For High-Risk Patients: ‘A Medical Home Within A Medical Home’

Jan. 9, 2017
Partners HealthCare offers patients with multiple chronic conditions access to specialized resources including mental health, community resources expertise, pharmacy, and palliative care. Analytics and IT tools support the effort.

What is a “patient-centered medical home within a patient-centered medical home”? According to Partners HealthCare’s Eric Weil, M.D., it describes his health system’s approach to dealing with patients with the most significant health risks.

Health systems are increasingly recognizing that better coordination of care for chronically ill patients with multiple medical conditions is key to improving care and reining in costs. But Dr. Weil, the medical director for primary care and high-risk care management within population health management for Partners, said that identifying which patients to target and how to set up the care management program can be challenging and depends on quality risk stratification, analytics tools and team-building.

Boston-based Partners has spent the last 10 years creating and then fine-tuning an integrated care management program (iCMP) for such patients. During a Jan. 5 webinar hosted by Health Catalyst, Weil detailed some progress and lessons learned.  

Early on, he said, Partners recognized that many patients with multiple chronic conditions were showing up in the emergency department or being admitted frequently because they didn’t have well-coordinated care, and that more preventive, proactive and coordinated work should be occurring. He also mentioned that all the changes it has made have been happening in an evolving payment environment as providers shift from a fully fee-for-service world to focusing more on managing risks and costs.

One of the key challenges is that among the core drivers for patients with complex illnesses, especially in Medicaid, are underlying social or behavioral health issues.

Weil gave an example using “Wordles,” which are visual representations of how often terms are mentioned in documents or on social media — the more common the term, the larger the word appears in the visual. Weil said wordles about iCMP patients pulled from EHR data highlight diagnoses such as diabetes or congestive heart failure. But wordles of how these patients are described by providers feature terms such as absent family, isolation, no family support, and noncompliance. “This highlights the value of the data and the perspective of providers,” he said. “You need both. You can’t do this well without either one. “

Weil explained that iCMP was developed over the last decade, starting with Medicare contracts, and provides:

• A care manager per approximately every 200 patients in the program;

• Access to specialized resources including mental health, community resources expertise, pharmacy, and palliative care;

• Involvement through continuum of care with home visits, telemonitoring, integration with post-acute and specialty services;

• Patient self-management with health coaching and shared decision making;

• IT-enabled systems to improve care coordination leveraging real-time, automatic notification of admissions/discharges and EMR flags identifying iCMP patients;

• Data-driven analytics to support strategic decision making and operations;

• Intensive, ongoing support and training for teams and staff; and

• A payer-blind approach, with initial attention to Medicare, followed by commercial and Medicaid contracts.

But the first question was, could Partners identify which patients are most likely to end up in the hospital with heart failure, sepsis or pneumonia and follow those patients longitudinally in order to catch these conditions upstream. These patients have more than one condition. They might have heart failure and schizophrenia. They might have renal failure, be chain smoking and living alone.

Partners runs claims data through risk predictive modeling software to develop a list of candidates for the program. But it also asks care managers and physicians to review the list and eliminate any false positives. Some people  might seem acutely ill, but the physician will say, “No, that guy is back to playing golf,” Weil explained.

Partners also has found that allowing providers to opt in patients who don’t get captured by algorithms or who claims data may not have caught up with generates good will with providers and increases engagement.

The remaining candidates are added to a final list of patients in the high-risk program. Providers rank them as high, medium and low priority. “Some are very high risk,” Weil said.  “Others are stable. They are in the dugout.  The group in the middle is warming up. They are going to be at bat soon. They make up one of our largest areas of opportunity. That group is often the most missed.”

Partners expanded the program with a Medicare ACO in 2012 after a CMS demonstration project ended and last year it expanded the program into the Medicaid space. The decision to scale up the program was based on several key outcomes: For one, the hospitalization rate per 1,000 patients was 20 percent lower than in a comparison group, with 12.1 percent in gross savings to Medicare.

Weil demonstrated how within Partners’ EHR system, the patients in this program are flagged with a little iCMP button that specialists or providers in the emergency department can click on to get more information or contact the care managers.

In patient surveys, when asked if they were aware of anyone besides their doctor focusing on their care,  75 percent answered yes and many can name the individual. “Of course, that means that 25 percent don’t know that,” Weil said, “so we still have work to do.”

Weil said among the lessons learned is that you have to make sure you engage all the players where they are and in ways that support them to be effective. “The more transparent and inclusive you are, the more likely you are to be successful,” he said. “It takes longer, but it works better in the long run. Top down is not going to work.”

Partners allows local teams the freedom to innovate. “Then we ask them to tell us how they did it. With innovations that work, we will try to adopt them system-wide. Allowing for the spread of innovation is valuable.”

In closing, Weil reminded other health system executives that the results from these efforts are not immediate. “You are not going to see a significant change for 18 months to two years,” he said.