, health plan director. They use an average of 13-15 prescriptions, at an approximate cost of $450 per member per month. Medication therapy is essential to maintain members’ health and quality of life. The plan employs two on-staff pharmacists to continually monitor medication therapy and drug interactions.
“We get people with numerous chronic conditions—the weave is very complex”—that can include congestive heart failure, diabetes, and multiple sclerosis, says Landkamer. “Most disease management models are great if you have one to three diagnoses. But the challenge to our care management team is that a patient may have 20 different diagnoses with 20 different clinical pathways [to follow in delivering care].One pathway may be contradicted by another, so the team has to meld it all together and make it work for the member. Maintaining quality of life while treating all this is the challenge.”
Further complicating their care is the fact that 75 percent of CHP members have behavioral health diagnoses as well as other disabilities. A state of Wisconsin study showed that “for people with major mental health issues, hospital days double for all kinds of services that on the surface don’t appear to be behavioral health-related,” Landkamer says. “When you have schizophrenia, depression, alcohol abuse, and other conditions thrown into the mix, it means our teams have to have a wide degree of expertise, and organizationally we have to have the resources available to treat members with mental health issues.”
A plan that integrates and coordinates health and long-term care services is especially important for patients with multiple conditions. Trying to obtain care from numerous specialists, follow different directives, and fill out the necessary forms can take over their lives, CHP executives point out.
In worst-case scenarios—which are all too common—without coordination of care, a frail patient whose caregivers can no longer manage his or her condition may simply be placed in the hospital. Once there, “typically, people’s capacities to care for themselves diminish. Older adults lose about 10 percent of their muscle tone within a week,” Landkamer says. “And perhaps they end up in an institutional setting where they probably don’t want to be” and where their conditions deteriorate further.
Remarkably, while every single CHP member meets Medicaid’s criteria for placement in a nursing home, CHP care and services allow 83 percent of members to continue to live in their homes. Between 92 percent and 95 percent live in a less restrictive setting than a nursing home, Bauman says.
Comprehensive, Cost-Effective Care
CHP receives a capitated Medicaid payment from the state of Wisconsin and, for the dually eligible, a capitated Medicare payment from the Centers for Medicare and Medicaid Services (CMS) and is responsible for a member’s total health and long-term care. Acting on that responsibility, CHP strives to keep members as healthy as possible so they will avoid being hospitalized and will continue to live independently.
CHP provides services beyond those covered under Medicaid and Medicare, including assistance with food shopping to ensure proper nutrition. “Perhaps people need to learn how to shop and prepare food differently than in the past,” Landkamer explains. “We send someone to the grocery store with them to help, and we teach people how to make meals consistent with dietary restrictions that are tasty. It’s about partnering with members so they learn how to take care of themselves.”
Services are often highly individualized. For example, Landkamer recounts that one member “was a really great cook,” but a disability made it difficult for him to work at his kitchen counter. “We got him a swivel stool so he could access everything on his counter, which added to his liberty and satisfaction.”
In another instance, he continues, a member was in the hospital but “hated it and wanted out,” to the extent that he was no longer complying with his doctor’s orders and developed an infection. He could not be sent home because he was on intravenous antibiotics. His nurse practitioner requested that the member be placed in a so-called swing bed, which is a step-down unit in the hospital where patients receive more intensive care while they recuperate. But he was a Medicaid patient, and only Medicare pays for swing beds.
Landkamer granted the request for a swing bed. “My response was if this is what this person needs, we’re capitated, and if it’s appropriate he should have it. If we were to try to define our benefit package, we could just about write every possibility on it. Nothing is automatically ruled out. We consider what is necessary to reach good outcomes for our members.”
Notes Bullock, “Ultimately, we work with members to coordinate the right service at the right time in the right amount. We are really not doing more than what needs to be done. It can be really deep, concentrated care for the patient who requires it, or in other situations it can be minimal care that is warranted.”
CHP controls costs by providing excellent primary and preventive care that keeps members out of the hospital. It also provides home-based services and links members to community services. Care team members visit CHP members’ homes to observe their living conditions and whether there are obstacles to their best possible health and quality of life.
“The typical cost of supporting someone in his or her home is significantly less per person per month than in some kind of assisted living facility,” says Landkamer. Because the plan is in control of total costs, managers can more easily identify unnecessary spending, and they have the incentive to maintain a member’s quality of life and independence outside of a nursing home, where most members prefer to be.
“We’re continually monitoring what is going on in a member’s life,” explains Bullock. “An elderly person’s health can be very dynamic and constantly changing, and care providers must be alert to those changes and respond to them.”
Keeping costs in check is the plan’s culture—the relationship of trust that CHP seeks to foster between members and caregivers, Bullock says. “A member doesn’t need to hoard supplies for fear he won’t get more when he needs them, or keep that piece of equipment he doesn’t need anymore because he might not be able to get it in the future.” Members have the confidence that services will be provided when they are needed.
Positive Outcomes
Enrollment in CHP is voluntary and is typically precipitated by a health crisis that opens a person’s mind to the possibility that a coordinated system might better meet his or her needs, Landkamer says. CHP members can use CHP cards instead of their Medicare and Medicaid cards to receive all the services they require from CHP providers.
“Once they become members, disenrollment is extremely low—less than 2 percent as a result of dissatisfaction with services,” Bullock says. In printed materials distributed by CHP, one member identified as Clarey describes herself as legally blind. She has had a heart attack and has diabetes, high blood pressure, heart valve disorders, and other cardiac problems. Yet with CHP’s assistance she lives at home with her husband, who requires her help because of his health problems.
CHP members enjoy stabilized and even improved health. Landkamer explains, “For people with physical disabilities served in the Wisconsin Partnership Program, the number of hospital days diminished by about half in the first year after enrollment. For older adults, the number of hospital days pre- and post-enrollment remained about the same but the number of nursing home bed days were reduced by about 30 percent.”
Thirty-seven percent of CHP members are diabetic, and 14 percent are considered to be at high risk, having had a hemoglobin A1c greater than 8.0.Yet, as a result of care monitoring and management according to best practices, the average hemoglobin A1c level of diabetic members has been reduced to 6.7, which is normal for people without diabetes, Bauman points out. “We have ensured that almost 100 percent of our members have their A1c checked on a regular basis.”
Concerns About Maintaining the Model
Nevertheless, Bauman concedes, “Quality measures have not been developed for the very sick population that CHP serves. Our challenge is that we may have to submit quality measures [as a Medicare Special Needs Plan] and there aren’t any yet. What benchmark data do you compare ours to?”
For example, he says, according to a standard quality measure it would be prudent for a healthy 65-year-old male to have a prostate exam every year. “But what about an 85-year-old male with congestive heart failure who is going into renal failure? Is a prostate exam appropriate if [prostate cancer] is not going to be what he expires from? But in standard quality measures we would be judged by whether we gave the exam.
“We’ve been very successful under the demonstration working with CMS and the state to come up with—not perfect—but adequately integrated material” so CHP members are not confronted with a barrage of documents explaining their rights and procedures under both Medicaid and Medicare, Bauman explains.
Authority enacted in the Medicare Modernization Act that permits special needs plans to be offered only to the special Medicare populations they serve is due to sunset at the end of December 2008. “If this occurs, we will no longer be able to exclusively market to our target population [Medicare/Medicaid dually eligible beneficiaries who also qualify for institutional care]. CHP instead will be required to market to all eligible Medicare beneficiaries in our service area,” Bauman says. While CHP’s specialized services for the very sick would not be attractive to all Medicare beneficiaries, the cost and administrative burden of marketing to a huge population would be significant, he says.
Meanwhile, counties adjacent to CHP’s current service area are considering having CHP manage the delivery of long-term care to their frail elderly and adults with physical disabilities and adding the management of the developmentally disabled. The plan also may be asked to provide primary and acute care management for those populations to deliver fully integrated services. In the face of various challenges, Bullock says CHP is poised for this potential growth.
Louise Kertesz is a contributing editor for AHIP Coverage.
