The programs supported by the Center for Population Health touch many points of care during a patient’s medical experience — whether it’s treating an acute illness, managing a chronic problem, or end-of-life care. Here is an example of how our population health management programs work together to provide the best and highest quality of care to patients:

Mike is a 75-year-old man with severe congestive heart failure (CHF) who has frequent flare-ups and is struggling with his health. He is part of our care management program so he can be monitored more closely and receive social support services for personal issues that might be impacting his health.

CHF is a serious chronic illness, especially for elderly patients like Mike with multiple complex medical conditions. It is one of the most common causes of hospital admission and associated treatment costs are estimated at over $30.7 billion each year.[1] Among the US Medicare population, CHF was the most common cause of readmission, with 27% of patients being readmitted within 30 days (about 1 in 3). Patients with CHF have a 1 in 10 chance of dying within 30 days of discharge from the hospital, a 75% chance of dying within five years after the first admission.[2]

When Mike experiences increased chest pains, he shows up in the Emergency Department (ED). Using the electronic medical record system, providers identify that he is enrolled in the care management program and has an acute care plan in place. The care plan includes specific instructions on the most effective treatments and how to coordinate care for Mike during an ED visit. His doctor and nurse care manager are notified so they can assist the ED staff in arranging for him to get the care he needs.

By following his acute care plan, Mike’s medical team determines that he does not need to be hospitalized, which could be as much as $11,000 for a five day stay. Instead, he is safely discharged from the ED to home where he will receive ongoing urgent care services comfortably in his own home.

By following his acute care plan, Mike’s medical team determines that he does not need to be hospitalized, which could be as much as $11,000 for a five day stay. Instead, he is safely discharged from the ED to home where he will receive ongoing urgent care services comfortably in his own home. Through our enhanced home care program, a home-based nurse practitioner and a home health nurse continue to visit him daily to evaluate his recovery and to assess whether his treatment plan needs adjusting.

Mike is also given a remote monitoring device to track his daily symptoms and to share that information regularly with his care team. This monitoring device acts as a safe guard and alert against the worsening of symptoms. If Mike’s health were to steadily decline between a discharge from the hospital and a routine follow-up appointment, he would risk possible hospital readmission—and a $20,600 price tag. With remote monitoring tools and enhanced home-based services in place to better coordinate care, the chances for emergency readmission are greatly reduced and he remains comfortably at home.

Although Mike experiences some improvement, his health continues to fail. Because it has been difficult for Mike to go to his primary care physician’s (PCP) office, his PCP conducts a virtual visit using a secure video chat program (similar to Skype) so that Mike can be evaluated in the comfort of his home. During the virtual visit a revised treatment plan is prescribed by Mike’s PCP which includes medication changes and moving up a previously scheduled appointment with his cardiologist. Virtual visits are convenient for patients and may reduce costs associated with in-office visits, which are about $199 per visit.

Shortly after the virtual visit, Mike talks with his cardiologist and is told he needs a heart transplant. They discuss the procedure in detail and Mike watches a video that allows him to better understand the risks and benefits of the procedure. To learn more, Mike signs up for an on-line patient community to connect with other transplant patients and to hear about their experiences with the procedure. Patient engagement programs like these increase opportunities for education and shared decision making, which may lead to better health outcomes and lower costs.

Feeling unsure about the procedure, Mike talks again with his cardiologist, who uses a structured set of questions about serious illness to make sure that Mike is fully informed of his care options. After the discussion, Mike decides to decline the transplant and connects with our home-based palliative care services. These programs prioritize patient preference, provide psychosocial support to the patient and the family, and assure that patient needs are met as illness progresses. Making a decision like this is difficult. Instead of going through with a serious and complicated procedure, at an expense of over $84,500, Mike chose a different pathway that better suited his own needs and preferences.

By using these types of integrated services, supported by the Center for Population Health and spread throughout the Partners system, patients are able to receive coordinated and high quality care that is more aligned with their life choices and better tailored for comfort and convenience. These services offer patients new and innovative alternatives to traditional care that also reduce health care costs. In Mike’s case more than $116,000 was saved based on the use of these integrated services.

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Topics: Affordability, Technology, Patient Experience

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