Extra Attention to High Risk Patients Saves Money, Improves Outcomes

This article first appeared on HealthLeaders Media on September 27, 2017.

By Gregory A. Freeman

A California physician network is reducing utilization by providing special attention to patients most at risk for readmission after hospitalization.

A physician network in California is addressing one of the biggest challenges in the healthcare community, high utilization that blows up budgets and cost projections, with a program that uses home visits to improve outcomes following hospitalization.

In its second year the program has reduced 30-day hospital readmissions for participating members by 57%, via home visits conducted by non-clinicians.

That is twice the reduction of the first year, with results improving as more data is collected and the program is fine-tuned.

Regal Medical Group, one of the largest physician networks in Southern California and part of the Heritage Provider Network (HPN) managed care organization, is using its Member Advocate program to improve outcome and reduce costs.

It employs non-clinicians who use a patient-centered approach to address the complex healthcare needs of high-risk Medi-Cal and dual-eligible members who experience an acute hospitalization, says Jennifer Dunphy, vice president of population health with Regal Medical Group and Lakeside Community Healthcare.

“We found that a large proportion of our Medi-cal and dual-eligible patients have very complex needs. They have low functionality, a high proportion of behavioral health disorders, and a lack of coordination in terms of all their providers and different aspects of their health,” she says.

“We determined that we needed a more supportive infrastructure for these people, who are unlike the rest of the population that we traditionally deliver care to. When you take on these patients, it changes the way you support your patients and look at efficiency, especially from a cost perspective as well as a care perspective.”

The program addresses not just the patient’s relevant medical needs, but also the social determinants of health with a team-based approach, Dunphy explains.

The representative of the Member Advocate program begins by visiting the patient in the hospital and then in the home after discharge, connecting patients with their nurse case managers, facilitating medication reconciliation, and identifying unmet needs and circumstances that place members at higher risk for acute utilization.

The advocates use assessment forms which standardize how data is collected and communicated to the interdisciplinary care team, Dunphy says.

The home visit assessments collect information regarding health status, clinical needs, social determinants of health, and other factors which may increase the risk of future hospitalization.

These are essential clues into the mental and physical well-being of members, she says.

“The person who visits the patient in the home speaks the same language and is culturally trained to interact with that member. We also try to match the community they’re from,” Dunphy says.

“They do not have a clinical degree, but have been trained in motivational interviewing, how to coordinate care, crisis intervention, and other skills that help them serve that member’s needs.”

For selected complex members deemed to be at high risk for readmission, Member Advocates offer continued follow-up and assistance through a more intensive intervention called the Multi-Visit Program (MVP).

These members are followed through 90 days post-discharge to ensure continuous support is provided to reduce subsequent hospitalizations and emergency department utilization.

The MVP treatment includes up to four in-home visits and additional telephonic check-ins with the HPN member to ensure coordinated and appropriate receipt of medical and support services.

Member Advocates accompany these members to primary and specialty care appointments and furnish pertinent information regarding the member’s hospitalization and health status.

Additional information is collected for members in MVP during the 90 days they are followed, including contact with the Member Advocate, medical appointments, emergency department visits, hospitalizations, identified needs by type and domain and their resolution.

“The Member Advocate and the patient cultivate a relationship, building trust over time,” Dunphy says. “We don’t rely solely on phone calls or technology to monitor the patient. We find that a relationship grows and that positively affects health behavior and outcomes, which also works to bring down costs.”