Medicare program reduces amputations and spending

Face-to-face sessions cornerstone of success

An intensive face-to-face care management program for severely ill Medicare patients with advanced congestive heart failure and/or complex diabetes has paid off for XLHealth, a Baltimore-based disease management firm. The company reduced spending by as much as 26% after 24 months of intervention for private HMO patients and has reduced lower-limb amputations by more than 60%.

The program provides face-to-face care management sessions with patients and person-to-person pharmaceutical consultations when needed. In addition, the nurse care managers meet with physicians and their clinical staffs to discuss the patient’s care plan. The patients picked for the program are those who are at risk for consuming the greatest amount of health care resources.

"Most are socially isolated and clinically depressed with little social support," says Paul Serini, executive vice president for XLHealth. "They don’t want to bother the doctor. They can’t drive to the podiatrist, and they don’t want to call a taxi because it costs too much."

Patients often unaware of ulcerated wounds

Serini credits the face-to-face interventions for the dramatic reduction in amputations and health care costs. For instance, many of these patients in Medicare programs have foot ulcers that they treat with over-the-counter medication, waiting until it becomes so severe that sepsis has set in or the patient is facing an amputation.

"We have found that when we call the patients before a home visit, about half of those who have ulcerated wounds say their feet are fine. If they have neuropathy, they can’t feel their feet. Many are obese and can’t see their feet. They may live alone and not know they have problems, or they may not know it’s serious," he says.

Home assessment helps identify any problems the patient has before they worsen into a costly health care episode, Serini notes. "Our medical experts tell us that almost 95% of amputations are avoidable from a clinical perspective if we intervene with the patient early enough," he says.

The nurse care managers call each patient and conduct a 15- to 20-minute telephone assessment. Depending on the patient’s level of severity, the nurse care manager asks the patient if he or she would be willing to participate in a 45-minute face-to-face assessment.

The assessment may be conducted at the patient’s home, at a special area set aside for XLHealth at a local pharmacy, at a physician’s office, a senior citizens center, or another location that is comfortable for the patient.

During the assessment, the nurse care manager collects clinical data, checks diabetic patients for neuropathy and hot spots, conducts a depression screening, reviews all the patient’s medications, and in some cases collects blood samples. "Based on 500 or more data points that we collect, the patient is restratified and the information is used to create a patient care plan that supports the physician’s plan," Serini says.

When the initial care plan is developed, the nurse care manager goes to the physician’s office and meets with the physician and clinical staff to walk them through the report, ensuring that the plan supports the physician’s efforts and telling them about frequency and content of follow-up reports.

Program designed to be physician-friendly

"The packages that are given to the physicians were developed over a period of four years by asking physician groups what information they want and what they want the reports to look like. They are very physician-friendly and helpful," Serini says, adding that the disease management company gets a 96% approval rating among physicians.

The patient also gets a copy of the care plan and a follow-up telephone call from the care manager.

Recommendations in the care plan are flagged in the company’s computer system until they are followed. For instance, if a patient has a history of hypertension and is not taking an ACE inhibitor, the physician receives a report suggesting an ACE inhibitor might be recommended for the patient, and the nurse care manager follows up with the patient, reminding him or her to speak to the physician about the drug. "These two tasks are scheduled by the system, and they remain on the schedule until they are completed," he says.

Patients in the highest risk categories receive the most interventions. There is no set number of interventions per patient. Instead, they are event-driven. For example, the nurse care manager may advise a patient with foot problems to go to a podiatrist and may arrange for transportation if needed. Two weeks after the podiatrist visit, the nurse care manager visits the patient to review what happened during the visit and to make sure the patient truly understands home foot care and foot issues.

"We are happy to pay for the follow-up because amputation can affect a patient negatively, and it is expensive; and it is always effective to have the care manager reinforce what the doctor told the patient," Serini says.