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Developing a disease management program for Medicare patients requires more than a one-size-fits-all approach because patients typically have more than one chronic disease. And for subacute providers, determining what services are provided at the subacute level becomes an equal challenge in the Medicare maze.
Rather than developing disease-specific programs first, Sutter/California Healthcare Systems in Sacramento first identified its Medicare members to determine their needs. A snapshot of each patient’s medical history and potential health risks are provided through the completion of a risk stratification tool first implemented more than two years ago, says Cheryl Phillips Harris, MD, CMD, who spearheaded the development of the Geriatric Care Coordination Program (GCCP). Phillips-Harris is the clinical resources director for the Sutter Health Center Region Continuing Care Division, also located in Sacramento.
Sutter is northern California’s second largest health care system. Included in the system are five skilled-nursing facilities, several hospitals, a hospital-based subacute care unit, a home health agency, and a group physician practice model HMO.
Developing a risk stratification tool for Medicare patients was viewed as an experiment because Sutter administration thought there should be an alternate way to care for these patients, says Phillips Harris. "We had no idea who these people were until they presented in a medical or social crisis. So I went to our medical group and told them that we needed to know who our [Medicare] enrollees are," she explains.
What started as an experiment has turned into a fully funded department with an annual budget of $200,000. "When we started, there was no budget. I got a nurse practitioner and master’s prepared social worker from other departments who agreed to volunteer some time. The only real expense we had was the postage for questionnaires to be mailed and returned," explains Phillips Harris.
Subacute care managers wanting to develop a disease management program with a risk stratification tool first must examine existing resources and the level of care provided. "I use the fishing net analogy to explain that this isn’t a cookbook approach. You have to look at the size of your net before attempting to fish. You can’t catch big fish with a minnow net," notes Phillips Harris.
She and her staff looked at several existing assessment tools but eventually decided on an internally developed tool because the others didn’t match Sutter’s resources, she says. Sutter looked at the Short Form 36 (SF-36) and tools developed by MCOs and other health systems before deciding to develop one internally.
"Everyone wants to have these standard sets of risks, but it all depends on your existing resources. What we have is nothing novel, but it complements our services," explains Phillips Harris.
Sutter stratifies Medicare patients into one of four levels. (To see what assessments and questions are used to determine risk levels, see tool, inserted in this issue.) Each level and appropriate interventions includes:
• Level one. Patients who score between 0 to 29 points on the 100-point scale are considered low risk or level one patients. "These are the patients who have no potential risks. Everything is fine," says Phillips Harris.
Examples of primary prevention services provided for level one patients include:
improvement of health habits (such as smoking, alcohol abuse, obesity, nutrition problems, physical inactivity, and sleep problems);
immunizations (such as influenza, pneumovax, and tetanus);
iatrogenesis prevention (such as nosocomial infections or catching a cold in the subacute unit);
• Level two. Patients with stable diseases who demonstrate adequate self-management are considered level two patients. Patients in level two score between 30 and 39 points.
"We haven’t really done much yet in this level, but this is where we will add our disease-specific interventions, such as patient education," explains Phillips Harris. Educational materials will be provided by Sutter’s in-house department called the Sutter Health Resource Center.
Examples of secondary prevention services provided for level two patients include:
screenings for hypertension, diabetes, periodontal disease, dental caries, sensory impairment, medication side effects, colorectal cancer, breast cancer, cervical cancer, prostatic cancer, nutritionally induced anemia, depression, stress, incontinence, podiatric problems, fall risk, high-risk tuberculosis, and high-risk syphilis;
control of hypertension to prevent stroke.
• Level three. Level three patients are characterized by psychosocial or community-based needs that outweigh current medical needs. Patients in level three score between 40 to 60 points.
"These are the social service nightmares in which if the social issues are not addressed, the patients’ problems become medically related," adds Phillips Harris.
Level three patients are triaged through Sutter’s social service department and referred to community-based services. Follow-up is supervised by the GCCP staff social worker.
• Level four. "These are the truly medically, functionally, at-risk patients. The patients are at risk of utilization, hospitalization, hospital readmission, functional decline, long-term care, and death," says Phillips Harris.
Level four patients score 61 points or more on the assessment scale. GCCP staff and the patient’s physician develop a highly specific care plan for these patients. Examples of tertiary services provided for level four patients include:
rehabilitation for physical deficits, cognitive deficits, functional deficits;
caretaker support and introduction of support necessary to prevent loss of autonomy;
pain control. Outcomes data from the questionnaires are collected for GCCP on a regular basis.
"What we are looking at is the risk stratification tool itself to determine if it adequately assesses a patient. We’re also looking at the interventions we currently perform to determine if they impact the patient’s risk level, such as hospital readmissions, visits to the emergency department, and admissions to a skilled nursing facility."
More importantly, however, is the support GCCP gets from physicians. "The physicians saw it as a potential cost-saving area, but it evolved into a resource or safety net because they can refer the patient to us, and they can remain productive."
Patients who enroll in the program remain under the care of their primary care physician, but Phillips Harris assumes care for patients who are admitted to a skilled nursing facility. GCCP staff have the authority to authorize benefits for GCCP patients, notes Phillips Harris.
Sutter’s risk stratification tool, called the Senior Health Questionnaire, is mailed to Medicare members upon enrollment. If the four-page document is not returned within two weeks, an additional survey is sent, and a staff member calls the patient with a reminder to complete the survey. Phillips Harris estimates that between 45% and 50% of the responses are sent after the initial request. The response rate for second requests averages about 60%.
GCCP serves Sutter’s Sacramento area and is open to approximately 7,500 enrollees. Patients are followed until disenrollment, problem resolution, or death. More than 4,000 Medicare patients have completed a survey since the program began, estimates Phillips Harris.
Completed surveys, along with the patient’s score, are entered into Sutter’s information system, and physicians receive a copy of the assessment. A completed survey gives physicians and GCCP staff information about the patient’s medical history, any assistance needed with activities of daily living, medical equipment used in the home, and current living arrangements.
Sutter’s computer system is not integrated, so communication among care sites is handled through telephone calls, internal assessment forms, such as critical paths, and fax machines, says Phillips Harris.
GCCP staff now need to develop a screening protocol and develop disease-specific resources for chronically ill but stable patients, says Phillips Harris. "We have no formal policy on rescreening yet, but usually if patients are hospitalized or admitted to a skilled nursing facility, we will rescreen them."
Phillips Harris would like to direct the department’s next focus to chronically ill but stable patients.