Central Oregon Sees Early Successes in Coordinated Care Model

As it prepares to become a coordinated care organization in 2012, Central Oregon’s pioneering coordinated care model proves there are cost savings in coordinating care
The Lund Report

November 10, 2011—A wide variety of organizations representing Central Oregon’s healthcare community were talking about creating a coordinated model of providing health care before the Legislature even began thinking about it.

In 2009, those organizations created the Central Oregon Health Council, a public-private partnership of 16 different organizations including the governments of Crook, Deschutes and Jefferson counties, PacificSource (the managed care organization covering Oregon Health Plan patients in the area), the region’s safety net clinics and other parts of the health system and the Oregon Health Authority.

That Council created the Health Integration Project, an ambitious pilot program to coordinate the care of Oregon Health Plan patients by having physicians, mental health providers, community health workers and a number of organizations collaborate, including St. Charles Hospital, PacificSource and the Central Oregon Independence Practice Organization.

Driven by the desire to cut escalating healthcare costs, the Council decided that the Health Integration Project would focus exclusively on people with high medical needs who are the most vulnerable, needy and expensive.

“We wanted to come up with ways that we could make a big difference very quickly,” said Robin Henderson, director of St. Charles’ behavioral health services and the interim director of the Health Integration Project. “The best way we decided we can do that is focus on high utilizers of healthcare services, the people who are most expensive in the system.”

The recent publication of the Health Integration Project’s first annual report shows startling results: among the project’s initial cohort of 144 people, there were 541 or 49 percent fewer visits to the emergency room during the first six months of 2011. That translates into roughly $750,000 in savings.

“We’ve seen dramatic decreases in ER utilization,” Henderson said. “[And] anecdotally, we have lots of examples where we’ve been able to change people's paths of care.”

Central Oregon’s efforts show that a coordinated model of care depends upon robust communication and collaboration among a patient’s different providers, even if it means breaking down some of the traditional barriers between providers.

But the work of those providers might not have been as successful if it were not for community health workers who act as a patient’s guide through a complex and multi-faceted healthcare system, and offer a source of empowerment.

Getting People Out of the Emergency Room and Into Primary Care

At the heart of the Health Integration Project is the Emergency Department Diversion Project, which connects patients -- who use the emergency room multiple times a year -- with a primary care provider.

To qualify, people must use the emergency room ten times or more in a year. In its first year, the Health Integration Project worked closely with 144 people fitting the program’s criteria. Initially, 350 patients were identified, but that was whittled down for a variety of reasons: children under 18 were excluded. some patients had died or moved and others refused to participate.

That initial group of 144 patients visited the emergency room 14 times a year on average. One person had actually visited the ER 56 times. The majority of patients, 69 percent, were Oregon Health Plan patients. Many suffered from a history of emotional, physical and/or sexual trauma, and had co-current physical and mental illnesses. “Many have untreated mental health conditions,” Henderson said.

More often than not, the patients went to the emergency room for illnesses that could have been taken care of in a primary care setting. According to the Health Integration Project’s report, people came to the emergency room suffering from headaches, abdominal pain, cycling vomiting and unspecified pain.

But the emergency room, Henderson said, isn’t designed to provide ongoing, basic medical care. It’s also far more expensive than primary care—by as much as 70 to 80 percent.

Henderson also discovered that very few of these 144 patients had access to a primary care doctor. When asked to give the name of their doctor, many responded with a doctor “they hadn’t seen in years,” according to the report. “Over half of the patients were not currently linked to a primary care provider and thus had no outpatient resources to avoid [emergency room] utilization.”

Eilene Knight-Burt, a 46-year old Bend resident, experienced the desperation of not knowing where to find appropriate healthcare. In April 2011 without warning or reason, she began suffering migraine headaches so debilitating and severe that she’d vomit and scream in agony.

Frightened and in pain, she’d call 911 and send for an ambulance whenever she’d have such an attack and would placed on a gurney until she arrived at the St. Charles Hospital’s emergency room. “I was in so much agony,” she remembers. “I was frightened.”

Emergency room physicians would give her intra-venous (IV) drugs to stop the pain. “They were fast,” she says.

But that solution was a short reprieve. The migraines didn’t stop. Between April and July 2011, Knight-Burt, who’s on the Oregon Health Plan, went to the emergency room 33 more times. And she never received any follow-up care or referral to a primary care doctor.

To solve that lack of connection for Knight-Burt and others, the program embedded two-full time community health workers who had been trained by Health Matters of Central Oregon, in St. Charles’ emergency rooms in Redmond, Bend and Prineville.

Community health workers are non-traditional health professionals who work directly with patients, as guides and advocates, to help them navigate the healthcare system.

Health engagement teams led by a primary care physician were developed to coordinate patient care including a case manager who’s a registered nurse, a psychologist or social worker, community health workers and representatives from the primary medical home.

Currently, ten clinics in Central Oregon either have such teams in place or in the development process. The team creates an “individualized plan of care” for each patient – a road map of interventions and goals tailored to their needs. It details information such as the patient’s demographics, their primary reason for a visit, a treatment plan for chronic conditions, including medications and other courses of action if the patient goes to the emergency room again.

The value of the individualized plan is enormous: it creates a clear record of the patient’s health needs, including the names of their providers and the goals to improve their care. If necessary, patients are also connected with a behavioral health consultant or a community health worker who visits them at home.

Knight-Burt, who began participating in July, said it’s saved her from a seemingly endless cycle of pain, short term fixes and ER visits.

She was also introduced to Becky Wilkinson, a community health worker with HealthMatters of Central Oregon, who proved to be a life saver. “I felt alone until I met Becky,” Knight-Burt said.

Wilkinson began working with Knight-Burt to find a neurologist who accepted Medicaid, and helped coordinate an individualized treatment plan for her migraine treatment medications.

She also visited Knight-Burt at her home numerous times to make sure the medication was working. They also talked on the phone or text messaged several times a week. “We were in contact quite a bit,” Knight-Burt said.

“Doctors don’t have time to do that,” Wilkinson said. “To have someone be able to manage your care is such a huge problem.”

Since the program started, Knight-Burt has only been back to the emergency room twice. And, because she had a treatment plan accessible through electronic medical records, the emergency department was able to give her the appropriate medication.

“When Becky stepped up, it really changed the situation,” Knight-Burt said. “I don’t feel alone. I feel healthier in that I have this medication.”

Collaborating Requires Going Outside of One’s Comfort Zone

Once the Central Oregon Health Council realized that a large majority of the patients participating in the Emergency Department Diversion Project had untreated mental illnesses, it began finding ways to make mental healthcare more accessible.

“Coordination of care between provider agencies and primary care was virtually non-existent,” the Health Integration Project’s report said.

Now five behavioral health consultants are embedded in five clinics. They work directly with a primary care provider to identify patients with mental illnesses, and develop a treatment plan working with the patient and their primary care doctor.

The embedding of mental health care in primary care clinics and the coordination between the mental health counselor and doctor is clearly paying off in Central Oregon: the Health Integration Project’s report said that follow-up mental health care has improved between 15 and 90 percent for patients with mental illness, and 593 patients have access to mental healthcare through a primary care setting.

Kim Swanson is a resident psychologist embedded at St. Charles Family Care in Redmond. Each day is completely unpredictable, she said, and the work she does is diametrically different from a traditional mental health practitioner.

“I don’t have any control over my time,” she said. You have to be extremely flexible. You have to get used to being interrupted. People are knocking on your door with questions all day.”

Now Swanson can now see between eight and 14 patients a day anywhere from 15 to 30 minutes. “The interventions are designed to be more brief.”

Many of her patients are same-day patients who are referred during a visit to their primary care doctor. Doctors, she said, will literally walk down the hallway to her office, knock on the door, and ask if she has time to see someone.

She often discovers that the patient complains of physical symptoms or illnesses, when they  have an underlying mental or emotional illness. For example, a patient’s blood pressure is affected by their drinking.

“We know that people’s emotions will often play into physical symptoms,” Swanson said, adding that many people will come see a doctor complaining that their body aches, or that they are tired, when they in fact they suffer from depression.

“You’re acknowledging that their physical health is impacting their well-being,” Henderson said.

Swanson helps patients develop stress reduction and relaxation techniques, work on sleep hygiene, build exercise into their daily routines, and other interventions and skill development that “engages people’s emotions and their mind” and impacts their physical health.

Swanson said her presence in the primary care clinic helps doctors develop a better understanding of how underlying mental health issues can impact people with chronic diseases. “Even if you’re a little depressed, how motivated are you to do the things that you know make you feel better? Swanson said. “That can influence the outcome.”

Henderson and Swanson realize that Swanson’s job is not for all mental health and primary care providers. “I think I work with a group of very unusual physicians,” who are willing to go outside of their comfort zones and work so closely with a mental health counselor, Swanson said. “We're all still learning.”

An example to the state

As the state prepares to develop coordinated care organizations (CCOs) that will provide the physical, mental and dental care for Oregon Health Plan patients, Central Oregon is considered a microcosm of the future healthcare system.

Dr. Bruce Goldberg, director of the Oregon Health Authority and a member of the Central Oregon Health Council, said there is much to learn from Central Oregon’s efforts, emphasizing the importance of collaboration.

“Most importantly, they’ve been successful in bringing together many parts of the community healthcare system to work together toward a common goal of improved health and lower costs,” Goldberg said.

And the Central Oregon Health Council is continuing to add patients to the Emergency Department Diversion Program: in January 2011, 192 patients were added, and another 195 patients last June.

Senate Bill 204, which was passed last legislative session, makes the Central Oregon Health Council a permanent body with 11 members, including one person from the Crook, Deschutes, and Jefferson county governments and the chief executive officers of “the healthcare serving the region” (in this case, St. Charles) and the managed care organization serving the area (PacificSource). Other members may include consumers, health care professionals and the business community.

The Central Oregon Health Council can also lay the framework to become a CCO, and conduct a regional health assessment, as well as a health improvement plan to improve the health of its population.

Henderson thinks the region is well positioned to become a CCO next July. “The work of the Central Oregon Health Council and the collaborative projects…has really helped everybody get together on how we are going to change healthcare in our community,” Henderson said. “I don’t know what’s going to happen around the rest of the state, but I'm optimistic for my region.”

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Comments

It appears the only outcome of this model is that the plan is paying less for ED due to increasing patient volume in the primary care office. Mr. Goldberg seems to give high praise for the model that boasts: "The best way we decided we can do that is focus on high utilizers of healthcare services, the people who are most expensive in the system.” Sure, stampeding 15 minutes quickie intervention visits may prevent ED visits, but this article lacks detail around any increased or favorable health outcomes as a result of this model.

Like the managed care of the 90's, you will see short term savings. In the long run, managing care will hopefully lead to patients who are healthier, longer. That is a worthy goal. Unfortunately, long term control of costs will require us to delay or prevent the use of expensive new treatments/drugs. At least according to the best studies on this topic (see www.kff.org/insurance/7670.cfm). For it is expensive new treatments/drugs which drive healthcare inflation, and managing care does nothing to control those costs. If managing care well, and changing the incentives for all providers, were all it took to give us long term control of healthcare costs, then we would all be working for Kaiser by now, since that has been their model for decades. So why are Kaiser premiums basically just competitive with other health plans? Because they must deliver on the same expensive new treatments and drugs as all of the others. Unless, as a society, we can bring ourselves to ration expensive new treatments/drugs, or figure out how to lower their costs down to the general rate of inflation, any new short term savings will be exactly that. Short!

Rationing "expensive new treatments/drugs" is always palatable if it's someone else who's on the receiving end. But try on the concept when it's your own parent or spouse or child who's being told "you can't have that because it costs too much." We don't subject "ourselves" to rationing: "rationing" is almost always reserved for the poor, who have no political power to spread the impact beyond their own ranks. Until the deeper problem of wealth inequality is addressed, we will not solve the health care crisis. Tim Baxter Lane County Legal Aid and Advocacy Center

Still seems that reports are all celebratory about the money but transformation is supposed to be about health outcomes rather than money outcomes. So what is next beyond the short term fixation on funds?

The collaboration between primary care providers and mental health providers seen in programs like Central Oregon’s Health Integration Project can yield tremendous benefits for patients, providers, and communities. Patients benefit if they receive primary care services and mental health services at the same clinic under the coordinated care model. Specifically, primary care providers and mental health providers can provide immediate consultation to each other regarding complex cases and complications that they encounter, which is likely to benefit the patient to a higher degree than asynchronous care. Hence, these patients are likely to have superior outcomes because their care is coordinated among health care providers. Primary care providers benefit because the availability of immediate consultation in questionable psychiatric cases. This detracts from the uncertainty some may have regarding specific mental health diagnoses and complications. Mental health providers also benefit by collaborating with primary care providers concerning medical issues that may affect psychiatric illness. The Health Integration Project showed this kind of collaboration decreased high frequency users of the emergency department and resulted in decreased health care costs, leading to long-term cost savings. This benefits communities because many emergency departments are constantly strained by acute and sub-acute community needs; thus, alleviating unnecessary visits to the emergency room will allow hospitals to direct their resources more appropriately. Oregon is able to provide more accessible and comprehensive physical and mental health services to its communities by utilizing nurse practitioners. Family Nurse Practitioners and Psychiatric Mental Health Nurse Practitioners are able to practice completely independently according to state law in Oregon; therefore, the full scope of practice of these providers must be utilized within coordinated care models to maximize their expansion in our state. These nurse practitioners can be employed within a coordinated care model alongside each other to provide comprehensive health care that benefits all stakeholders. As Doctor of Nursing Practice students studying to become Family Nurse Practitioners and a Psychiatric Mental Health Nurse Practitioner, we are proponents of the coordinated care model and the Health Integration Project in Oregon. Further, we assert that nurse practitioners should be fully incorporated into these models as they are implemented in health care systems across Oregon. Respectfully, Katherine Hammond, BSN, RN, CEN Cherry Pisigan, BSN, RN Bryan Hagen, BSN, RN Doctor of Nursing Practice students Oregon Health & Science University Portland, OR