Coordinating Care for High-Needs High-Cost Patients: What Works, What Doesn't?

Understanding the complexities of health care is just one of the many challenges facing health care professionals, policy makers, and the general public who often struggle to keep pace with the rise in their health care costs. For high-needs, high-cost patients, the challenge is even more daunting. Quite often these patients enter the health system through emergency room doors, seeking treatment for symptoms of chronic diseases and conditions including obesity, diabetes, and cardiovascular disease.

Many of these patients also face social and economic challenges such as access to affordable housing, social services, and treatment for mental illness, drug use, or alcoholism. The plight of these unique patients and the essential care coordination needed to address their health concerns were the central themes of a NYAM lecture, “Coordinating Care for High-Needs High-Cost Patients: What Works, What Doesn’t?” that took place on Thursday, May 2, 2013.

The lecture, one of several in a series sponsored by the NYAM Section on Health Care Delivery, featured detailed presentations on care coordination from Henry Chung, MD, Chief Medical Officer of the Montefiore Care Management Company and Medical Director for the Montefiore Accountable Care Organization, Irene Kauffman, Senior Assistant Vice President for Community Provider Services at NYC Health and Hospitals Corporation, and Margaret Leonard, Senior Vice President for Clinical Services at Hudson Health Plan. The event was moderated by Susanna Ginsburg, President of SG Associates Consulting. Ms. Ginsburg was instrumental in the evaluation of the implementation of the New York State’s Medicaid Chronic Illness Demonstration, a precursor to the current health homes efforts.

While each presentation was distinct, a common theme of coordination emerged—one involving not only physicians and nurses, but also social workers, housing specialists, and ancillary health care providers such as pharmacists and home health care providers. The goal of these efforts is to treat both the immediate health concern and the ongoing challenges facing high-risk, high-cost patients.
Coordination is the key, Ms. Ginsburg said: “Each provider needs to understand and acknowledge the expertise of their colleagues—and they must be able to understand the role each plays” Ms. Ginsburg said this was critical when creating a care plan for this patient population).

Dr. Chung described Montefiore Hospital’s structure to treat high-risk, high-cost patients, noting that great emphasis is placed on coordination of treatment of individuals in a coordinated structure, even in a large health care system such as Montefiore. The hospital currently provides care coordination for more than 200,000 residents in the Bronx and Lower Westchester. “Our goal is to lower emergency room utilization, improving the quality of care, lowering costs, and improving patient satisfaction,” Dr. Chung said.

Ms. Kauffman spoke at length about the NYC Health and Hospitals Corporation’s approach to care coordination, which focuses on a consistent care provider that combines chronic disease management with acute care and is integrated with behavioral health She said that HHC’s Care Plan Management System utilizes telephone-based health care, keeping patients in touch with their care coordination team at all times and the use of patient data to act on health issues before they occur.

“We encourage effective patient engagement and teaching patients to self-manage their health care;  no one strategy works for all patients,” Ms. Kaufman said.
Ms. Leonard detailed Hudson Health Plan’s award-winning Westchester Cares Action program (WCAP), which seeks to provide care coordination to high-risk populations such as the homeless. Ms. Leonard noted that patients are often treated for the obvious health problems but little is done to address their social needs.

“The social needs of vulnerable populations far exceed their health issues,” Ms. Leonard said at a recent award ceremony honoring WCAP’s work and success. "You can’t begin to deal with the medical issues until you’ve resolved the social issues. The first concern of a homeless person with diabetes is finding a place to live, not going for an eye examination.”

Despite the challenges in identifying and proving services to this population, Ms. Leonard cited great success in a short period of time, adding that “inpatient stays were reduced by 47 percent and visits to the emergency room were reduced by 15 percent.”

On June 3, 2013 at 6 p.m. NYAM will present “Managing Long Term Care” featuring Bruce Vladeck, PhD, Senior Advisor to Nexera, Mary Ann Christopher, President and CEO for Visiting Nurse Service of New York (VNSNY), Mark Kator, President and CEO of Isabella Geriatric Center, and Michael Fassler, President and CEO of CenterLight Health System (formerly Beth Abraham Family of Health Services).

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Posted on May 3, 2013

Contact:
Andrew J. Martin
Director of Communications
The New York Academy of Medicine
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New York, New York 10029
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amartin@nyam.org

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