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News Roundup: July 31, 2015

How coordinated care gives patients the freedom to stay at home

Published by PBS News Hour
July 31, 2015

Editor’s note: As America’s population ages, more families will be faced with rising health care needs. As we reported in November, nearly 79 percent of adults who need long-term care live at home or in community settings, not in an institution. And in January, Medicare started paying primary care doctors a monthly fee to better coordinate care for the most vulnerable seniors — those with multiple chronic illnesses — even if they don’t have a face-to-face exam. The goal is to help patients stay healthier between doctor visits, and avoid pricey hospitals and nursing homes.

So how does coordinated caregiving work? Meet three older Americans with chronic illnesses who are benefitting from coordinated caregivers in their homes.

Betty Valdez has chronic lung disease, known as COPD, high blood pressure, kidney disease, arthritis and diabetes. Remembering when to take her 20-plus medications is difficult. Getting up from a chair is a significant obstacle, making any regular exercise unlikely. With a primary care provider and help at home, maintaining her current health would be a challenge. Without them, the 65-year-old Valdez spent a lot of time in the emergency room.

At least she did until about a year ago. After complaining of problems breathing, Valdez visited the ER at a Denver hospital. While there she agreed to enter a new program called Bridges to Care, run by Metro Community Provider Network, a community health center outside Denver. “We usually come into contact with patients who are dealing with one or more acute issues. That’s why they end up on our radar,” said Linda Skelley, a clinical care coordinator in the program. “Typically, there are also multiple underlying issues or preventative services they might not have been receiving.” The main goal of the program is to reduce ER visits for patients like Valdez, so-called high utilizers, by conducting an initial assessment and organizing resources to fill the major gaps.

In the ten months Valdez has been in the program, she has seen a primary care provider who performs regular preventative screenings and maintenance tests for existing conditions. She also sees a nurse several times a week at home for help with taking medications and to check vital signs. Skelley works with the rest of Valdez’ healthcare team to identify areas of need. When Valdez’ pulmonologist recommended a lift chair to ease problems standing up, Skelley got the chair approved and paid for through Medicaid. When Valdez’ primary care provider suggested an automatic pill dispenser to simplify her daily medication routine, Skelley again made sure it was approved and paid for.

The Bridges to Care approach has been effective. When she began the program, Valdez was not only visiting the ER, she was often admitted to the hospital. After 3 admissions in the first 3 months of the program, Valdez has been once in the last 3 months. She has seen the difference. “Since all the medical care that I got here, my mobility is stronger, I got so much better. It gives you more of a reason to want to keep going and live longer.”

Eighty-seven-year-old Eileen Daniels lives by herself in New York City. She prepares her own meals and pays strict attention to even the smallest aches and pains, scheduling doctor visits when necessary. Daniels is remarkably healthy and motivated to stay that way.

“She’s in great shape. She takes responsibility for her medication, for her care,” says Michele Walcott, who has coordinated Daniels’ care for four years, helping her manage her hypertension and sporadic mobility issues. People with more serious chronic conditions have significantly more complex daily routines and a much greater need for outside help. For a comparatively healthy patient like Daniels, that means helping to organize (and reminding her to take) prescriptions, setting up a regular home health care aid and referring specialists according to need.

As she ages and the severity and number of health issues increases, Daniels will likely depend more on Walcott to keep her healthy at home.

If Burt Kramer wants to keep living at home, he knows he needs help. “When you’re elderly, you have to have people to help you.” Even a relatively healthy 75 year old may have problems with grocery shopping or household tasks. Kramer has to manage two serious chronic conditions: congenital heart disease and diabetes. He takes 15 different medications a day — some more than once.

Christine Spates, a care coordinator at Visiting Nurse Service of New York (VNSNY), checks in with Mr. Kramer regularly to make sure he remembers to take his medications, eats right and reports any indications of heart problems. Kramer also has a home health aide who helps with personal care (bathing and fixing meals). “He needs another set of eyes, another set of ears to make sure he is adhering to all the instructions as related to his illnesses, so that he can remain healthy at home,” Spates says.

So far it’s worked. Kramer hasn’t been hospitalized in more than a year while under VNSNY’s care.

House Bill Aims to Expand Home, Community Care Options

Published by Home Health Care News
Tim Mullaney
July 31, 2015

A bipartisan group of federal lawmakers is seeking to increase the number of people who can remain in their homes thanks to the Medicare Program of All-Inclusive Care for the Elderly (PACE), introducing a bill in the U.S. House of Representatives to expand that program.

The PACE program is designed to enable seniors who need a nursing home level of care to instead remain at home or in a community-based setting, by providing more flexibility than traditional fee-for-service Medicare and Medicaid rules allow. Under PACE, rather than entering an institution, a beneficiary can receive coordinated care through an interdisciplinary team of providers. There currently are 114 PACE programs in 32 states.

The PACE Innovation Act of 2015—introduced Tuesday in the House—would allow certain individuals who are younger than 55 to participate in the program, as well as other groups who are deemed likely to benefit from taking part.

“The PACE program continues to be a comprehensive, provider-based health plan with a proven track record of high quality care for seniors while enabling them to live independently at home,” said co-sponsor Rep. Chris Smith (R-N.J.). “PACE significantly boosts the quality of life for the seniors it currently serves and my legislation would broaden eligibility so more individuals can get the help they need—at a time it could be even more beneficial.”

Other bill sponsors include Reps. Earl Blumenauer (D-Ore.), Kevin Brady (R-Texas) and Jim McDermott (D-Wash.).

“We appreciate leaders in Congress supporting our efforts to expand the number of individuals who can benefit from the PACE model of care,” said Shawn Bloom, president and CEO of the National PACE Association (NPA), in a statement issued Wednesday. “NPA and PACE organizations have been working for years to provide opportunities for innovation of the PACE model. PACE providers recognize that the model can serve as an effective platform for the delivery of long-term services and supports for vulnerable individuals living in many different types of circumstances.”

A companion Senate bill was unanimously reported out of the Finance Committee earlier this summer.

Aging in America: Treating The Nation’s Sickest, Oldest and Costliest Patients At Home Could Save Billions In U.S. Healthcare Costs

Published by International Business Times
By Amy Nordrum
July 31, 2015

NEW HYDE PARK, New York -- Helen Panajoti welcomed Dr. Joseph Milano into her living room where her 89-year-old husband, Peter, waited in a wheelchair. Milano was there to check up on Peter’s progress after a nasty fall that Helen says was "his fault.”

But recovering from the fall was only the first of his problems -- Peter also suffers from diabetes and chronic compression of the spinal cord, called spinal stenosis, which causes muscle weakness. Plus, only about half of his heart is functional.

Peter seemed to take little interest in the discussion between his wife and the doctor, though. Instead, he made a simple request -- some earwax had built up in his ears and he wanted Milano to get it out.

After a five-minute cleaning, Peter said he could hear much more clearly. He smiled his wide signature grin while Helen consulted with Milano about the medications she administered daily to keep all his other problems in check.

“If we didn’t get the help we’ve been getting, I think he’d be in a nursing home,” Helen says.

Though it sounds like a quaint scene from a bygone era when physicians regularly made house calls, Milano’s visit with the Panajotis last week is part of a long-running program at the North Shore-Long Island Jewish Medical Center. The program is a model for a much broader, national initiative that would send physicians on home visits to elderly patients based on the idea that doing so boosts patients’ health, improves quality of life and saves taxpayers money.

As administrators of the nation’s largest health insurance program, Medicare officials are particularly interested in the concept. Medicare covers 55 million people who are at least 65 years old, and the number of Americans eligible for the program is expected to grow to 72.1 million by 2030. Three years ago, Medicare launched a pilot program to test whether doctors and nurses who spent an hour in a patient’s home asking basic questions about medications, loneliness and diet and exercise might provide better and cheaper care than hospitals or nursing homes.

Following a legislative directive in the Affordable Care Act, Medicare launched a program called Independence at Home that enlisted 17 hospitals to send physicians, nurses and social workers to visit elderly patients such as Peter, who was part of that demonstration. Upon arrival, the healthcare team performs simple tasks such as adjusting patients’ medications and recording their blood pressure to head off any medical emergencies from occurring later.

In the program's first year, healthcare professionals who treated 8,400 patients in their homes created $25 million in savings for Medicare – or $3,070 per patient. The American Academy of Home Care Medicine, which advocated for the demonstration, estimates that 1.5 million Americans would be eligible for the program if it were rolled out nationwide, for a cost savings of $4.5 billion a year or $45 billion over 10 years.

The program addresses what some critics have said is a missing component of Obamacare. That is, an effort to rein in costs. The rate of Medicare spending per capita is expected to grow from about 1 percent between 2010 and 2014 to about 4.1 percent through 2024. Medicare spending accounts for 14 percent of the federal budget and one-fourth of the program’s total expenditures go toward hospital services.

While the value of home-based care seems evident to many patients and their families, health policy experts say a large-scale demonstration is essential to test the assumption that providing these services will keep people out of hospitals, and actually save money.

There’s good reason to suspect it will. AARP compiled 38 studies between 2005 and 2012 that found states that had expanded home services saw slower growth in healthcare-related expenses. In Arkansas, a program that connected 919 seniors at risk of entering a nursing home to services that helped them stay in their own homes saved $2.6 million, which cut government spending by 24 percent for those participants. A Maryland evaluation showed that the cost for patients who transitioned to community care after being in a facility dropped from $9,114 to $5,957 per month, and those patients reported a higher quality of life. However, none of those studies demonstrated results on the scale that Medicare would require.

The pilot program focused on helping Medicare cut back on a particularly costly trend: About 30 percent of payments are spent on treating just 5 percent of enrollees. For that reason, patients who enrolled had to have three or more chronic illnesses and have been hospitalized at least once in the past year.

Patients certainly seem to prefer this approach. At the nearby home of 92-year-old Josephine Milmoe, Milano detects slight changes in her heart rate and rhythm. He orders an electrocardiogram to be conducted at her home the following week.

Milano asks what she thinks about taking another medication for her heart.

“Well, whatever you think -- as long as I can stay in my home and don’t have to travel anywhere,” she says.

The facilities in Medicare's pilot program also lowered rates of hospitalization and showed a decrease in patients’ reliance on emergency services during the demonstration, but Medicare did not reveal by how much these rates were reduced in the first year.

Reducing End-of-Life Costs

By visiting patients in their homes, Milano is also poised to help both patients and their family members understand options for care as they reach the end of life, which is some of the costliest care a person ever receives. Currently, about 28 percent of the money Medicare spends is paid out in the final six months of patients’ lives.

Milano estimates that he has had 1,500 end-of-life discussions with patients and family members over his years of practice. During nearly every visit, he reviews advanced directives with patients to dictate their preferences for resuscitation, life support or invasive procedures.

Eva Wagan has been caring for her 91-year-old mother, Lucita, for the past 15 years. Lucita is paralyzed at the waist and has end-stage kidney failure so must be transported to a dialysis center three times a week for treatment. The strain of those transports has caused her to suffer two broken hips, which have never healed.

At her bedside, Milano asks Lucita to make a muscle with her forearm. She does. He asks, "How do you feel right now?"

"I feel okay," she responds, with a few deep breaths and a faint sigh.

Back in the living room, Wagan sits down across from Milano and asks a simple question: Will my mother be alive in a year?

Milano pauses for a moment before he speaks, gently and frankly.

"If you were to ask, 'Would I be surprised if my patient were to die within a year?' I would not be surprised," he says. "If you were to ask would I be surprised if my patient were to die within six months? I would probably also not be surprised."

As he leaves, Wagan says she's grateful for the service and comfort that Milano provides in her home.

"When he talks to me, I feel like he's my brother," she says. "He treats Mom like his own mom."

Scaling Up

Based on the first year's results, Congress recently approved a two-year extension of the Medicare demonstration, which President Obama is expected to approve.

“We're delighted it's going to be extended,” Constance Row, executive director of the American Academy of Home Care Medicine, says. “We hope it will become a Medicare benefit because there are so many elderly who need this service who aren't getting it.”

Secretary of Health and Human Services Sylvia Burwell announced in March that Medicare hopes to transition 85 percent of traditional fee-for-service payments to a model that considers quality of patient care by 2016. If the results of home-based care can be demonstrated more widely, the system will be better poised to favor such care over hospitals.

Gail Wilensky, former director of the Centers for Medicare and Medicaid Services, says the demonstration is “promising but quite limited in its numbers and scope.” She says it’s important to wait for year two and three results, and the program must be expanded to more communities and patients in order to make an informed determination as to whether it can be successfully applied across the country.

Kavita Patel also has concerns. The health economist at Brookings Institution says it’s difficult to say that the program would save money nationwide because several locations in the demonstration had high start-up costs in the first year. The majority of facilities did not qualify for reimbursement in the first year because they failed to show the necessary savings.

“There's an assumption that doing this will save Medicare money in the long run. It's not clear if that's the case,” she says.

It’s difficult to quantify much of the care that Milano provides, even in a nationwide demonstration. Much of the service he offers may not save patients a trip to the hospital, but it still makes a difference in their lives.

Raffaele Cursio turned 106 this month and still lives at home with a live-in aide, Nora. He seemed distressed upon seeing Milano in his living room. Nora interjected and told Milano that lately the milk Cursio drinks at breakfast has started to leak out through his nose.

Milano asked him to sip a glass of water and watched his technique. He observed that if Cursio bent forward instead of tipping his head back, it may open up his esophagus and make it easier to drink. He also put in a request for a specialist to visit Cursio and conduct a swallowing evaluation.

“I feel a lift," Cursio said as Milano waved goodbye.