Northside Medical CARE Coordination Program


 
Rock Helms, MD and CARE Program Director Dianna McCain study notes from a CARE patient's case.

First in State Focuses on Medical Conditions and Barriers to Care

Research shows that about 75 percent of healthcare costs come from just 10 percent of the population. And almost half the people in this small group suffer social deficiencies that affect their health. How many millions of dollars could be saved if this was addressed? And how much more productive and happy might these patients be?

Northside Medical Associates of Pell City decided to tackle this problem by launching its CARE Team which is designed to link patients to all the appropriate resources in order to enhance their quality of life and reduce hospital readmissions.

"We want to connect the patient to all the applicable medical team members," said Rock Helms, MD, CEO of Northside Medical. "And then we want to focus on the social determinants. You can give someone the right medication and schedule them with the best doctors, but if they don't have a car to get to the doctor, it doesn't matter." So Northside has enlisted community partners like St. Clair County that provides transportation; or churches and food banks for patients who need nutrition.

The CARE Team, which is the first of its kind in Alabama, was launched in April and now serves over 200 patients.

A nurse practitioner usually makes the initial visit to a patient's home where she records the patient's vital signs and performs any needed diagnostic work. Next, the NP accesses the patient's social situation, including issues such as isolation; transportation; lack of adequate nutrition; financial barriers to medical care; or medication compliance problems.

Based on the initial assessment, the CARE team develops a care plan and works with the patient to follow it.

The CARE team works with patients with dementia or parkinson's disease; patients with complex issues such as congestive heart failure or lung disease; chronically ill patients, like those suffering from diabetes, high blood pressure, depression, chronic obesity, renal disease and COPD.

Maybe the most important aspect of the program is the focus on the patient's social determinants. Recently, for example, Northside saw an uninsured patient who had been in the emergency room approximately 25 times in the past year, mostly for chest pains. But there was nothing wrong with his coronary arteries. "He has mental health issues," Helms said. "If a little money was invested to make sure he got the mental health services he needed, many hundreds of thousands spent in the ER would have been saved."

In some ways the program is reminiscent of healthcare in the early part of the past century when doctors knew the patient on a more personal level. When a recent patient was unable to walk after his last hospitalization, the CARE team found an agency that donated needed supplies, including a wheelchair, and helped build a ramp at his home. Then the CARE team, along with other members of the Northside practice, cleaned and painted the house themselves.

Northside Medical Associates is not able to bill for much of the CARE team's work. "Medicare is beginning to pay for it through their care coordination efforts. It's not a lot," Helms said. "But they will pay a per-member, per-month fee to provide these coordinations. And we have a small contract with an insurance company as a trial pilot program.

"We're having to take profits out of other areas and funnel it into this program. It's still in its infancy but our goal is to have a robust team of case managers, social workers, dieticians, mental health workers, and medical coaches who can do the hard legwork required.

"If you're in primary care with specialists at your disposal and you're working as a team, ideally, we should be able to coordinate services to lower the costs. And when we progress to a bundled payment system where we're rewarded for saving money because we're more efficient, then it all pays off.

"That's our strategy and it's the right thing to do."

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Tags:
MD; Dianna McCain; Northside Medical Associates; Pell City; CARE Team; St. Clair, Rock Helms

 

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