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In This Issue:
Sandra, a BWH patient, with Nurse Care Coordinator Pia Young.
When Sandra, a 70-year-old Dorchester resident who suffers from a number of chronic health conditions, had eight hospital admissions during a seven-month period, staff at her primary care provider’s office knew there was a way to help improve her health and quality of life. Pia Young, BSN, RN, CCM, a nurse care coordinator at Sandra’s practice, reached out to her, and after a phone conversation and some gentle persuasion, Sandra agreed to enroll in a unique program offered at Brigham and Women’s Physician Group.
The Care Management Program is part of a larger project that began five years ago at Massachusetts General Hospital after the Centers for Medicare and Medicaid Services (CMS) sent out a call for proposals asking for health care organizations to come up with ideas and solutions for managing high-risk Medicare patients. These patients account for high health care expenditures and sometimes don’t see improved outcomes or better quality of care.
“About 10 percent of Medicare beneficiaries account for 67 percent of all Medicare expenditures,” said Lisa Wichmann, MS, RN, ACM, nurse director for the Care Management Program at BWH. “Mass General worked with CMS to develop what is called the CMS Demonstration Project. After five years of successfully rolling out the model, they came to BWH and North Shore Medical Center to see if we could replicate the program with equally positive results.”
The efforts began at BWH and Faulkner Hospital more than two years ago, and patient enrollment kicked off in February 2010. Today, there are 1,091 patients enrolled in the program, at 12 primary care practices throughout BW/F, and an additional approximately 1,200 patients enrolled at North Shore Medical Center. After Medicare identifies a group of high-risk patients who would potentially benefit from the program, CMP nurse care coordinators at the practices recruit and enroll the patients.
“The program is a multi-pronged, team approach to care,” Wichmann said. “Once patients are enrolled in the program, they have access to an enhanced primary care team: besides their primary care provider, or PCP, they have a nurse care coordinator. Their team also includes a social worker, a psychiatrist, resource specialists and a pharmacist.”
These services are all integral to the program’s success, explained Wichmann, as the patients enrolled in the program not only have complex medical backgrounds, but they also face a number of other barriers to care that the team helps them address.
“The resource specialist can help patients arrange transportation to their medical visits, find people to help them cook healthy meals, even help them get oil to heat their apartments during the winter,” Wichmann said. “All of the additional support members on the team address things that are important and essential to receiving care, but that the nurses and doctors don’t have time to do.”
Rebecca Cunningham, MD, medical director of the Care Management Program, says that the program provides services for patients that otherwise would not be available and also helps to reduce costs for patients.
“This kind of ambulatory care coordination that is embedded in primary care practices not only improves quality of care and patient experience, but it also produces substantial cost savings,” Cunningham said. “So far, our inpatient admissions have reduced by about 9 percent, and the inpatient costs have been reduced by about 19 percent. That’s a big marker if we think of inpatient admissions as the result of situations that might have been handled in an outpatient setting instead rising to a crisis level. It’s very encouraging data in terms of our performance so far.”
Cunningham adds that as program evaluation continues, those involved remain hopeful that the positive results will also continue.
For patients like Sandra, the program’s success is measured in units far more valuable than dollars.
“When Sandra came in to visit me 11 months after beginning the program, I knew we had turned the corner,” said Young. “She was engaging and talkative and wanted to update me on her medicines, how the VNA was helping her and how her weight had improved. I have been able to help coordinate her care with Kristine Leone, LICSW, Patricia Brennan, RN, Renal Clinic, and Joyce Rockwell, her Partners Home Health nurse.”
Young added, “Two of Sandra’s former colleagues in the OR, Cynthia Smith, RN, and Katrina Mabry, RN, help support her at home. Her care is still tenuous and requires ongoing maintenance, but we have improved it and stabilized it, and it’s been a pleasure to get to know her.”
View the June 1 Quality Rounds Presentation: “Care Management Program at BWH: Can Ambulatory Care Coordination Bend the Cost Curve” at BWHPikeNotes.org/Employee_Resources/EdTechVideoLibrary/cce.aspx