Project cuts costs, admissions and more

Health plans and physicians join forces

An innovative care coordination pilot project jointly developed by AmeriHealth Mercy Family of Companies' Keystone Mercy Health Plan based in Philadelphia, PA, and providers affiliated with the Mercy Health System, also based in Philadelphia, PA, resulted in decreased costs, reduced hospital admissions, and a decrease in inpatient days for members in the health plan's Medicaid managed care plan.

In the pilot, the health plan placed a care manager in the provider setting to help overcome barriers to care for participants. The care manager addressed social concerns such as transportation and child care and provided coaching on self-care issues such as medication adherence and preventative care measures.

The program started in November 2008 with the care coordinator working at the practice one day a week with the physician champion and nurse manager. The pilot program was so successful that the care manager works with the entire team at the physician practice five days a week, and the health plan is looking at ways to implement similar programs at other provider settings.

"The project started as the result of a working relationship between the health plan and the health system," says Karen Michaels RN, MSN, MBA, vice president of clinical services for AmeriHealth Mercy. "We were serving the same people and wanted to find a way to leverage our strength and improve our services."

Spreading the model is a goal, but they know it won't work the same way at all provider settings, particularly if they don't provide care for a large percentage of Keystone Mercy members, Michaels says. "We're looking at other ways the health plan can support care coordination at the physician practices," she says.

Among patients engaged in care coordination, hospital days per 1,000 members dropped from 2,689 to 1,408, while hospital days for those not in the program remained stable. Members participating in the pilot spent an average of 2.7 days in the hospital per admission, compared to 4.3 days before the program began.

Face-to-face encounters

Having a care manager on site is a key component of the program's success, says Grace Lefever, PT, MS, MPH, project leader for coordinated care management at Mercy Health System.

"We found that the face-to-face encounters with the patients were more effective than when the care manager worked with them on the telephone," Lefever says. "Patients are more willing to engage in a relationship when they meet the care coordinator in person."

The program focuses on coordinating care for high-needs Medicare members who have health conditions that put them at risk for increased hospitalization, but it looks at the entire population of members as well. If members are overdue for a visit or missing a recommended test or procedure, the care manager reaches out to them, Michaels says. "The health plan has an outreach team who works in the community and attempts to contact members if they can't be reached on the telephone."

The health plan assigned Lynne Major, MSW, CCM, a social worker who is a certified case manager, to work at a physician practice where 80% of the patients are AmeriHealth Mercy members. Major works closely with the physicians and the medical residents in training at the practice to ensure that the needs of the members are met. She leverages the information gathered by the health plan, as well as records at the physician practice, to identify gaps in care and ensure that members have the recommended screenings and preventive care they need to keep their chronic conditions under control.

Major has a laptop that connects remotely to the information system at the health plan, which allows her to access information not immediately available to the physician practice, such as what medications have been filled. She also has access to physician office information such as X-rays, laboratory results, and physician notes about member visits, which gives her a broad view of the patient's condition and helps her identify areas where she can help improve the outcomes.

Michaels says, "The health plan has a much broader view of patient care than the physician office does and can give the provider a comprehensive picture of the patient. We have access to all the claims for services or prescriptions the patient has received outside of the physician's system. The physician doesn't have a health information exchange with other providers and has to depend on the information the patient shares and any information in his system."