American College of Physicians: Internal Medicine — Doctors for Adults ®

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CMS tests ways to help sickest patients

Home visits and innovative technology are helping improve care—at less cost.

From the November ACP Observer, copyright © 2006 by the American College of Physicians.

By Yasmine Iqbal

Christopher K. Pollick, MD, a San Clemente, Calif.,-based family practitioner, knew before he saw his 80-year-old patient for the first time that she'd been plagued by multiple chronic illnesses, including severe osteoporosis. What he didn't know was that her osteoporosis was almost certainly brought on or exacerbated by a powerful steroid she had been ordering from Mexico for almost 20 years in an attempt to control her debilitating asthma symptoms.

"She'd been too afraid to tell anyone, even her primary care physician," said Dr. Pollick. He discovered it indirectly during a visit to her home while conducting a thorough review of her medications.

Dr. Pollick is a Personal Visiting Physician (PVP) with Care Level Management, one of six organizations participating in CMS' three-year "Care management for high-cost beneficiaries" (CMHCB) initiative. According to CMS, 15% of Medicare fee-for-service beneficiaries, the ones who have multiple costly conditions, account for almost 75% of total Medicare expenditures in any given year. The CMHCB project is testing various care models to see if they can help increase adherence to evidence-based care, reduce unnecessary hospital stays and emergency room visits, and help beneficiaries avoid costly and debilitating complications.

The program has been a great boon for Dr. Pollick's patient, who stopped taking the Mexican steroid and has stayed out of the hospital, despite experiencing various health scares over the past year. Dr. Pollick also keeps in touch with her primary care physician, Raymond Chang, MD, who said he appreciates the help. "I don't have to worry about her as much," he said. "I know there's another pair of expert hands and eyes looking out for her."

CMS is hoping that the CMHCB project, which is currently active in eight states (California, Texas, Florida, Oregon, Washington, Nevada, Massachusetts, and New York), produces other similar success stories.

"CMS has a number of initiatives that are disease management programs and demonstrations, but for the CMHCB project, the agency wanted to test provider-based models that would offer 'high-touch, on-the-ground' care management," said CMS spokesperson Amy Knight, PhD.

While the government has not yet released any hard data, physicians involved with the various projects are speaking up about what's working, what isn't, and how these models might be expanded to benefit a broader range of patients. Here's a look at the projects so far.

Providing care in the home

Care Level Management

As of last month, about 7,600 patients were enrolled in the Care Level Management project (more than 25,000 are eligible to participate). All are beneficiaries who have at least two chronic illnesses and a history of at least two hospitalizations within the past 12 months. Participants have 24-hour access to a PVP employed by Care Level Management, whom they can call or ask to come to their homes at any time.

"All of the medical profession will tell you that they wish they had more time to spend with patients," said Henri Becker, MD, founder and chief medical officer of Care Level Management. "PVPs have this time to deal with not only the physical issues, but the social and economic problems that are happening in the home."

Michael S. Smith, FACP, an internist based in San Pedro, Calif., became a PVP in December 2005 after 30 years of private practice. "I got very tired of seeing 25 to 30 patients a day," he said. "Now I have the opportunity to spend much more time with them and go into greater depth."

He typically visits six patients a day in their homes and is responsible for about 75 in total (he noted that he eventually expects to see seven to eight patients a day and have 175 patients in his pool). A visit can last anywhere from half an hour to over an hour if he's seeing a patient for the first time or a new issue has cropped up. He sees almost all his patients twice a month on average, and at least once a month; he also coordinates with a Care Level Management nurse who checks in with his patients several times a month.

In addition to performing exams, routine bloodwork and monitoring, Dr. Smith spends time with the patient's family, examines the home environment for fall risks and other safety issues, and helps educate patients about their health issues. "I really get to know these patients - they become like family," he said.

Almost all of Dr. Smith's patients have primary care physicians with whom he keeps in close contact. "I make it clear to both the patient and the physician that I'm serving in a complementary role," he said. "If I think significant changes need to be made in a patient's care, I'll always discuss it with the patient's physician first, sometimes while I'm in the patient's home, which puts both parties at ease."

"A few primary care physicians have refused to work with PVPs, perhaps because they think that we're looking over their shoulders and taking business from them," he noted. "Most, however, have more to do in one day than they can handle, and they're grateful for the help."

He's also run into some resistance from patients themselves, even after they've agreed to participate in the program. "Many Medicare patients are fiercely independent and loyal to their own physicians, so you have to tread lightly and gradually build up trust." He recalled one patient who had lost both legs to diabetes and was also suffering from alcoholism. It took months of working with this patient (who only spoke Spanish) and his family to start to turn things around.

"Its cases like these that convince me that we're providing a very high level of care to our patients," he said.

Final results on costs savings from this project won't be available for a while, but Care Level Management claims that PVP delivery systems implemented to date have reduced acute hospital admissions by an average of 60%, resulting in an average net savings of 30% to managed care payers.

RMS Key to Better Health

The Key to Better Health program, which focuses on patients with chronic kidney disease (up to 5,000 beneficiaries are eligible to participate) aims to show how home visits and other interventions can enable patients to delay the progression of their disease and, in some cases, avoid progression to renal replacement therapy.

"Our goal is to try to prevent or retard the progression of chronic kidney disease and help ensure that patients who start dialysis start as an outpatient when possible," said Steven Fishbane, MD, regional medical director for the program. A team of nephrologists, nurses, pharmacists, dieticians and social workers proactively monitor patients and intervene early when there are problems to avoid hospitalizations.

During home visits, field nurses also check for medication compliance, look for safety issues, answer questions about medical bills and manage other aspects of patients' overall healthcare.

Using technology

Health Buddy

Up to 1,500 patients with congestive heart failure, COPD, or diabetes are eligible for the Health Buddy Program at Bend Memorial Clinic in Bend, Ore., and Wenatchee Valley Medical Center in Wenatchee, Wash. The Health Buddy is a user-friendly communication and monitoring appliance that connects to a patient's phone line.

It asks patients a series of daily questions about their vital signs, symptoms, and behaviors; patients respond by pushing one of the blue buttons on the device. After the session, which typically lasts a few minutes, the Health Buddy appliance automatically dials a toll-free number to send the information to a secure data center, where healthcare professionals review and monitor it.

Peter D. Rutherford, ACP Member, an internist at Wenatchee Valley who has about 25 patients using the appliance, said he's been seeing clear benefits.


Peter D. Rutherford, ACP Member, uses a "Health Buddy" to monitor elderly patients in their homes.



"Health Buddy has been very helpful in picking up things like unexplained weight gains or a sudden onset of shortness of breath that might indicate problems in patients with heart failure," he said. He recalled an 85-year-old patient with heart disease and restrictive lung disease who recently recorded a three-pound weight gain in her daily session. After that data was transmitted, a case manager immediately called and asked her to come into the office, where her diuretic medication was adjusted.

"This patient never would have thought to call anyone," said Dr. Rutherford. "As it happened, we were able to catch a problem before it progressed to something much more serious."

He added that the Health Buddy appliance has helped many patients improve their health habits. "I've had patients tell me that they're exercising more, monitoring their blood sugar more regularly, and watching what they eat more carefully. They're more aware of the global effects of their disease, and they're grateful for the extra attention."

Dr. Rutherford noted that Health Buddy hasn't been as helpful with patients with cognitive dysfunction whose caregivers have to answer the questions for them. "It just becomes one more thing on the caregiver's already overloaded plate," he said. However, he said, the system should prevent unnecessary hospitalizations for compliant patients. According to Health Hero Network, the appliance's manufacturer, this technology has reduced hospitalizations by up to 63% in similar programs.

Institution-based programs

Massachusetts General Care Management, Montefiore Care Guidance, and Texas Senior Trails

Selected beneficiaries with multiple chronic conditions who are already seeking care from the Massachusetts General Healthcare System, Montefiore Medical Center, and Texas Tech Physician Associates are eligible for these three programs. All three involve using RNs and other trained healthcare professionals to proactively reach out to patients via phone calls and home visits to help them navigate through the healthcare system and catch potential complications early on.

The Massachusetts General Care Management project is modeled on a pilot program that ran from 2002 to 2005 and involved 119 patients and six physicians, including internist Sandra M. Sweetnam, MD, and one case manager, Susan Lozzi, RN (both Dr. Sweetnam and Ms. Lozzi will be participating in the CMS demonstration, as well).

Dr. Sweetnam had high praise for the project and for Ms. Lozzi's work. "Many of my patients have overwhelming needs that are not only physical, but financial, legal, and emotional," she said. "Ms. Lozzi understood all of these issues and where to locate all possible resources that might help. She was like a fairy godmother to my patients."

"I had one 86-year-old patient with multiple chronic conditions whose memory was starting to fail," she recalled. "Ms. Lozzi worked with a visiting nurse to provide care in the home, and when that wasn't enough, she was able to convince the patient's daughter that her mother needed to live with her."

According to project director Eric M. Weil, ACP Member, the pilot trended toward fewer hospitalizations and shorter lengths of stay among patients who were hospitalized, although the results were not statistically significant. While the pilot produced encouraging results, project organizers realized that an even more comprehensive approach was needed.

The CMS project, which includes 2,500 prospective patients and 11 case managers, combines the successful elements of the pilot with other clinical resources, such as psychiatric and social work evaluation, pharmacy, palliative care, and geriatrics, said Dr. Weil.

The Montefiore program, with a potential patient population of 6,800, and the Texas Senior Trails program, with a potential patient population of 8,200, also incorporate care managers, although each program has unique features. Montefiore, for example, makes use of in-home monitoring equipment, and the Texas project focuses on developing individualized care plans based on participants' specific circumstances.

Keeping physicians at the center of care

Although the College hasn't had any specific involvement with choosing or monitoring the individual projects in the CMHCB program, it approves of the overall goals, according to Brett Baker, Director of ACP;s Regulatory and Insurer Affairs Department. "On a macro level, the goals of the College and CMS are aligned," he said. "We know that care is fragmented, patients don't always get the care that evidence-based guidelines would dictate, and reimbursement systems are broken, so we applaud CMS's decision to try different approaches.

"Our main concern is keeping the physician as the leader of the team effort to best care for patients," he continued. "Physicians will ultimately make most decisions about a patient's care, so we want to make sure that all the professionals working with the patient, especially those that are providing services outside the office, continually report back to the physician in order to provide the most patient-centric care."

Yasmine Iqbal is a freelance writer specializing in health care.

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Pilot participants take different tacks

In attempting to improve care for frail elderly patients, participants in CMS' Care Management for High-Cost Beneficiaries initiative are employing three basic strategies: home visits, innovative technologies and expanded services.

CMS chose the eligible patient population for each project and is giving each care management organization (CMO) engaged in a project a monthly fee per beneficiary to cover administrative and care management costs. The agency is also monitoring claims data, hospital admissions and a variety of clinical metrics on a monthly basis and comparing them to control groups of patients. Each CMO has agreed to assume financial risk if it doesn't achieve a certain percentage of cost savings; for example, according to Dr. Knight, who is the CMS project officer for the Key to Better Health Project, that particular project must demonstrate cost savings of at least 5% of net costs. CMS has not released any data on results. Its final report is due in 2010.

Here are the six CMO awardees and the areas they are focusing on:

Home visits using a distributed network of providers:

  • Care Level Management (launched October 2005; based in California, Texas, and Florida)
  • RMS KEY to Better Health (launched November 2005; based in New York)

Innovative technologies that monitor and educate participants:

  • Health Buddy (launched February 2006; based in Oregon, Washington, and Nevada)

Expanded services beyond traditional institutional care:

  • Massachusetts General Care Management (launched August 2006; based in Massachusetts)
  • Montefiore Care Guidance (launched June 2006; based in New York)
  • Texas Senior Trails (launched April 2006; based in Texas)

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