TUCSON, Ariz. -- University Physicians Health Plans, in conjunction with UA Healthcare (UAH) leadership, is providing $560,000 to a team of UA health professionals to organize and test a new system of care for high-risk, high-cost patients with complex chronic illnesses.
The project, UA Healthcare Chronic Care Model Pilot, will enroll more than 300 patients in FY 2012 who are eligible for coverage through Medicare, the federal health program for seniors, and Medicaid, the federal health program for the poor. These patients, known as “dual-eligibles,” have chronic, disabling conditions and very complex health-care needs. They are frequent users of hospital emergency and in-patient care.
To determine just how frequent their use of emergency and in-patient care is, the UA group tallied services provided to 307 Medicare “special-needs” patients at University Physicians Healthcare. After nearly a year, one-third of the individuals in this group accounted for 90 percent of the program’s costs of providing care. In 2010, this one-third required 140 emergency room visits and 151 hospitalizations, many of which could have been prevented, says project leader Bruce Coull, MD, vice dean for clinical affairs at the University of Arizona College of Medicine.
“The ‘patient-centered’ approach that is the foundation of the new chronic care pilot project is designed to decrease the need for ER visits and hospitalizations. We are thrilled to have been funded to go forward and do this important work,” Dr. Coull says.
The chronic care pilot project is a collaboration of health-care professionals and administrators from the Arizona Health Sciences Center and the greater community, including Mindy Fain, MD, chief, geriatrics, general internal medicine and palliative medicine; Tammie Bassford, MD, head, UA Department of Family and Community Medicine (FCM); Jane Mohler, RN, MPH, PhD, associate director, Arizona Center on Aging; Sally Reel, PhD, RN, associate dean, UA College of Nursing; Tom Ball, MD, chief medical officer, University Physicians Health Plans; Donna Cochran, CPA, assistant dean, finance and administration, UA College of Nursing; Beth C. Stoneking, PhD, MSW, CPRP, director, RISE unit (Recovery thru Integration, Support & Empowerment , FCM; John Murphy, PharmD, UA College of Pharmacy; and many other colleagues across various departments and colleges. Natalie Landman, PhD, project manager for the new, Phoenix-based Healthcare Transformation Institute, provided expert business consultation to the working group.
Patients enrolled in the pilot project suffer from such chronic conditions as heart disease, diabetes and psychiatric illnesses. This project will utilize patient care practices that have been shown through research to be the most effective, both medically and from a behavioral health standpoint.
Hallmarks of the patient-centered approach to caring for these patients include providing team-based primary care, in some cases, to patients in their own homes; “telehealth” monitoring of patients’ heart rates, blood pressure and other health measures; and coordinating the care patients receive from multiple health professionals. Primary care providers, nurses, clinical pharmacists, behavioral health experts and health mentors will work together to improve the quality of care and reduce overall costs.
The development of this comprehensive and innovative approach to chronic care supports several UA Healthcare key strategic initiatives, including the development of new ways of providing care that are good for patients and that reduce health-care costs. It also will involve collaboration between UA health professionals and community organizations, including Pima Council on Aging and the Community Partnership of Southern Arizona, the region’s behavioral health funding organization.