“The goal of coordinated care is to ensure that patients, especially the chronically ill, get the right care at the right time, while avoiding unnecessary duplication of services and preventing medical errors,” according to Centers for Medicare & Medicaid Services (CMS) website.
The coordinated efforts are part of an end-goal to provide higher quality care at a lower cost, said Dr. Amy Frankowski, chief medical officer for Mercy Health Select. Mercy Health is one of only eight Medicare Shared Savings Programs in Ohio; 220 in the United States.
Frankowski said the hospital network has 28,000 Medicare patients being served under the model, with thousands of privately-insured patients also receiving the benefits of coordinated care. More than 4,300 of those patients are living in Butler and Warren counties.
“Our group of physicians and hospitals are sharing in the responsibility for caring for them,” Frankowski said. “We’re taking on more work but it’s a different kind of work.”
As an Accountable Care Organization, about 6,000 employees within the Mercy network of physician offices, nursing homes and hospitals are increasing communication between providers, utilizing electronic health records and educating patients on the treatment and maintenance of illnesses, according to Frankowski.
“To bring the most value for the customer,” Frankowski said.
As part of the contract with CMS to be a Medicare Shared Savings Program, Frankowski said the network is being challenged to reduce by 2.5 percent the annual cost for caring for the Medicare patients.
An average Medicare patient costs about $10,000 per year, Frankowski said. Specific figures on Mercy Health Select’s benchmark have not been released, but any realized savings would be shared between CMS and Mercy Health Select.
“We have found this challenging but rewarding because it’s made us look at how we can transform our care delivery to be responsive to payment model changes,” Frankowski said. “Instead of compensated by procedure, we’re paid for keeping them out (of the hospital).”
As well, the potential for a shared savings payment comes if the organization meets quality performance standards. Each ACO is responsible for providing annual reports to the CMS based on 33 quality metrics in categories of Patient Experience of Care, Care Coordination/Patient Safety, Preventive Health, and At-Risk Population.
Individual data from ACOs have not been disclosed by the CMS.
Frankowski said Mercy scored above 90 percent for some measures in a patient satisfaction survey sent by CMS, including how the patient perceives they care they receive, preventive measures and chronic disease measures.
Over the past two years, Mercy Health has moved to an electronic health records system, as well as hired more than 30 nurse care coordinators, in order to tailor one-on-one attention to each patient.
Nurse care coordinators are assigned to help physicians “manage high-risk patients,” Frankowski said. The nurse care coordinator acts as the patient’s point-person for getting questions answered, weekly or monthly check-ins by phone or house visit, and electronic communication with the patient.
“Instead of waiting for patients to come to us, we will reach out to them,” Frankowski said.
Holly Talmage, a nurse care coordinator in the medical office of Dr. Edward Herzig in Fairfield, said she’s spent her entire nursing career with the Mercy network, and was one of the first nurse care coordinators in August 2012.
Talmage said usually after a patient is discharged, the nurse “just hopes they follow through,” on taking medications and setting appointments. Now there’s a focus on educating and building a relationship with the patient.
“This is my favorite nursing job; it’s been the missing link in health care,” Talmage said. “I get to follow these patients through long term.”
Using the electronic health records, Talmage can search for a specific population within her 146 patients — such as diabetes patients or those who recently visited the emergency department — to see who’s due for follow-up testing and read notes from the last provider.
Talmage said she checks in with patients at least monthly if not weekly, depending on their health needs. She does home visits as needed, and has even done Zumba with her patients.
“It’s the perfect nursing job in that we have time to get to know the patient and understand their barriers and create a nursing plan for individuals,” Talmage said. “Sometimes they need a push, a motivator to keep them accountable.”
Talmage said about 80 percent of her patients are Medicare beneficiaries, but all patients are served under the ACO model of coordinated care.
One of Talmage’s patients, Linda Cain, 55, of Hamilton, has been a patient of Dr. Herzig’s since her initial diagnosis of systemic lupus, an autoimmune disease, at age 19. Cain said just a year ago she was on life support and given two weeks to live after her bowel ruptured.
In April she underwent a bowel transplant.
“There’s so much information, tests and appointments to schedule,” Cain said. “Holly took care of everything … got all the old records and scheduled tests for me. I was so ill I wouldn’t have been able to.”
Cain said Talmage is there for her when she needs questions answered, and will remind her when prescriptions need refilled or tests updated. Talmage also helps coordinate care and records between Cain’s medical providers in Indianapolis where she had the transplant.
“I love it because you feel like you get the one-on-one attention,” Cain said. “If it wasn’t for someone like that (nurse care coordinator), there are so many things that would be missed.”
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