Bay Area News Group: High-cost patients across the Bay Area get closer care to keep them out of hospitals

Sandy Kleffman

Hospitals have become too familiar to Mary Janelle Granger.

She used to rush to the emergency department at least twice a month when troubled breathing panicked her.

"Everybody in the emergency room knows me by name," said the 58-year-old Concord resident, who has a chronic lung disease. 

Now, a new John Muir Health pilot program is helping to keep her out of the hospital.

Health care systems around the Bay Area and across the nation are experimenting with a new style of care that offers more personalized attention for patients whose frequent needs are driving up the price Americans pay for health care.

The goal is to lower the cost of treating the 1 percent of the population whose chronic problems account for more than 20 percent of the nation's health care spending.

Known as "patient-centered medical homes," the programs generally are based in a clinic or office where doctors team with nurses and others to coordinate patient care. A team member regularly checks in with patients, makes sure they get needed treatments, and educates them about managing their health issues.

Stanford is setting up a similar clinic, initially for employees who have serious, chronic health problems. Sutter Health has a medical home in Davis and plans to add them in Albany and Santa Rosa later this year. 

Many patients say they love the idea, and the John Muir program based in Concord reports success since it began in 2010: 

Participants had 14 percent fewer emergency visits and 43 percent fewer hospitalizations. 

The extra services are free, yet keeping people healthier and out of the hospital saves an estimated $253 per person per month.

"We probably save twice what it costs us," said Dr. Michael Kern, senior vice president and medical director of the John Muir Physician Network. "These are very complex patients, and if they're in the hospital, they're using a lot of resources."

John Muir plans to expand the program to its outpatient facility near the Rossmoor retirement community.

Muir's Concord medical home has two nurses in doctors' offices who coordinate care for about 260 participants. The average patient is in the mid-70s, has complex health problems and takes eight to 10 medications a day, Kern said.

Debbie McBride, a 49-year-old diabetic Martinez resident, hears weekly from her care coordinator, Tracy Haack.

"She is like my mother, my doctor, my therapist, my everything," McBride said. 

Before she joined the program, McBride was hospitalized numerous times as her blood sugar levels went out of control. Last April, she was hospitalized for five days.

But now, Haack helps keep McBride out of the emergency room by encouraging her to monitor her blood sugar regularly, exercise and do what's necessary to stay healthy.

"Knowing that I'm going to have a call from her just reminds me that I'm going to have to focus on this or Tracy is going to kick my butt," McBride said.

Haack also helps McBride navigate through the health care system so she doesn't run out of insulin and other medications.

Some organizations, including John Muir, fund their own programs. Others are financed through the Center for Medicare and Medicaid Innovation, set up under the national health care reform law.

In many ways, the old-style primary care doctor who knew patients intimately and could closely monitor their care has become obsolete, said Sophia Chang, director of better chronic disease care for the California HealthCare Foundation.

Today, a typical doctor may have 2,000 to 2,500 patients, Chang said. With limited appointment time and the many medical regimens now available, it is difficult for one person to adequately oversee everyone's care.

"What we can do with and for patients has become so complex that it takes a team," Chang said.

Some of the John Muir participants regularly receive automated phone calls asking them questions about their health. Case managers contact people who appear to be having a problem. 

Because they are based in the doctor's office, the case managers can easily consult with physicians and often meet with patients before appointments to uncover problems needing attention.

Although the idea may appeal to many patients frustrated by the slow pace and impersonality of the medical bureaucracy, such care is not available to most people.

"We have to think carefully about when is a patient-centered medical home really appropriate," Chang said.

If patients are relatively healthy, the program won't save money and would be costly. John Muir picks high-risk patients who routinely enter the hospital.

Actually making a difference in patients' lives "is the most fun I've had in years," said Susan Jones, John Muir's lead case manager and a longtime nurse.

Many health experts view medical homes as a way to control soaring costs.

"Health care reform is really going to reward people for coordinating care better and getting a lot of the waste out of the system," Kern said. "But this is also about what's right for the patients."

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