Mak­ing lemon­ade

Re­vamp­ing care of home­less when fund­ing is cut

Modern Healthcare - - From The C-suite - Ti­mothy Har­lin Ti­mothy Har­lin is chief op­er­at­ing of­fi­cer of Hen­nepin County Med­i­cal Cen­ter, Min­neapo­lis.

How do you care for child­less adults caught up in the chaos of poverty who don’t qual­ify for Med­i­caid? In Min­nesota, prior to June 1, 2010, you signed them up for Gen­eral As­sis­tance Med­i­cal Care. This pro­gram cov­ered pa­tients who in many states are unin­sured.

How­ever, all that changed last sum­mer. GAMC was de­funded and the state of Min­nesota re­placed the pro­gram with a Co­or­di­nated Care De­liv­ery Sys­tem. CCDS is an an­nu­al­ized block grant of $72 mil­lion from the state to four Twin City hos­pi­tals— cap­i­ta­tion in its purest form. Seven­teen hos­pi­tals were in­vited by the state to par­tic­i­pate, 13 de­clined. Hen­nepin County Med­i­cal Cen­ter, a 471-bed aca­demic trauma cen­ter in Min­neapo­lis, was one of the four that said yes. The pro­gram funded about 30 cents on the dol­lar from the pre­vi­ous year’s re­im­burse­ment for the same pa­tients.

The pur­pose of this col­umn is not to re­hash the prob­lems associated with CCDS—of which there are many—but rather to share with you the op­por­tu­nity HCMC found in the midst of the up­heaval.

Our ini­tial es­ti­mate was that HCMC would lose $42 mil­lion an­nu­ally un­der the CCDS pro­gram, com­pared to a loss of $6 mil­lion in 2009 un­der the GAMC plan. As we stud­ied our pa­tients, we found that they seemed to fall into three cat­e­gories. Tiers 1 and 2, rep­re­sent­ing low uti­liza­tion of ser­vices and low ad­mis­sions, ac­counted for 93% of the pa­tients and 70% of the costs. Tier 3, de­fined as three or more ad­mis­sions in the past 12 months, rep­re­sented only 7% per­cent of the pa­tients but 30% of the es­ti­mated costs. If we could find bet­ter ways to take care of these very sick Tier 3 pa­tients, we could im­prove their lives, bend the cost curve and be­gin to mit­i­gate our fi­nan­cial risk.

Our strat­egy, there­fore, re­volved around the Tier 3 pop­u­la­tion, the sick­est of the sick. They suf­fer from ad­dic­tion, un­man­aged med­i­cal is­sues and se­vere and per­sis­tent men­tal health prob­lems. They were of­ten home­less. In light of (not de­spite of) these facts, we de­cided to in­vest an ad­di­tional $1.2 mil­lion based on an untested re­turn on in­vest­ment of “lose less.” We ap­plied those funds to build what we call an Am­bu­la­tory I.C.U.

Our Am­bu­la­tory I.C.U. is staffed by a ded­i­cated team of physi­cians, phar­ma­cists, reg­is­tered nurses, nurse prac­ti­tion­ers, care nav­i­ga­tors and oth­ers. Pain, men­tal health and ad­dic­tion physi­cians were made avail­able to sup­port the core clinic work. Vi­tal com­mu­nity ser­vices such as home health, hous­ing and home­less ad­vo­cates, county men­tal health and oth­ers were en­listed to help.

Once pa­tients are ad­mit­ted into the Am­bu­la­tory I.C.U., their care is ag­gres­sively man­aged. Con­tact is made weekly. Trans­porta­tion is as­sured. Provider phone num­bers are given out with in­struc­tions to call if they have ques­tions. Pa­tients who miss vis­its are tracked down. Med­i­ca­tions are cat­a­loged and man­aged. Pa­tients who show up in the emer­gency room are re­trieved back to the clinic. If the pa­tient is ad­mit­ted, clinic staff mem­bers co­or­di­nate with in­pa­tient providers to en­sure a smooth hand­off back to pri­mary care.

In short, our Am­bu­la­tory I.C.U. wraps des­per­ately needed ser­vices around these vul­ner­a­ble pa­tients and im­proves their health while keep­ing them out of the hos­pi­tal.

The re­sults have been dra­matic. In the fi­nal six months of 2010, we cut hos­pi­tal­iza­tion rates for this Tier 3 pop­u­la­tion by 42% and emer­gency room vis­its by 38%. Not sur­pris­ingly, we in­creased pri­mary-care en­coun­ters by 349%. Pre­lim­i­nary es­ti­mates show the cost of care fell 19%. We still lost a lot of money on CCDS, but we proved we could en­hance the lives of sick pa­tients at a sig­nif­i­cantly lower cost.

The gov­er­nor has an­nounced CCDS will be re­placed by an ex­pan­sion of Med­i­caid. This rep­re­sents some badly needed fi­nan­cial re­lief. How­ever, the fi­nan­cial in­cen­tives to re­duce ad­mis­sions and emer­gency room use go away in a fee-for-ser­vice world. The next big chal­lenge for our Am­bu­la­tory I.C.U. won’t be how best to care for pa­tients, but rather how to con­tinue to grow and in­no­vate as we wait for ac­count­able care or­ga­ni­za­tions and pay­ment re­form to catch up.

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