Robert Graham Center Research

Report Examines Exemplary Approaches to Team-based Care

June 16, 2017 03:30 pm Michael Laff Washington, D.C. –

Allyson Schwartz, president and CEO of the Better Medicare Alliance, speaks during a briefing held to launch a report prepared by the Robert Graham Center for Policy Studies in Family Medicine and Primary Care about exemplary Medicare Advantage plans.

Medicare patients visit an array of medical specialists in multiple settings so their need for a coordinated, team-based approach to health care is especially urgent.

The average Medicare patient sees seven physicians across four different practices, and 75 percent of those who are admitted to the hospital cannot identify the clinician responsible for their care. Twenty percent of Medicare fee-for-service patients who are discharged from the hospital are readmitted within 30 days. All of this contributes to a staggering $130 billion wasted because of ineffective health service delivery.

But some coordinated care initiatives are working to combat these statistics. In a new report titled Bright Spots in Care Management in Medicare Advantage,(bettermedicarealliance.org) researchers at the Robert Graham Center for Policy Studies in Family Medicine and Primary Care profiled four Medicare Advantage practices that each exemplify a coordinated approach to providing both primary care and support services.

Story Highlights
  • Researchers at the Robert Graham Center for Policy Studies in Family Medicine and Primary Care recently profiled four Medicare Advantage practices that exemplify a coordinated approach to providing both primary care and support services.
  • Each plan cited in the report cares for a distinct patient panel, but they all targeted either a specific demographic or desired outcome.
  • The authors emphasized that exemplary care management requires a team-based approach and ongoing evaluation of more than just a patient's physical health needs.

Each plan cited in the report cares for a distinct patient panel, but they all targeted either a specific demographic or a desired outcome, and they all relied on coordination with allied health professionals to assist patients with essential health tasks that often cannot be addressed during an office visit. The authors also found common barriers to wider adoption of effective solutions: technology gaps and inconsistent payment.

The authors emphasized that exemplary care management requires a team-based approach and ongoing evaluation of more than just a patient's physical health needs.

"At the patient level, successful care management programs are adept at customizing plans to individual patient needs," the report stated. "This means addressing all barriers to improved health regardless of whether they are medical, social, financial or psychological in nature."

Geriatric In-home Care

One of the programs the report examines, Geriatric Resources for Assessment and Care of Elders (GRACE) Team Care, based at Indiana University, began more than 10 years ago and now includes 300 patients in a program that focuses on in-home care to support primary care functions. Patients in the program are low-income elderly individuals who have chronic conditions and functional limitations. Three care management teams were formed, each with a nurse practitioner and a social worker who go to patients' homes together for all annual visits. A comprehensive care plan is developed after the initial visit, and patients continue with their own primary care physician.

The program seeks to decrease ER and hospital admissions among the targeted patient group. Patients who are identified as "high utilizers" are sought for the program -- specifically, individuals who could thrive at home with appropriate care management and can attend patient appointments. In the second and third years of the GRACE program, this approach saved $1,500 per patient.

To complement primary care, the team's protocols focus on 12 geriatric problem areas, including medication management, walking/falls, dementia and depression. The team assists patients who do not have medications or proper heating in their homes, issues they might not bring up during a visit with a physician but which could contribute to poor health.

"We ask patients, 'What matters to you?’ instead of asking, ‘What's the matter?'" said Steven Counsell, M.D., executive director of GRACE Team Care, during a recent press event held to release the report. "Almost 100 percent of them say they want to be independent at home."

Team-based Care for Most Complex Patients

InterMed is a physician-owned group based in Maine that focuses on patient-centered primary care with integrated specialty services. Using an electronic health record system that ranks patients in terms of complexity, teams can focus on higher-risk patients. Teams, or "pods," consist of four or five physicians, a designated care manager and a medical assistant or registered nurse.

Nurse practitioners and physician assistants serve as care managers, splitting their time equally between patient care and care management. This allows physicians to dedicate their time to the most complex patients. The teams work on patient transitions from hospital to home, schedule walk-in visits for high-need patients, plan advanced diabetes management strategies and reach out to patients who have gaps in care. Private insurers pay on a fee-for-service basis plus an enhanced per-member-per-month payment based on quality measurements that are mutually agreed on.

'Holistic' Care from Community Health Workers

In Maryland, the Johns Hopkins Medicare Advantage Plan is noted for its creative use of community health workers who live in the same communities as the patients they serve. A three-month training program teaches them to handle "holistic" care.

During annual home visits, they complete paperwork for patients, review bills, conduct safety checks and provide health education. Patients have a direct phone line to reach community health workers for anything they need, even after office hours. Many patients report being lonely and appreciate this human contact.

In weekly meetings, the community health workers discuss patients who were admitted to hospitals or skilled nursing facilities for at least a week or who had multiple admissions. They address social support, discharge planning and patient follow-up with the goal of reducing those utilization rates.

Fewer Hospital Readmissions

Viewing any hospital admission as a failure, the California-based CareMore Medicare Advantage plan developed the concept of "extensivists" -- physicians who bridge the gap between hospital care and outpatient settings. CareMore acts as both a health care provider and payer.

To reduce the risk of hospital readmission, the plan opened CareMore Care Centers near or on hospital campuses. The centers are staffed by a physician, a case manager and other health professionals including physical therapists, pharmacists and dietitians, among others. The program views care as a long-term commitment regardless of how long a patient is a plan participant.

"You can't just say, 'Well, we'll only have them for four years so we won't do these things,'" David Ramirez, M.D., chief quality officer for CareMore, said at the launch event. "We do everything as if we will have them forever."

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