Community-based care helps Florida seniors stay healthy

Three-year pilot program is part of CMS initiative

A team approach by community-based personnel from Green Ribbon Health is helping chronically ill Medicare participants learn to manage their conditions, improve their health, and preserve their independence.

Green Ribbon Health is a joint venture of health insurer Humana and pharmaceutical company Pfizer.

It's too soon for outcomes in the three-year pilot program, named Medicare Health Support, being conducted for the Centers of Medicare & Medicaid Services (CMS), but anecdotal information and patient satisfaction data indicate that the program is very successful, says Jean Bisio, RN, CEO of Green Ribbon Health.

The organization received the "Gold Angel Award" from Elder Care Advocacy of Florida for its services to seniors through its model of health support.

CMS randomly chose about 20,000 Medicare fee-for-service beneficiaries with either complex diabetes or congestive heart failure or both to participate in Green Ribbon Health's pilot projects. The project is one of eight Medicare health support project pilots selected by CMS.

The seniors selected by CMS live in nine counties in central or southwestern Florida. They were required to be in a Medicare fee-for-service plan. Seniors with end-stage renal disease or who were receiving hospice care were eliminated because they were eligible for other programs that addressed those issues, Bisio says.

The care of participants is managed by a team that includes personal nurses who work with the participants over the telephone; field care managers who work with the beneficiaries in person, in the home, at the doctor's offices, or in nursing homes or hospitals; and community health workers, who help conduct community seminars on chronic disease and work behind the scenes researching and setting up community services when needed.

All of the Green Ribbon Health staff who work with the beneficiaries are based in the community. The organization has offices in Florida in Tampa, Clearwater, Venice, and Ft. Myers.

The personal nurses are RNs and serve as the clinical quarterbacks of the care management team, developing a close relationship with the beneficiaries and working with the rest of the team to make sure all the needs are met, Bisio says.

Field care managers are either registered nurses or master's-prepared social workers who spend most of their time in the field, conducting face-to-face interventions with participants.

The community health workers are not clinicians but many have degrees in related fields, such as health education or social work. They may have a chronic disease themselves and have it under control or they may have experienced caring for someone with a chronic disease.

The program is designed to address three major issues that the Medicare fee-for-service population faces: fragmentation and access to care, cost of care, and quality of care, Bisio says.

The purpose of the program is to improve health outcomes from a clinical perspective; to preserve the senior's independence, allowing them to stay in their homes; and to reduce health care costs to CMS for Medicare fee-for-service beneficiaries.

"People in this age group don't have just one issue. They have many issues. We put together a model that is very different from traditional disease management. Our model takes a holistic approach to managing the care of this population," Bisio says.

The program is individually focused and addresses a broad range of needs in addition to participants' medical needs. These include safety, financial and cognitive issues, and functional needs.

"A cookie-cutter approach would not be effective. We assess each person's individual needs and address those," Bisio says.

Another component of the program is helping participants learn about and access the resources that are available in their communities.

"There are people who can't get to the doctor because they don't have transportation or who are not eating properly because they don't cook but they have diabetes and have special dietary needs. We help them access agencies that provide transportation and arrange diabetic meals on wheels," she says.

Green Ribbon Health communicates with the seniors' providers, coordinating the care the participants receive and supporting the physicians' treatment plans.

"With Medicare fee-for-service, there is no gatekeeper. There is not an electronic medical record across providers so that Dr. Smith knows that Dr. Jones is also treating the patient. The provider piece is extremely important in helping avoid the problems that occur when people take multiple medications or have the same treatment more than once from different physicians," Bisio says.

Members may call a personal nurse 24 hours a day, seven days a week.

"Round-the-clock access is very important in this population, particularly if they live alone or don't have access to caregivers. With certain types of diseases, especially those involving cognitive issues, night can be a difficult and scary time," Bisio says.

Each beneficiary works with the same personal nurse over and over.

"With this population, it is very important to develop a trusting relationship and that doesn't happen when they talk to a different person every time," Bisio says.

A participant's particular personal nurse may not be available at 3 a.m. but she will follow up the next day, she adds.

The personal nurses stay in touch with the participants on a regular basis, depending on their needs, according to Kate Marcus, RN, MS CPHQ, a personal nurse coach in Tampa.

"We may call someone as frequently as twice a week or as infrequently as every three months. It depends on the acuity of a patient. If we have a participant who has his diabetes under control and plays golf several times a week, he doesn't need as much help as someone who is struggling to manage his condition," Marcus says.

The personal nurses assess the participants on their understanding of their disease and how to manage it. For instance, with congestive heart failure patients, they determine if the participants have a scale, if they weigh themselves regularly, if they understand why they are weighing themselves, and if they know what to do if they have gained five pounds.

"We talk about functionality and their ability to move around. Preventing falls is as important as checking the Hg A1c regularly," Marcus says.

The nurses educate the seniors about their laboratory values, what they mean, and the importance of keeping them at a certain level.

They assess psycho-social needs, such as helping with housework or if there is someone in their home or the community who can take care of them if they get sick.

"We communicate with family members around the country on a regular basis. We alert them if there is a change in status and work with them to find a solution," Marcus says.

The personal nurses conduct telephone assessments of participants' health on a regular basis.

"Health status changes frequently with people this age, particularly when they have a chronic condition," Marcus says.

For instance, a senior may report that her spouse had a stroke and can no longer care for himself. The personal nurse calls on the field care manager to visit the home and help the family decide what level of care is needed.

"We support the family through the entire decision-making process and help them gain access to the resources they need," Marcus says.

When appropriate, the personal nurses can call on the field care managers to visit with the beneficiaries in their home, the hospital, a nursing home, or a doctor's office to make a more comprehensive, face-to-face assessment than is possible over the telephone.

"When the field care mangers go into someone's home, they can find out a lot more about the situation than the personal nurse can over the telephone. They may open the refrigerators and see what type of food is there, or in some cases, that there is no food or inappropriate food," Bisio says.

The personal nurses may ask for a home assessment if they pick up on a cognitive impairment, if a senior seems to be concerned about multiple medications, or if they need instruction on how to test their blood sugar level.

The field care managers visit the home, paying special attention to environmental and safety issues. By observing the participants, they are able to conduct more thorough functional, cognitive, and psychological assessments than over the telephone.

"Those eyes are very important. They can tell the personal nurse something over the phone and when the field care manager gets there, it's not what they see," Bisio says.

When needed, the field care managers give in-home caregiver training, as well as education and support for people with chronic illnesses.

The personal nurse may send field care managers into a facility to work with family and caregivers of a patient with end-stage Alzheimer's disease.

"They may make sure a participant has an appropriate treatment plan if they are in a long-term care facility and make sure that it is being followed. They educate the participant and family on advanced directives, end-of-life issues, and hospice," Marcus adds.

The field care managers work with the care management nurses at hospitals and post-acute facilities to make sure that the patient is discharged to a safe place, that there is a caregiver in the home or community, that home modifications are completed, and that durable medical equipment is in place.

"The field care managers ensure that there is a smooth discharge and that the patient will be safe at home. We don't want them to be unable to manage at home and have to be readmitted," Marcus says.

The community health workers provide support for the field care managers by researching how beneficiaries can access community resources for services or equipment that Medicare doesn't cover. For instance, they may research how to get grab bars and ramps built and what community agencies will provide funding.

They provide group classes on living with chronic illnesses in churches, senior centers, or other locations throughout the community.

The three disciplines in Green Ribbon Health work as a team.

For instance, the field care manager may determine that the senior needs a certain type of durable medical equipment and report back to the personal nurse who contacts the physician's office to make sure orders are in place for the equipment.

The community health worker does research on where to find a specific type of equipment.

In another example, during a workshop for seniors, the community health worker may determine that a participant has just started on a new medication and doesn't understand how to take it.

When the personal nurse gets the information, she calls the participant to discuss the medication and to answer any questions. If needed, the personal nurse may call the senior's physician to clarify the medication order.

The personal nurse will request that a field care manager make a home visit to provide the senior with education about his or her medication if she encounters barriers that make it difficult to provide the education over the telephone.

Some of the participants in the program are snow birds, who spend several months a year in Florida, then return to their homes in the north. The personal nurses continue to follow them when they return to another state and call on the community health workers to research what is available in those communities.