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Patient-centered care management saves money
Provides contact for people with late-stage illness
Patients with life-limiting conditions who received patient-centered management had dramatically reduced utilization and cost of care compared to patients with similar conditions who received regular case management, a study by Blue Shield of California has concluded.
The study was so successful that the health plan opened the program to its entire commercial population who meet the criteria and has begun providing patient-centered management to its seriously ill Medicare HMO population with late-stage illness, according to Andrew Halpert, MD, senior medical director for the San Francisco-based health plan.
During the 18-month study, half of the patients received typical telephonic case management and half received patient-centered management, which included an initial home visit followed by an average of 10 hours a month of telephonic contact.
All of the participants in the study had access to the same benefits, network of providers, and HMO approval process.
The average utilization cost for the patients receiving patient-centered management was $49,742 during the 18 months of the study compared to $68,341 for the control group.
The patient-center management reduced hospital admissions by 39%, hospital days by 36%, and ED visits by 30%, while increasing home care by 22% and hospice care by 62%.
In addition, patients in the program gave it high scores in patient satisfaction studies, Halpert adds.
"We knew that patient-centered management was beneficial for our members who had complex medical needs. This study showed that it has value to the company as well," Halpert says.
The study included 756 patients in California with a life-limiting diagnosis and multiple comorbid conditions. About 75% of the participants in the original study were oncology patients. All were members of Blue Shield of California. The patient-centered management was provided through a contract with Paradigm Health Inc., a medical management company based in Upper Saddle River, NJ.
Blue Shield has continued its contract with Paradigm Health to provide management for patients in the expanded program.
"They have the infrastructure, expertise, and experience to run the program. We felt it would be more effective to continue to work with them, rather than doing it ourselves," Halpert says.
Currently, about 900 members are enrolled in the patient-centered management program at any one time. The RN case managers who coordinate their care handle a total of about 1,500 to 2,000 cases a year, Halpert says.
The expanded program includes Medicare patients who have neurological conditions, such as stroke and late-stage cardiac disease, as well as terminal cancer.
"We don't have the results of the interventions on the managed Medicare population but I anticipate it will work as well as in the commercial population. This program works very well for people who have very complicated diagnoses," Halpert says.
The health plan is conducting another study involving patients who have multiple complex conditions that do not qualify as late-stage illness. The program has the same design and structure with fewer interventions and no home visit, Halpert adds.
The patient-centered management team includes a care manager, a team manager who acts as a liaison with the health plan, and a physician advisor.
When members are enrolled in the program, the care manager makes a home visit and works with the patient and family members to create goals in six "care domains" — disease knowledge; treatment plan; terminal care planning; benefit plan management; family and living environment; pain and symptom management; and provider support.
A goal for the pain control domain might be to work with the physician to obtain better pain medications for the member, Halpert says.
"The nurse might encourage the patient to alert the physician to issues of poorly controlled pain. Often patients are hesitant to broach this issue, " he says.
A goal for the care plan domain might be to come up with a plan to deal with the side effects of medication and keep the patient from the emergency department.
Terminal-care goals might be to deal with financial issues or family support, such as having a caregiver in the home, he adds.
For instance, in one situation, a nurse worked with an employer so the wife of a terminally ill man could telecommute instead of leaving her husband to go to work.
"What these nurses do goes off the typical playbook for case management. They do whatever their patients need," he says.
The care managers in the patient-centered management program have a caseload of about 22 patients at a time, compared to typical health plan case managers who oversee the care of 75 to 100 or more people at a time, usually working intensely with the members for only a week or two then calling them occasionally, Halpert says.
After the home assessment, the patient-centered management care managers make frequent telephone calls, an average of 14 a month, to the patients.
The outbound calls from the RNs to patients helped identify potential lapses in care, such as the case of a brain cancer patient who was about to run out of his anticonvulsant medication.
During a home visit, the nurse discovered that a patient with metatastic lung cancer, who was repeatedly being admitted for diarrhea, had confused his Lomotil with milk of magnesia. She removed the milk of magnesia from the medicine cabinet and the hospital admissions ended.
Members of Blue Shield who have chronic illnesses but don't qualify for the patient-centered program are enrolled in the health plan's disease management programs.
If their illness intensifies, Blue Shield of California's disease managers can refer them to the patient-centered program.
"Our disease management programs are very robust but they aren't geared to the late-stage illness paradigm. When patients' conditions become life-threatening, they can benefit from more intensive care management," he says.