Community DM program pays off for MSO

Nurses, social workers, pharmacists are on team

A community disease management program aimed at the frail elderly has saved Physician Health Partners of Denver 50% on patient care for congestive heart failure patients within six months after patients are identified and enrolled in the program.

Nurses, social workers, and pharmacists who work closely with the patients’ primary care physicians staff the multidisciplinary program.

Physician Health Partners is a management service organization (MSO) that is 90% owned by physicians. About 500 patients are enrolled in the frail elderly community case management program. About a third of them are in the congestive heart failure disease management program.

"When you look at the senior population, congestive heart failure is one opportunity where increasing compliance can dramatically reduce the global costs," points out Jay Want, MD, medical director. Physician Health Partners currently works with three independent practices associations (IPAs), covering about 58,000 lives.

"We provide all managed care infrastructure for each group, utilization review, looking at referrals and precertifications, and a case management program that follows patients through hospitalization and into the community," Want says.

Physician Health Partners started its disease management efforts in 1997 as a way of examining and controlling utilization in a market where providers increasingly were under global capitation. There was one case manager on staff.

"The disease management efforts grew out of a sense that there were people who repeatedly came in and out of the hospital and that it would be a good idea to manage them. At that point, there may not have been literature and data to support such an approach," Want says.

"At that point, we decided that there needed to be a lot more discipline in the frail elderly program before we could figure out whether or not we were doing anybody any good," he says.

The organization had good anecdotal data, but it was hard to prove that the success stories were typical patients rather than atypical incidents.

The management contracted with Pfizer Health Solutions for its customized Clinical Management System disease management modules. Physician Health Partners currently uses the Healthy Lifestyles and Heart Failure modules. The software is used to collect patient data; organize information from patients, case managers, and physicians; apply clinical guidelines; and produce treatment recommendations.

Physician Health Partners made the decision to contract with a vendor for the software but manage the program in house as a way to continue its personal link with the patients and physicians.

"We feel that they are more likely to respond to treatment recommendations or to call us if they have questions when there’s a local presence rather than someone out of state," Want says.

When the patients are in the hospital or skilled nursing facility, the on-site nurses flag patients with congestive heart failure, chronic obstructive pulmonary disease, and diabetes and refer them to on-site case management for assessment. About a third of the patients are referred for community case management, says Rosalind Bader, MSW, director of case management.

Other referrals come from physicians and home care agencies. The organization also conducts a patient data review to find other patients with multiple emergency room visits, frequent readmissions, and chronic conditions that fall in the top 10% of costs.

"The data says that any single screening method is no more than 60% sensitive. That’s why we use multiple screening methods," Want says.

Disease management is essential in today’s health care environment because complex cases often go beyond the ability of the primary care physician to manage them well enough to keep patients out of the hospital.

"If a physician has 10 minutes of contact with a patient once a month, it’s difficult to manage them well, especially if it’s a patient with complex conditions such as congestive heart failure or diabetes," Want adds.

The program began with physician commitment and evolved over time as it became more data-driven.

Setting up a disease management program is always difficult, especially for physician groups who don’t always have a large cash reserve, Want points out. "It’s a tough call to commit the money to hire a nurse to follow patients with a sense that you’re going to recoup your investment somewhere along the line," he adds.

The MSO is focusing on congestive heart failure and is considering adding chronic pulmonary obstructive disease and diabetes.

In addition to the hard outcomes, the physicians believe that the disease management program gives their organization something above and beyond what other types of payers can provide, Bader says.

[For more information on Pfizer Health Solutions and its disease management programs, contact the company at (866) PHS-2002 or visit www.pfizerhealthsolutions.com.]