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Leffler, Calderara and Peterson Discuss Care Outside the Hospital at VAHHS Panel

October 06, 2018
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At this year’s VAHHS annual meeting, a panel of three health care providers from different organizations discussed how innovative care outside of hospitals is helping to provide better outcomes at a lower cost.
 
Dr. Steven Leffler, chief population health and quality officer at the University of Vermont Health Network, kicked off the discussion about why this type of care helps the entire system, especially through the OneCare All-payer Model.
 
“Health care costs too much,” he stated. “The old fee-for-service system pays for volume, so there’s not much of a down side to keeping someone in the hospital for one more day or doing one extra test,” he noted.
 
“In the fee-for-service system, hospitals are where you make a margin and invest back in the system. In a capitated system, hospitals are a cost center—they’re big drivers of how we spend our health care dollars—it’s a total flip,” he said. “So keeping people out of the hospital—in their homes, having VNAs visit them, going to hospice at the right time at the end of life, for example, suddenly seems to make a lot of sense.”
 
He gave the definition of population health as improving the health of a defined population of attributed lives who enter the program through their providers. To make the system work, providers keep patients healthy and improve their care experience.
 
“Almost everyone would like to get care in their homes,” he gave, as an example of a better care experience.
 
The All-payer Model is the enabler that allows us to create innovative programs that can meet the goals of population health, he explained.
 
“This model is a five-year experiment between the federal government and the state of Vermont,” he related.
 
“Can we keep health care growth to 3.5 percent among three payers—Medicare, Medicaid and commercial--across all the payers each year?” he posed. If nationally, they go up 4 or 5 percent, we’ve committed to only going up 3.5 percent,” he explained.
 
Another question posed by the experiment—can we bring 90 percent of Medicare and Medicaid beneficiaries and 70 percent of Vermonters into the program as attributed lives?
 
“Since providers bring the people in, we must all come together to keep this population healthy. Providers, hospitals, independents, nursing homes—all together.
 
“Finally, we’ll learn if, In this new payment model, are Vermonters better for it? Is there less chronic illness, less suicide, fewer substance abuse deaths? The All-payer Model will let us make some investments upstream in our communities that keep people healthier
 
Leffler described the four quadrants of participants in a population health model:
·     First there are the Level 1 people who are Healthy and well, who need good screenings, to wear their seatbelts, and make sure they’re not overweight. Investments in long-term wellness, like programs through RiseVermont, can ensure these individuals stay well.
·     Next are the Level 2 patients with early-onset stable illnesses (for example, hypertension or diabetes). To best serve them, we should make sure they take their medications and get their diets under control, and address early care gaps or gaps around compliance.
·     Level 3 are the people whose disease burden is affecting their lives and also starting to impact the system—they are a big expense and they’re utilizing the system a lot. In the early stages of a capitation system, it makes sense to put a lot of work in to make these people well—make sure when they go home from the hospital, there’s someone who can visit them in the home, make sure they have their medications right, keep them from needing further hospital care.
·     Level 4 are catastrophically ill—those with end-stage cancer or victims of catastrophic car accidents. These people consume a lot of resources, Leffler said, but in the early part of a capitation model that’s not where you can have an impact.
 
“It’s not surprising that we spend 75 percent of our health care dollars on chronic disease,” he noted, which explains why Level-3 patients are the best source in which to invest effort.
 
“My favorite part of the new system is that it allows investment upstream. I’ve had many students ask—what’s the thing you hate to see the most in your work? Well, I don’t like seeing people coming in who can’t pay for the meds, who don’t have a place to sleep, who say ‘the shelter won’t take me because I’m still drinking and I can’t stop.’
 
“In this model, my job is investing in helping them, really making a difference in the lives of Vermonters who need help,” he stressed. He mentioned some of the organizations the Network partners with to do this work: Howard Center, Agewell, Cathedral Square, the City of Burlington and the VNA are all critical in this model.
 
Next, Alison Calderara, CEO of the Community Health Centers of Burlington spoke. Calling herself a shameless advocate for primary care and for Federally Qualified Health Centers (FQHCs), she said that FQHCs across the state represent 160,000 primary care lives.
 
As an urban FQHC, her organization charges sliding-scale fees and serves as a safety net for vulnerable populations like the homeless.
 
“The hospital invests in us so that we can provide care to homeless children and adults. Our Safe Harbor Health Clinic provides the chronically homeless with a washer, dryer, shower, psychiatric care, nutritionist, primary care, mental health and substance abuse treatment and case management,” she noted.
 
She presented about two different programs through which FQHC clinicians provide care in the home.
 
Karen Sokol is a doctor who serves more than 100 patients their homes.
 
“These patients are frail and can’t get to the doctor,” Calderara said.
 
“Karen is on-call 24/7. She only hands over her beeper when she’s on vacation,” she explained.
“Because of the time she takes with each patient, listening to them and explaining in detail why they should, for example, re-commence taking their medication, on any given day, she can see only four patients--sometime six, yet she is certainly reducing the likelihood that they’ll end up in the hospital.”
 
Calderara gave an example of how a lengthy discussion with a patient allowed Sokol to figure out that the patient hadn’t taken a shower because she was afraid of doing so—indicating a psychiatric issue. When it becomes obvious that people can’t take care of themselves anymore, Sokol helps get them into assisted living.
 
“When I asked patients about Karen, they said they thought she was an angel,” Calderara recalled. “This is health care reform from the ground up. This is what it should be,” she stressed.
 
“What I don’t know,” she admitted, “is how much Karen saves the system. I can’t demonstrate value. That’s why we joined OneCare this year. I can tell you that we are providing valuable care, but I need to demonstrate that. This program will give me the data I need to be able to do that.”
 
She stated that the organization may decide to continue with this type of care, regardless of whether the data makes a business case for it.
 
“We make business decision with our heads. We make mission-driven decision with our hearts,” she explained.
 
She also outlined another program which began when she and Judy Peterson, CEO of the VNA of Chittenden and Grand Isle Counties, had a conversation about how Peterson’s staff were overwhelmed with some of their home bound patients with psychiatric disorders.
 
“We have a family medicine doctor named Adam Greenly who is also board-certified in psychiatry,” she stated. “We got a grant that allowed us to begin sending him into homes of VNA clients who have psych conditions that are a bit too complex for VNA staff to handle. The human response was that the care is great. It was great support to Judy’s staff, too,” she added.
 
Peterson spoke next about how the All-payer Model has allowed her organization to reduce repeat hospitalizations by providing care to patients after Medicare stops covering them.
“We deliver what we call an episode of care after a hospitalization,” she explained. “It usually lasts about 60 days. With the new program, we can discharge a patient from their Medicare-paid episode of care, but still have a nurse keep in touch with them. Through tele-monitoring, we can check on factors like their blood pressure, oxygen levels and weight.”
 
This program, which she calls “longitudinal care,” began as a pilot with 14 patients from December of 2016 to November of 2017.
 
“We selected patients who had had multiple hospitalizations,” she said, noting that 38 percent of those in the pilot program had five or more chronic conditions.
 
She explained that skilled home care is much less expensive than hospitalization, but also importantly, it’s patient-centered.
 
“We use community health workers for some of this work,” she noted. “For example, we care for a population of New Americans and have trained community health workers who are Nepalese to provide care to Nepalese patients in their homes,” she said.
 
She said when they compared the data during the pilot program with the eight months prior to see if there were changes in utilization, they found that, among a group of 14 individuals:
·     Their emergency department visits went from 37 to 17.
·     Observations in the hospital decreased by one.
·     Hospitalizations decreased by three.
 
When the grant for the pilot ran out, Peterson said they turned to OneCare care coordination dollars and are still delivering the extra care to patients today.
 
Leffler pointed out that coming together under the OneCare All-payer Model, we can demonstrate how innovative care models can improve care and reduce costs.
 
“We’re going to have the data to show what’s working and what’s not,” he concluded.