The Central Ohio Primary Care Physicians Senior Care Advantage program is designed to improve quality, efficiency, patient experience, and outcomes for Medicare Advantage patients.

• Patients in the program who make their primary care follow-up appointments after discharge experience lower readmission rates.

• The program focuses on prevention and highly coordinated clinical care.

• For high-risk patients who are homebound, the program includes two physicians who make house calls, each seeing one or two patients per day.

A new population health management program in Ohio is expanding to transform care for Medicare Advantage patients. It’s building on its success with providing a toolbox of services to patients, centered around primary care.

The new program is designed to improve quality, efficiency, patient experience, and outcomes for Medicare Advantage patients.

“We found, through our own data of 4,000 patients discharged in a year, that we can get the readmission rate down to 6% if the patient keeps that primary care physician visit,” says Bill Wulf, MD, chief executive officer of Central Ohio Primary Care Physicians (COPC) in Columbus.

“If they don’t see the primary care physician, the readmission rate is as high as 28%,” Wulf says.

The COPC Senior Care Advantage program takes the value-based model to a new level, focusing on prevention and highly coordinated clinical care. COPC physicians will coordinate all care for enrolled members, including primary care, specialists, major local health systems and hospitals, laboratories, and all ancillary services. The program also will use data analytics to support clinical decisions.

COPC began treading on the population health pathway in 2014 with a patient-centered medical home (PCMH). Then, the organization moved to a shared savings model with its commercial and Medicare Advantage plans, Wulf explains.

“Now, we want our patients to understand that we’re taking both clinical and financial responsibility of their care,” he adds. “As primary care physicians who are independent and not tied to procedural specialists or hospital systems, we can look for value for our patients in any situation, and it puts us in an enviable position.”

Changing reimbursement models to pay primary care physicians for their patients not experiencing costly medical events is a way to change both a population’s health and physicians’ and patients’ behavior, he says.

COPC will work with a major health system to provide primary care, case management, and wraparound services, he says.

Hospitalists care for primary care patients when they’re in the hospital, and transitional care nurses assist with transitioning patients to their homes or to a skilled nursing facility. The transitional care nurses are responsible for the patients until their first primary care physician (PCP) visit. After patients are transitioned to the community, care coordinators, including RN case managers and social workers, handle post-discharge coordination of patients’ care. Care coordinators work out of the primary care offices.

With access to patients’ medical records from the PCP, hospitalists and transitional care nurses assist with the continuum of care. “Their job is to manage the patient from the hospital to home or skilled nursing facility and to arrange a follow-up to the primary care physician, ensuring it takes place,” Wulf says.

“The transitional care nurse calls the patient within 48 hours, saying, ‘Hi, this is Kathy. I’m checking in on you. Did you make the adjustment to your meds?’” he says. “Then they check the outpatient record to make sure the patient was seen, and then they are done with the transition.”

For high-risk, homebound patients, the program includes two physicians who make house calls. “Two physicians might see one patient per day, but they manage 50 high-risk patients at a time,” Wulf says. “They might get a call saying, ‘Betty Smith is in trouble, and if we don’t see her today, she may end up in the hospital.’ The physician goes out to her home and arranges for home care or hospice and prevents hospitalization.”

The home visit physicians provide high-intensity visits. They can intervene in an acute situation that could take hours to arrange the patient’s necessary services, says Larry Blosser, MD, outpatient medical director for COPC.

“The physician spends as much time as needed to get everything buttoned down,” Blosser says. “They get care plans in place, get the patient medication, and if the patient needs home health, then they bring in home health.”

It’s more cost-effective than sending patients to the ED, where they may end up hospitalized, Wulf says. “We have evidence that we have a fairly high conversion rate from home visits to hospice to palliative care,” he says.

Congestive heart failure (CHF) patients are the type who might qualify for the home doctor visit. “A lot of times, a CHF patient needs an adjustment in medicine and then to be checked back on every three or four days,” Wulf says. “If the patient runs out of medication, then things get worse.”

Other examples are patients with exacerbated chronic obstructive pulmonary disease or out-of-control diabetes, and patients who develop infections that can be treated with oral antibiotics, Blosser says.

“Each of those two home visit physicians prevents 40 to 50 hospitalizations a year,” he says. “At $10,000 for the average hospital admission, preventing 100 admissions a year makes it easy to pay two doctors to see one patient per day.”

The home visits also prevent unnecessary skilled nursing care.

“In central Ohio, there’s a tremendous utilization of skilled nursing post-hospitalization,” Blosser says. “These visits can prevent 20 days of skilled nursing care and costs.”

Patients and families grow comfortable with the home visit physicians and will call them when there’s a new symptom or problem. “They might call to say, ‘Mom is confused. I think she has a urinary tract infection again,’” Blosser says.

For other members of the patient population, care coordinators become patients’ and families’ go-to healthcare person.

“Patients have a direct line to the care coordinator’s cellphone, and they feel comfortable touching base with them,” Blosser says. “The care coordinator becomes the intermediary between the doctor and patient.”

Again, the goal is to improve care and prevent hospitalization and ED visits. “Care coordinators can get a patient on the doctor’s schedule and have them seen quickly, avoiding the necessity of the patient going to the ER,” Blosser explains.

Care coordinators make phone contact and at least one home visit. The number of home visits varies, depending on the patient’s condition. Patients stay in the care coordination group for as long as their conditions are high-risk and not improving. Those who improve will no longer need extensive care coordination. Since care coordinators become less effective with too high of a caseload, the goal is to keep the caseload manageable by discharging patients who no longer need such attention.

“We have learned to discharge people from care coordination,” Blosser says. “Patients do attach themselves to it, and it’s hard to give up. But we reassure them that if they need it again, we’ll let them back on.”