ALTHOUGH PREVENTION has become a key element in traditional disease management programs—trying to prevent or mitigate a chronic
disease before it exacerbates—that may not be sufficient when a patient has a late-stage or end-of-life condition. Americans
are living longer: People 65 and older represent 12.4% of the population, and 35% of those older adults are between ages 75
and 84, according the U.S. Census Bureau. There is a new emphasis on caring for older adults with multiple comorbidities.
Almost 80% of people 65 and older report having a chronic illness, according to the Robert Wood Johnson Foundation.
MHE EXECUTIVE VIEW
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According to a RAND Health white paper, the healthcare system has been slow to adapt to the new challenge of chronic illness
in old age. Many of these patients must navigate a fragmented care system, offering them a patchwork of uncoordinated services.
They have an overriding need for continuity of care, both across settings and across the changing challenges of worsening
illness. The white paper states there is a disconnect between the different settings—nursing home, hospital, home, and doctor's
office—where healthcare is delivered.
According to Care Level Management, based in Woodland Hills, Calif., the top 2% of the elderly population represent the highest
demand for care and account for 24% of all Medicare spending.
Some MCOs are taking a new look at aging populations with severe chronic illnesses, and developing care delivery to meet their
needs. At the heart of these programs is individualized attention from providers—nurses and physicians—who can fill the gap
which often exists between hospital and home care in end-of-life situations. MORE INTENSIVE INTERVENTIONS
Health Dialog, a care management company based in Boston, has a collaborative care program and shared decision-making approach
in addressing chronic care management. Its health coaches encourage individuals to share in making healthcare decisions through
discussions with their physicians. Now Health Dialog is testing the waters to see if enhanced care management through more
intensive coaching leads to cost savings.
A plan can see 2% to 4% savings with traditional programs, says George Bennett, CEO of Health Dialog, "so now we have programs
that can generate 7% to 9% savings." Health Dialog plans to begin offering a program that boosts results another fivefold.
One of the concerns Bennett has is the unwarranted variation in care—overuse, underuse and misuse—which he says accounts for
about 30% of total medical costs. When these costs are reined in, Bennett anticipates that the quality of care will improve
while healthcare costs decrease.
Using analytics, Health Dialog co-mingles information on patients and their conditions with treatment practice patterns of
the community to match individuals with the appropriate outreach level. Its predictive modeling can help determine how receptive
members are to certain interventions.
"That information enables us to find out who really needs help, how to engage them and what treatment they need," Bennett
says.
THE NEW "BLACK BAG"
Care Level Management is bringing care for chronically ill patients—mostly frail elderly in Medicare—into their homes with
its Personal Visiting Physician (PVP) program. The 24/7 healthcare delivery system's primary objectives are reducing the reliance
on emergency rooms, improving quality of care and decreasing hospitalizations. Care Level Management refers to this system
as the new "black bag."
Supported by a nurse case manager, PVPs provide patients with their cell phone numbers and are available any time of the day
to perform a physical examination in a patient's home.
"Our system fills a gap in care for those who are most at risk for emergency room visits and subsequent hospitalizations—those
that have no real delivery system or coordination of care to fit their needs. It is not concierge medicine," says Raouf Khalil,
founder, chairman and CEO.
He explains that the program's patients often get lost in the healthcare system, lack immediate access to a primary care physician
and end up relying on an emergency room. Once they return home, the cycle begins again.
