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Succeed in transitional and chronic care


Across the various models for shared-service delivery in chronic care, one theme that stands out is the huge benefits that home visits can bring.

Internist Alison Guile, MD, is part of a five-provider practice in rural Plattsburgh, N.Y. The practice serves about 5,000 patients, who are mostly geriatric and tilting toward lower socioeconomic status. 

Roughly 10 years ago, Guile says, she was getting extremely stressed by her job. There were several reasons, but a big one was “all the psychosocial components to good health that we weren’t able to address” because of a lack of resources. 

It was around that time that Champlain Valley Physicians Hospital, through its Adirondacks ACO, began hosting a shared care management team to focus on transitional and chronic care management for internal medicine and family medicine practices. 

Guile, who has been with the Adirondacks system for 23 years, calls embedded care managers one of the best ideas the ACO has ever had. Her practice has an embedded RN as a care manager, and “It feels like she’s part of the practice,” Guile says, even though the care manager is paid by the ACO. 

The most valuable work the care manager does is diabetes education, and she’s working on her CDE certification, according to Guile.  Between the care manager’s home and in-patient visits, “It’s really a return to what physicians used to do before we had the siloing of care,” Guile says. 

Guile adds that shared staffing has boosted her quality of life: “It’s enormously helpful from a standpoint of physician stress to be able to unload these tasks to someone who can handle them.” 

The struggle 

While many primary care physicians struggle with issues around transitional and chronic care management simply because they don’t have staff who can handle these important tasks, shared services by way of independent practice associations (IPAs) and other healthcare organizations have given many individual practices capabilities they otherwise wouldn’t have. 

When the Adirondacks ACO’s care management team was started in 2011, says Karen Ashline, the ACO’s associate vice president, “Our primary care docs were feeling like they couldn’t get everything done.” There was little continuity of care and not enough follow-through in areas like diabetes education-and the price was paid in heavy ED use and high rates of hospital readmissions. 

The care management team now comprises 14 RN’s, two LPN’s and four community resource advocates, who together support 24 provider sites and focus on the highest-risk patients, according to Ashline. Larger practices get an assigned care manager, while smaller practices share one. 

Initially the program focused on managing diabetes, hypertension and coronary artery disease, but now it includes any chronic disease, including behavioral health, substance abuse, pediatric obesity, COPD and congestive heart failure. 

“Part of what made our arrangement work was that the hospital system was able to support hiring the team that was needed to share across small practices,” Ashline says. 

The hospital is responsible for hiring, salaries and benefits, IT, malpractice coverage and centralized office space. In their region, she says, an RN care manager is typically paid $60,000 to $85,000, depending on experience, plus benefits. “If one RN care manager can work across even two small practices, it is much more affordable.” 

More models 

Though primary care practices’ experiences with shared services are broadly similar, the types of organizations offering them vary. 

In San Jose, Calif., the county-owned Santa Clara Valley Medical Center undertook a pilot project to embed a transitional care manager in an outpatient family medicine clinic, specifically to help high-risk, high-cost (HRHC) patients. This resulted in reduced ED visits and hospital admissions in a group of 50 HRHC patients, as well as cost savings and better patient outcomes. 

Analiza Baldonado, NP, has been a transitional care manager at SCVMC for about five years, as the pilot program was disseminated throughout the county hospital system. She describes some of the typical tasks for a transitional care manager as arranging for a public health nurse to assess a patient at home, educating patients regarding their post-discharge situation or making appointments for lab tests. 

In addition, if a patient is having difficulty getting an appointment with their primary care physician, transitional care staff will see if there’s a way to squeeze the person into the physician’s schedule. 

Baldonado emphasizes the complexity of patients’ situations and the diverse skill sets needed, saying, “It’s different every time…. It takes a village to manage a high-risk, high-cost patient.” 

John Paul Pham, MD, a family physician at a clinic in the SCVMC system, values his practice’s access to complex care nurses who track hospital discharges and schedule post-discharge appointments. 

He says that typically a patient gets a follow-up call from a nurse about a week after discharge, then roughly a week later has an appointment (for 30 minutes instead of the usual 15) with his or her primary care physician.  These actions are required for payment under the TCM codes. The transitional care team also has pharmacists who conduct medication reconciliation at hospital discharge. 

The system is good at identifying weak points in patient care, such as transportation or housing issues, in which case the complex care nurses coordinate with social workers, Pham says, adding that the process increases communication between the inpatient and outpatient teams and reduces preventable readmissions. “I see less patients falling through the cracks.” 

Better communication with the patient and their family also increases buy-in for things like medication adherence, he adds. 

For independent physicians, being part of an IPA can provide the entree to shared services for transitional and chronic care management. 

The Greater Rochester (N.Y.) Independent Practice Association (GRIPA) encompasses about 350 primary care physicians in about 160 practices; overall, roughly half of its physicians are independent. GRIPA’s care management program began in 1998, and the staff now consists of five nurses, 3.5 pharmacist full-time equivalents and two social workers, says Jeanette Altavela, PharmD, BCPS, the vice president of care management and pharmacy services. 

The shared care management staff has reduced hospital readmissions and ED visits and, by having pharmacists on the team, has decreased the cost of drugs, which has also boosted medication ­adherence. 

For patients who received care management, in-patient visits decreased by 45 percent and ED visits by about 15 percent. “Savings have been in the tens of millions over the last five years,” Altavela says. “The savings we generate well exceed the cost of the program.” 

The house call, evolved 

Across these various models for shared-service delivery in chronic care, one theme that stands out is the huge benefits that home visits can bring. 

Home visits have become more frequent at GRIPA over the past five years, to a point where about 70 percent of high-risk patients get them, says Altavela. “There’s nothing like a home visit to find out what’s going on.” 

Mark H. Belfer, DO, GRIPA’s chief medical officer, recalls a patient believed to have COPD who’d been admitted to the hospital seven times in one year. Eventually, a home visit by an RN care manager determined that the walls of the patient’s home had black mold, a well-established cause of respiratory problems. The patient did not in fact have COPD, and once the mold was removed, the readmissions stopped. “That’s care management at its best,” Belfer says.  

Getting in on shared care management 

In theory, accessing shared services for transitional or chronic care management should be possible without joining an IPA or having a relationship with a health system. And there are specific CPT codes for care management, such as 99495 and 99496 for transitional care management and 99487, 99489 and 99490 for chronic care management. However, if such grassroots, practice-to-practice arrangements do exist, they appear to be well under the radar. 

 “It is difficult for small practices to pay for a robust care management services team for their practices,” Altavela says, while in contrast GRIPA provides the care management team free to physician members. 

When starting to implement shared services, Belfer advises, be aware that these might be new for many providers. “When our program started, it was important to work with our providers to ensure we were care managing the patients with the highest need.” 

Ashline’s advice is to be clear with physicians about the role of shared personnel. For example, a care manager is not “an additional nurse for my practice,” but instead has a very different role. 

Guile concedes that some physicians are less enthusiastic about shared services and care management than she is, often because of concerns over turf. “There are people who need to be convinced that this is the logical way to go,” she says. 

Once shared care management services are up and running, however, they seem to leverage providers’ time and efforts and to improve patient care, while also being cost-effective. 

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