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When patients suffer acute care episodes that land them in one of the 12 clinics Hidalgo Medical Services operates in the remote, mountainous deserts of southwest New Mexico, diagnoses for hypertension or diabetes are not uncommon — nearly half of the 34,000 residents of the sprawling region where the nonprofit health care and community development organization operates are overweight or obese.

All patients with diagnoses for hypertension and diabetes, or who exhibit signs of developing those conditions, are automatically enrolled in a family support program that includes a long-term care plan and a referral to a community health worker. Over the course of their care, the community health worker to whom they're assigned will drive hundreds of miles to visit them in person and check on their health and compliance, instead of waiting until they end up back at one of the clinics.

"Sometimes, the patients don't wind up in a clinical setting," says Charles Alfero, M.D., who founded Hidalgo Medical Services two decades ago and now runs its Center for Health Innovation.

Improving the treatment of chronic disease is a critical front in national efforts to improve overall health and reduce health care utilization. According to the Centers for Disease Control and Prevention, 75 percent of all health care costs are linked to chronic conditions. The human toll is striking: the CDC reports that heart disease, cancer and stroke together account for half of all deaths in the United States each year. The Agency for Healthcare Research and Quality estimates that 23.6 million U.S. adults, or 7.8 percent of the entire population, have diabetes.

In 2010, heart failure afflicted 5.8 million Americans — including 670,000 new diagnoses — and cost a staggering $39.2 billion in health care services, medications and lost productivity, AHRQ reports.

In response, a growing number of hospitals and communities have begun developing detailed care plans for patients with the warning signs of chronic disease. The programs are typified by regular primary care, behavioral health services that target the linkages between depression and other chronic conditions, and routine phone calls or visits from dedicated disease managers or, as is the case at Hidalgo Medical Services, a community health worker.

These efforts rely on a range of competencies, including strong internal referral systems to track patients and coordination among providers, local governments and social service agencies to reach patients in their communities or homes. And increasingly, providers are looking to start those relationships well before patients end up in the hospital.

"We're trying to create a model of community and family support services for populations along the spectrum, from prevention models and early intervention to care coordination at the highest end of the cost curve," Alfero says. Ideally, he adds, "a person with a first-time diagnosis is in the system before they get sick."

Often, the early adopters of these strategies have relatively high proportions of uninsured or low-income patients, says Carol Beasley, the director of strategic projects for the Institute for Healthcare Improvement.

"If you look at where the energy's likely to come from, for hospitals, the interest in this [is] if they're providing a lot of charity care," Beasley says. "It's frustrating to be caring [for this population] themselves."

Yet the delivery system is entering an era when the Centers for Medicare & Medicaid Services and private payers expect all providers to demonstrate improvements in population and community health, and penalties for readmitting patients are mounting. As such, a broader range of organizations is taking notice as partnerships between providers and payers demonstrate the financial value of better follow-up care for their most regular patients.

Jason Dinger, CEO of MissionPoint Health Partners in Tennessee, an accountable care organization aligned with Saint Thomas Health, says successfully treating high-frequency patients with chronic conditions will be key to the ACO's success. MissionPoint was selected to participate in the CMS shared savings program earlier this year.

"You have a very small number of patients generating the good portion of the cost. We give them a real big bear hug," Dinger says. "We visit them in the hospital. We visit them in their home. We often join them at their physician office visits, really making sure they're getting a great experience in what is typically a really challenging time of their lives. We work with ... the folks with chronic diseases and their families who are struggling to maintain and respond to those needs."

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Working Across the Community

Treating high-frequency patients, providers say, often means bringing together not just health care institutions, but also other community resources to reach patients in their everyday environments.

In Cincinnati, a coalition of local groups, including Cincinnati Children's Hospital, has coordinated a number of projects targeting high-cost diseases that often are associated with socioeconomic factors — including asthma, preterm birth and gun violence. For instance, Beasley notes, the hospital has worked with the United Way locally to create a "web of services" for expectant mothers to reduce preterm births. "All of these reach outside the edges of the delivery system to get the job done," she says.

Another example: The North Colorado Health Alliance links systems like Banner Health, a number of behavioral health providers, the United Way of Weld County and several county public health agencies to share information on patients in the hope of raising overall community health one referral at a time. The network of relationships gives the group a chance to reach populations that otherwise might fall off the radar screen — from migrant farmworkers to inmates in local correctional facilities.

"It's a partnership alliance of both providers of services and other community entities along the Triple Aim model," NCHA President Mark Wallace says, referring to the Institute of Medicine's Triple Aim of improving the experience of health care, improving population health and controlling per capita costs.

A 'Concierge' Model

At Mount Sinai Hospital in Chicago, all new heart failure patients are entered into the Project Red readmissions reduction program. A multidisciplinary team monitors everything from sodium levels to medication adherence — which sometimes means figuring out if the pharmacist has access to the prescriptions patients need.

Behind the scenes, the team stands poised to monitor patients' medication adherence, review their diets and pass along suggestions for grocery shopping to key family members. It also takes a bit of creativity.

"None of these patients belongs to a gym," says Jennifer Weiss, Mount Sinai's director of rehabilitation services. And suggesting that patients go for a walk or exercise in a nearby park can be unrealistic because of safety concerns in the neighborhoods in which they live. Instead, Weiss advises patients to "park your car as far as you can from the entrance to Target."

In the first 11 months of the program, the hospital saw the readmission rate for the enrolled patients drop by 55 percent. That's a key indicator; the average Medicare payment nationally for an episode of care with no hospital admissions is $11,162; the average payment jumps to $28,377 for one admission and $46,394 for two admissions.

High-frequency patients also often have checkered histories in their interactions with providers, notes R. Corey Waller, M.D., who runs the Center for Integrative Medicine for Spectrum Health Medical Group, Grand Rapids, Mich., which focuses primarily on high-cost patients who often suffer from one or more chronic diseases. In fact, he says, "a lot of these patients have been fired by their primary physicians."

Waller's program won't do that — instead, new enrollees receive several months of what he calls "concierge care," with the center taking complete responsibility for their health care during that time. That gives the center unique insight into patient lives, Waller says, by melding high-intensity medical interventions with case management tactics more typical of a social service agency.

"If a patient calls and says 'I'm in trouble,' we may know the electricity is out again," Waller says.

Mental Health Care Is Key

Many providers also offer a complement of mental health services to support primary care interventions, inspired in part by groups like the IHI, whose Triple Aim initiative targets patients who suffer both from chronic conditions and associated comorbidities such as depression or substance abuse.

The IHI's Beasley calls for the "integration of realms of … medical care and behavioral health care."

"Unaddressed needs in that domain can get in the way of other medical conditions," Beasley says.

A 2012 AHRQ study, "Practice-Based Interventions Addressing Concomitant Depression and Chronic Medical Conditions in the Primary Care Setting," analyzed 11 chronic disease studies, finding that patients receiving collaborative care interventions with mental health components had greater improvement in depressive symptoms than their counterparts, reported higher quality of life scores and saw a moderate improvement in mortality rates.

"We found that recipients of collaborative care had significantly greater improvement in depression outcomes as compared with patients receiving usual care for people with arthritis, cancer, diabetes, heart disease and HIV," the report found.

At Hidalgo Medical Services, there are mental health workers in every primary care facility ready to take referrals from physicians. The North Colorado Health Alliance takes a similar approach, embedding some of its primary care clinics within mental health facilities.

"It's our belief that there should be no wrong door in establishing a medical home," the NCHA's Walker says.

From Passive to Positive

By emphasizing wellness across a broad range of primary care and behavioral health interventions, providers ultimately hope to change chronically ill patients' perspectives and behaviors — and ultimately their overall health. It's a strategy that relies heavily on the creation of a detailed care plan with specific, day–to–day instructions for patients and their clinicians.

"We have a menu of things that support patient decisions around how they're going to take care of themselves," Alfero says. "It's all those things that don't happen all the time in a brief exam visit."

At the Southcentral Foundation in Alaska, new patients and their physicians develop a wellness plan that shows up in the system's records any time they enter an emergency department or clinic, says Douglas Eby, M.D., the system's vice president of medical services. "Initially people say, 'Why are you putting a label on me?' Are you telling me I'm lazy or stupid?' That's where trust becomes so important."

Over time, the system has used the care plan and other key interventions to achieve a 50 percent reduction in ED use. In the best outcomes, Eby says, the hospital is able to transform not just a patient's behavior and health, but also his or her overall outlook on life.

"If someone's highly dependent and highly passive, at the beginning you're directive," Eby says. "As you gain trust and you partner with them, what you're gradually doing over time is getting them to be more positive and optimistic."

Haydn Bush is senior online editor for Hospitals & Health Networks magazine.

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