Recently in Care Coordination Category

As Medicaid budget pressures grow, more states are turning long-term care over to private managed care companies. USA Today reports that six states now require both frail elderly and younger adults with disabilities to enroll in insurance-run Medicaid managed care plans. Another 10 states are planning to either create or expand these programs, according to the story.

The reason, of course: money. States pay the insurance plans a fixed amount to care for these patients. And the private insurers say they can provide quality care for less cost through their use of care coordinators and by keeping many people at home. 

Tennessee, for instance, pays private insurers an average of $4,400 per patient per month to provide Medicaid long-term care services. Under this system, if the insurer can provide care for less, it makes a profit. If its costs are higher, the insurer is at risk for the difference. This is a big incentive to create a care plan built around home care, which for many beneficiaries can be far less costly than a skilled nursing facility.

USA Today reported that one Tennessee insurer, Amerigroup, spent about $3,000 per month to care for one patient at home. The cost for this patient in a nursing facility would have been almost $4,600 per month and a money-loser for the insurer.     

Medicaid managed care isn't new. States have been using it for acute care beneficiaires (mostly low income mothers and kids) for years. But long-term care patients are a very different challenge.

One one hand, more than any other population, the frail elderly need to have their care coordinated. They have complex medical needs, often suffer from multiple chronic diseases, and frequently take many medications. If a mix of care managers, personal assistance, nursing, and other services and supports can help them get the care they need at home for less money, that is great.

This flat fee, or capitated, payment model works well with programs such as hospice and PACE, for instance.   

On the other hand, many insurance companies badly damaged their reputations in the 1980s and '90s with managed care plans that seemed more intent on maximizing profits than care. It will be important to put protections in place to be sure that the frail elderly, who are often unable to advocate for themselves, are getting the care they require.

The other problem with Medicaid managed care is that these beneficiaries often receive their physician and hospital care through Medicare, not Medicaid. Because these two programs are so poorly coordinated, seniors who transition from, say, home to hospital to rehab and back to home may not get proper care as they cross settings.

This lack of coordination between Medicare and Medicaid also creates some perverse and dangerous incentives. If, for instance, a Mediciad managed care patient winds up in the hospital as a result of poor care, neither Medicaid nor the managed care firm is on the hook. The bill, instead, is paid by Medicare.

If managed care is going to work well, there will have to be much closer delivery and financial relationships between these two payers, as there is with successful programs such as PACE or through provider-based managed care mechanisms such as Accountable Care Organizations.           

For seniors trying to manage multiple chronic disease, moving from one care setting to another can literally be a matter of life and death. That's why it is so important that health providers--doctors, nursing homes, hospitals, assisted living facilities, and home care agencies--work together to make sure that those moves happen safely.

Too often in our poorly coordinated health and long-term care systems, those transitions fail: Somebody loses track of a medical record, fails to correctly administer an important medicine, or repeats an unnecessary, costly and uncomfortable test. Transitions even within hospitals are notoriously dangerous. When they require cooperation of different providers, the risks are even greater.

Transitional care was the subject of the Gerontological Society of America's annual meeting this week in New Orleans. Just the fact that physicians, social workers, nurses, and academic researchers spent five days talking about this topic was hugely important. It is evidence that the issue is finally getting the attention is deserves.

Even better news: There are transitional care models that both improve patient health and save money. New training programs are making doctors, nurses, and aides aware of the importance of careful transitions and teaching them how to better accomplish them. Other programs work with families to help make them strong advocates for patients during these challenging moves. And models such as those developed by Eric Coleman at the University of Colorado, Mary Naylor at the University of Pennsylvania, and Chad Boult at Johns Hopkins University, have all redesigned the systems we use during transitions.

At the same time, old models are being improved. Palliative care programs do a great job combining medical treatment with social and spiritual care as well as symptom management to improve outcomes for patients. But now they are being better integrated into hospitals and physician practices--a key element to their success.   

On the other hand, it was clear how far we have to go, especially in our wildly inefficient fee-for-service health system. Discharge planning in both hospitals and nursing homes continues to be a broken link in the chain of care. Too often, patients are sent home or to a nursing facility without an appropriate care plan in place. Discharge planners are overworked and ill-prepared, and too often the focus is on a quick discharge rather than a good plan. 

In addition, while many creative experiments are sprouting up all over the country, it was clear from listening to researchers that we have a lot to learn before we know which will work and which will disappoint. 

On December 13 and 14, I'll be participating in an important conference in St. Louis on ways to better integrate care for chronically ill seniors. Sponsored by the Catholic Health Assn., the program will bring together health providers to share successful ideas and help work though some of the financial and medical challenges to better coordinating care.   

In an important new study, Lynne P. Snyder and Christopher Baker show the importance of energy assistance for elders living at home. The paper, Affordable Home Energy and Health: Making the Connections, was published by AARP. It is another example of why it is not enough for states to provide Medicaid waiver programs to help people receive long-term care at home. Without additional supports, such as energy assistance, the dream of aging in place can easily become a nightmare.

The problem is that rising energy costs put low-income seniors at serious physical risk. About 900 older adults suffer either heat-related or cold-related deaths each year. But those killed directly by extreme weather are only a fraction of those who die as a result of their inability to manage very high or very low temperatrues.

Seniors are at greater risk for death from respiratory or cardiovascular disease in the high heat of summer and from heart disease in the cold of winter. Not surprisingly, those with access to central heat and air conditioning are far less likely to die than those who do not.

Snyder and Baker report that 80 percent of housholds receiving federal energy assistance through the program known as LIHEAP have at least one member who suffers from a disease that puts them at risk of extreme temperature.

This study is yet another example of why states must do a far better job of managing all the needs of low-income elders who require long-term services. These people need more than a Medicaid-paid home health aide. They need an accessible home, transportation, good nutrition, companionship, and, as this study shows, assistance with energy bills. Without a full package of assistance--and without the ability to find and access that help--aging in place is doomed to fail, despite our wishes.

Some of this help, such as transportation and companionship, can be provided by neighbors helping one another. But other services very likely will have to come from government. And unfortunately, Medicaid dollars can normally not be used for supports such as energy assistance. The Snyder-Baker paper is more evidence of why policymakers must think outside of their narrow silos if they are going to do their part to keep frail elders safe at home.     

I spent yesterday with more than a hundred elder care professionals at the Seven Acres senior care campus in Houston. For a while they listened to me, but for much of the time I had the opportunity to listen to them. And what I heard was striking, and an important addition to the HSC Foundation's recently published study based on listening to family caregivers.

We had a wide range of professionals at this program, the 24th annual Lou Lewis Symposium in Gerontology: executives from nursing homes, assisted living facilites, and home health agencies; case managers, social workers, nurses, and maybe even a physician or two. Early in the program I asked how many had also been caregivers for their own family members. At least 80 percent raised their hands.

After I spoke, the participants broke up into a dozen small groups to come up with their own ideas for improving today's long-term care system. Not surprisingly, there were many suggestions. But there was also a striking consensus on a few broad themes.

Participants were tremendously frustrated at how poorly the system works today. Their biggest frustration may have been over the lack of communication between families and professionals and the absence of care coordination within the health system itself.

A word I heard over and over again was education. These professionals felt passionately that family members, aides, doctors, and--yes--politicians need to learn much more about how elder care works, not at a broad policy level but for individuals. The resources out there today, such as Area Agencies on Aging and Aging and Disability Resource Centers, help. But the participants thought they need to do much more. 

We talked about the need for better training for all caregivers, both family members and aides.

The participants felt strongly that community groups, local businesses and, especially, faith-based organizations need to play a greater role in caring for the frail elderly. We talked about the village movement, where seniors join together to form community non-profits to help one another. But many participants felt that churces, synagogues and other religious institutions could do much more to aid their own congregants. This assistance could come from volunteer committees who help arrange rides, friendly visits, and phone calls.

We also discused the importance of financing long-term care. This group, at least, was skeptical about whether young people would enroll in the voluntary CLASS Act. Even though this was Texas, some even felt the country would do better with a social insurance design for long-term care. But, once again, they felt that better education is the key to encouraging people to begin preparing for future long-term care needs.

I learned a lot yesterday, and I hope the participants follow up on some of their teriffic ideas. 

Those of us who are caring for our parents or other loved ones know how tough it is. The emotional, physical, and financial burdens are sometimes overwhelming. Bathing your father or changing his adult diaper puts both of you in a new, uncomfortable, and difficult world.

But at a Syracuse University long-term care conference I attended last Thursday and Friday, Carol Levine reminded me about the medical expertise caregivers need these days. With patients being discharged quicker than ever to their homes from the hospital or from nursing facilities, adult children and spouses increasingly are being asked to do the work that was once left to highly trained nurses. 

Carol, a former family caregiver herself and director of the Families and Health Care Project at the United Hospital Fund in New York, has a long list of these tasks, for which few caregivers are ever prepared. Among them:

Medication management: It is common these days for a senior with many chronic diseases to be taking a dozen different medications. If you've been a caregiver, you know the drill--the green pill three times a day, the blue pill twice a day with meals, the other blue pill twice a week....Worse are the sometimes deadly interactions among these drugs. With few doctors keeping track of all these meds, preventing medication disaster is up to family caregivers.

Operating medical equipment: This is work that you'd need a license to do if you were not a family member. Is the oxygen tank full, are drugs flowing freely through IV tubes, are wounds being kept clean and appropriately bandaged, are you giving injections properly? And this is the easy stuff. Some family members must do even more complicated work, such as managing complex ventilator care.

Coordinated care: This may be the toughest task of all.Somebody must make sure that all the doctors and other health professionals are on the same page. With a few exceptions (such as hospice), docs and nurses won't do it. So it is up to family members who must learn medical jargon and become disease epxerts in their own right. And keep in mind, as hard as it is for adult children to provide this complex medical care, it can be far more challenging for spouses, who may face their own physical and cognitive struggles.     

There is almost nowhere for family members to go to get this training. I have found only a handful of such programs around the country. The Schmieding Center in northwest Arkansas is a great model. But they are few and far between. 

And even if this training were available, who has time to take classes when they in the midst of a caregiving crisis? 

We all want to be cared for at home, but to make it work, family members will need the training to perform increasingly sophisticated medical tasks. And right now, there are far too few people thinking about where their education is going to come from.   

In the new health bill, Medicare is planning to pay family practice doctors extra money to organize complicated care for the chronically ill--a role known as a medical home. But as family caregivers know all too well, they are the real medical homes--and probably will be for the forseeable future.     

Nobody wants to see chronically-ill elderly patients making repeated trips to the emergency room. These visits are obviously bad for the patients themselves, who often suffer stress, disorientation, and high risks of infection. They are no good for Medicare, which has to pay the bill: The estimated cost of these readmissions is $17 billion annually. And, despite the common perception, they may not be good for hospitals, which are facing payment cuts for these patients.

Many of the families I met while researching Caring for Our Parents struggled with this problem. Remembering which medicines to take; learning that it is a bad sign when a congestive heart failure patient like my dad gained weight; even something as basic as being able to get to the doctor for a checkup could be the difference between staying at home and ending up in the ER at 3 AM.   

But keeping frail seniors (and others, for that matter) out of the hospital turns out to be hard. One in five Medicare patients is readmitted within 30 days. Although Medicare has been running several demonstration projects aimed at keeping this population out of the  hospital, most have failed. According to a new study by Randall Brown at the highly respected consulting firm Mathematica Policy Research, very few experiments have reduced either hospitalizations or costs.

But the news isn't all bad. Brown identified three models that seem to be working. Two focus on patients who are already in the hospital. In one, advance practice nurses begin to work with patients before they are discharged and then follow them intensively for 4-6 weeks after they go home. In the second, for 4-7 weeks after they are discharged, patients are enrolled in programs that train them to self-manage their care.  

The third model identifes patients at high-risk for hospitalizaton and intensively monitors their symptoms before they get so sick they end up in the ER. These projects, called the Medicare Coordinated Care Demonstration program, have met with mixed success. Only 3 of 15 have reduced hospitalizations and costs. But Brown says they can work if they carefully target patients, if nurses and social workers spend face time with those in their care, if nurses work closely with primary care doctors and carefully tailor services to these patients' needs. Two keys: teaching how to manage medications after discharge and helping arrange for non-medical social assistance, such as transportation and adult day care.

The problem is that setting up these programs is not cheap. Massachusetts General Hospital says it spent as much as $9 million to get its model going, although it says it eventually saved between $7 million and $10 million after covering costs.

With Medicare expected to cut hospital payments for patients it believes could have avoided that round-trip to the emergency room, Brown's lessons will be increasingly important to both hospitals and patients. The trick will be to find ways to not only save money but improve care. If that sounds like a smaller version of the big health reform story, that's because it is.         

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