MetroHealth Medical Center in Cleveland has partnered with two health plans to provide intensive care coordination for high-cost patients with multiple medical problems and, often, behavioral health issues.
-
Nurse practitioners at two primary care sites provide one-on-one care coordination for super-utilizers.
-
They assess the patients' needs, help coordinate community resources, and prepare a treatment plan that is flagged when patients visit the emergency department.
-
The nurse practitioners meet with health plan representatives monthly and brainstorm on ways to meet patients' needs.
Through a partnership with two health plans, MetroHealth Medical Center’s Red Carpet Care program provides one-on-one support and care coordination for patients whose average healthcare costs have been running $60,000 to $70,000 a year.
"The program rolls out the red carpet for a segment of the population that has been mostly ignored. The people in the program have multiple medical problems, and many have behavioral health issues. Some are narcotic-seeking, but others don’t know better than to use the emergency department for primary care or simply do not have the wherewithal to plan ahead when they have health issues," says Alice Petrulis, MD, FACP, medical director, care management for MetroHealth Medical Center in Cleveland.
The health system received the grant for the program from the Robert Wood Johnson Foundation through Better Health Cleveland and partnered with a Medicaid managed care plan and a commercial plan to create the Red Carpet Care program. The health plans provided a list of super-utilizers, based on hospital and emergency department costs. Patients with cancer, who were on dialysis, had suffered significant trauma, or were pregnant were eliminated.
The 136 remaining patients were assigned to nurse practitioners, located at two MetroHealth primary care sites for care coordination. The health system chose nurse practitioners to take on the care coordination role because they can write prescriptions and can see patients in the event of an emergency when the physician is not available, Petrulis says. The health plans pay for the nurse practitioners’ salaries and share the savings with the health system.
Patients in the program are treated for their medical problems by their primary care provider. The nurse practitioners develop a close relationship with the patients and work to eliminate barriers to care and ensure that the physicians, the health plans, and any other practitioners treating the patients are aware of what their counterparts are doing.
When patients are identified for the program, the nurse practitioners call them, explain the program, and enroll them. They set up an appointment for the patients to come into the office and complete a comprehensive health risk assessment that includes their socioeconomic needs.
"Many of the patients in the program have more socioeconomic needs than medical needs. When patients don’t have a place to live or their electricity has been turned off, they aren’t concerned with healthy behaviors. Our nurse practitioners get to know the patients and establish trust so they can find out about their needs," Petrulis says.
The nurses create a care plan for each patient and enter it into the medical record with the patient’s name in red to alert the emergency department staff that the patient is in the Red Carpet Care program.
"The plan may be as simple as stating that the patient has recurrent abdominal pain and should be referred to the primary care provider or nurse practitioner for treatment," she says.
The nurse practitioners work to overcome barriers to care, such as lack of transportation, inability to pay for their medication, or psychosocial issues. The health system has partnered with community agencies that can provide resources such as housing assistance, help with filling out forms for assistance programs such as Social Security and medication assistance, and help with transportation and utilities.
The care coordinators refer many patients to behavioral health management programs at the health plans. When they feel it’s needed, the nurse practitioners go to the patients’ homes to assess the living situation and review their medication.
"The key to the success of the program is one-on-one interaction between the case managers and the patients," Petrulis says.
The nurse practitioners call the patients at least once a week, and the patients can call the nurse practitioners as often as they want. The nurse practitioners use smartphones with a caller ID patients can recognize. "Many patients don’t answer the phone when the caller ID says [private,’ and that is what happens when the call comes from the hospital," Petrulis says.
One health plan donated cellular phones for patients who don’t have telephones so the patients could call their case manager whenever they needed help. "The patients did not abuse the privilege. The nurse practitioners receive a few phone calls in the evenings, primarily from patients who work and can’t call during the day," she says.
The program hasn’t been in effect long enough to have a full year of data, but patients in the program have had fewer emergency department visits and hospitalizations, Petrulis says. There has been only one instance of a patient in the program being readmitted to the hospital within 30 days after discharge.
The nurse practitioners collaborate with the case managers at each health plan to make sure they don’t duplicate their efforts. They meet with health plan representatives every week to collaborate on the care plan.
Petrulis, the nurse practitioners, and representatives from both plans meet regularly to talk about problems with patients and brainstorm on solutions. The nurse practitioners and Petrulis choose the cases to review and alert the patients’ payers, but when the team meets, the patients are identified only by initials to respect their privacy. In addition to suggesting community resources for the patients, the team members often volunteer to do whatever it takes to make sure the needs of patients are met, she says.
For instance, one patient kept all his possessions in a wheeled cart, which was stolen. A member of the team had an extra one and donated it. When one patient was moving and had no one to help her, the medical director from one of the plans recruited his son and friends to move her.
Before starting the program, the Red Carpet team conducted a focus group with 18 super-utilizers to find out what they wanted from the healthcare system. The patients said they wanted a relationship with a primary care physician who really cares about them and a medical team that listens to their concerns. Some patients said they couldn’t find a physician who speaks their language or that they couldn’t afford their medication. "They didn’t really want to go to the emergency department every time, but the healthcare system wasn’t meeting their needs," she says.
