Atul Gawande leads a discussion on Chronic Care Management.
Care Delivery/Chronic Disease Innovation Case Study
Moderator: Atul Gawande, MD, MPH
Surgeon, Writer, Public Health Researcher
Kenneth Coburn, MD, MPH
Chief Executive Officer and Medical Director, Health Quality Partners (HQP)
Chairman and Chief Executive Officer, WellPoint/CareMore
Vice President, Healthways Fitness Division, Healthways
Mary Naylor, PhD, RN
Professor in Gerontology, University of Pennsylvania School of Nursing
DJ: Complex model. Targeted messaging based on demographics.
Mail campaigns (majority of activity), phone calls. some clients they work with physicians. (Healthways client is the health plan or employer)
Fitness centers are trained to deal with seniors.
MN: Nurse “hold the family and patient’s hand through the transition from hospital to home. This starts before release. Patients in hospital go from 24×7 care to 24×7 nothing upon release.
AH: The component pieces of care are nothing new. What is new – for Health Plans to be accountable. CareMore focuses on the 10-20% of patients that exceeds the PCP’s ability to care for them.
So…. CareMore is an outsource model.
50% of chronic condition seniors admitted to hospital are either dead or readmitted within 12 months.
MN: Focus on medicare and dual eligibles, multiple chronic conditions, multiple acute service use. Work in hospital and with PCP’s. Pick people up at a point of risk and support them to a point where they are no longer at risk.
DJ: beenfits seen in Year 1, benefits pay for all participants in Year 2.
KC: High risk groups has ROI in first year. Wider beneftis in 4.5 yrs. Once people ar ein the program they stay in and continue to benefit.
MN: TCM has a continued investment needed in systems and training. Hospitalized patients show an ROI within months.
AH: CareMore Model is a platform and patients are divided in to many sub-groups. Differing payback returns. CareMore looks for broken systems that enable 20-50% reduction in cost in a 6 month time frame.
Innovative models don’t fit the regulations. Regulations are designed for the healthier 75% and not the sickest 25%.
MN: Our biggest barrier is us
KC: No part of health system can stand apart. We need collaborative models.
DJ: Short term risk is short term thinking about costs