Healthy start for care plan: early signs promising

Editor’s note: This is the first in a two-part series detailing the care services provided by Accountable Care Collaborative case managers in Northern Colorado. This piece focuses on Weld County.

GREELEY – A three-year-old boy named Adrian, clad in a Captain America t-shirt, squeals with delight when his family’s Accountable Care Collaborative case manager, Fatima Groom, walks through the front door of his home.

Adrian’s mother, Luisa, happily greets Groom in Spanish while on the phone with the hospital where her son receives medical care.

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On the other side of U.S. Highway 85, a woman named Victoria is painting her nails a vivid shade of purple. She once was the most frequent user of emergency departments in Colorado, sometimes visiting daily for issues associated with her diabetes and a heart condition.

Both people are clients of North Colorado Health Alliance, which works with Evans-based Sunrise Community Health to implement care-management services as part of the Accountable Care Collaborative. Their last names are being withheld to protect their privacy.

Victoria was contacted by Joanna Martinson, North Colorado Health Alliance director of care coordination, in spring 2012 when the program first launched.

Today, Victoria rarely visits the emergency room, said her case manager, Meredith Wagner, because she now gets help organizing her medications and managing her health conditions with the assistance of a home nurse.

Adrian and Luisa also have been a part of the program since the beginning – and also have seen dramatic improvements in their quality of life.

Adrian was born with a condition that prevented full development of his trachea and esophagus, Groom said. He also is developmentally delayed, which means that he was unable to speak or walk when she began working with the family. He was born in Greeley, but immediately was moved to Children’s Hospital’s Broomfield location, where he underwent two different operations, one right after birth and another two months later.

His parents weren’t able to bring him home until he was four months old. Luisa thought she had brought the hospital home with her as well, she said, with Groom acting as translator. The hospital gave Luisa some training to take care of her son, she said, but she would often take him back to Children’s Hospital for what would be minor issues for any other child, such as a cold.

Transportation to and from providers and making appointments through a language barrier were persistent issues for Luisa and Adrian, whose father works in retail in Greeley.

But in the year and a half since the launch of the Accountable Care Collaborative, which enables Groom to visit the family and help them connect with social and transportation services, Adrian’s situation has improved dramatically.

While he still has to be fed through a tube and often has bouts of stomach sickness, Adrian began preschool last spring, and with the help of special shoes procured by Groom, can walk on his own. He also has begun seeing a speech therapist and has learned 15 words so far, Groom said.

The statewide care-management pilot program is designed to improve coordination of patient care, improve medical outcomes and reduce Medicaid costs. The idea is to pay doctors and clinics based on how well their patients do rather than the number of services they perform.

Health-care providers, under the Affordable Care Act, are being paid incentives if they can meet certain performance benchmarks in the Medicaid program, such as reducing hospital readmissions. Several providers are using those incentive payments to experiment with new care-management models, such as those used by Adrian and Victoria.

In the ACC’s Region 2, which encompasses Weld County, about $25,000 in performance incentives have been given to providers and their regional support networks so far, said Gretchen McGinnis, senior vice president of public policy and performance improvement for Region 2.

The work that Groom and other case managers do with patients is one part of the three-pronged approach used by the ACC to address not only patients’ medical needs but also their social and mental needs.

As the case manager, Groom’s job is to help patients take care of things that aren’t necessarily part of their medical care but that play into how well they are able to manage their care and how well that care works for them.

In many cases, these patients are seeing dramatic improvement, according to Martinson.

Those who benefit most from the care-management services are “intensives,” who are visited by case managers multiple times a week and require many services and different providers.

Adrian, for example, sees as many as six physicians and four therapists regularly, according to Luisa.

Four case managers, plus Martinson, work with the alliance, managing about 500 cases, but only 20 to 25 of those are intensives who require frequent attention from case managers. The rest are lighter users who require fewer visits and services, and some who are completely healthy but enrolled both in Medicaid and the ACC program.

While helping patients find services such as these may not seem directly linked to health-care costs and payment models, helping keep patients healthier and allowing them easier access to services they need reduces the use of high-cost services, which is the goal of the Accountable Care Collaborative.

The program focuses on three key metrics: reducing 30-day readmissions, emergency room visits and high-cost imaging. When patients’ basic needs are better met, these metrics improve, as evidenced by improvement in two of the three measurements in the first months of the program.

Early data on the 20-month-old program shows that hospital readmissions were reduced by 8.6 percent and high cost imaging was reduced by 3.3 percent in Region 2.

Emergency room visits, though, increased slightly, by 0.23 percent. This is likely because many Medicaid patients haven’t had a relationship with a primary-care provider, and prior to enrolling in the collaborative, visiting an emergency room was their go-to for receiving treatment, according to health care officials.

Beyond the cost savings for health-care systems and Medicaid, the program also has the potential to make a monetary difference decades down the road for some patients, Martinson said.

She pointed to Adrian, whose quality of life and potential for education has improved drastically. The little boy is still an expensive patient – just one of his medications costs $639 per month – but Martinson said long-term costs of his care will be less as Adrian grows up and reaches the age when he might start working. With improved opportunities as a child, Adrian has greater potential to get a better job as an adult, bringing in a higher income and securing better health benefits.

“With him, do we see cost savings today? Probably not,” Martinson said. “But now he’s in school, walking, et cetera. That saves for his family, school and employer on health care costs down the road.”