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Madison hospitals try to coordinate care, avoid Medicare penalties

Wisconsin State Journal (Madison, WI) - 10/19/2014

Oct. 19--When her son had a problem with his feeding tube last year, Liz Alford had to wait two months for doctors to examine him and decide how to respond.

Jackson Alford, who turns 2 next month, sees 11 specialists at UW Health for complications of a rare genetic disorder.

When the problem arose again this year, Liz Alford called UW Health's pediatric complex care program and got a prompt action plan. Jackson had been enrolled in the new program a few months earlier.

"We got a decision right away," Alford said.

The complex care program, supported by a $9.5 million federal grant through the Affordable Care Act, is one way health care organizations in Madison are boosting efforts toward a long-stated goal: coordinated care.

Care coordination is a systematic approach to improving communication and management of health care, especially for patients with chronic diseases. The aim is to improve health status, reduce errors and save money by making sure patients get the appropriate tests and procedures when needed.

"It's bringing the right care to the right person at the right place at the right time," said Dr. Jonathan Jaffery, chief population health officer at UW Health.

Hospitals and clinics have been working toward coordinated care for years, but rewards and penalties through the Affordable Care Act of 2010 have given the efforts more immediacy.

Medicare payments to hospitals are being increased or decreased based on performance in three areas: readmissions, quality of care and hospital-acquired conditions.

In addition, some hospitals and doctor groups have joined together to become accountable care organizations, or ACOs, which can also gain or lose money through Medicare.

Meriter Hospital, St. Mary's Hospital and UW Hospital have seen mixed results in the three years that payments to hospitals have been adjusted, getting bonuses in some areas and penalties in others.

In the first results of the ACO program, released in September, UW Health didn't gain or lose. St. Mary's, paired with Dean Clinic, lost $4 million after choosing to be in a special part of the program that offers more potential risk and more potential gain. Meriter doesn't have an ACO.

Dean-St. Mary's was below the national mean for Medicare patients in measures such as weight and blood pressure screening. But the organization has improved diabetes monitoring and smoking cessation counseling, among other areas, a spokeswoman said.

"Dean and St. Mary's continue to identify and implement best practices and we're confident it will lead to improved outcomes and lower overall costs," spokeswoman Kim Sveum said in a statement.

Improving care

One way Dean-St. Mary's have tried to improve care coordination is by forming a "quality improvement pod," said Kim Volberg, Dean's director of quality care and management. Nurses and medical assistants in the pod remind patients to come in for routine tests.

Meriter-UnityPoint Health is paying closer attention to patients with diabetes and high blood pressure, spokeswoman Leah Huibregtse said. Nurses, pharmacists, dietitians, psychologists and others monitor patients with the conditions and encourage them to make healthy lifestyle changes, Huibregtse said.

Sally Kamin, 59, hadn't seen a doctor for 10 years when she became thirsty and had to urinate frequently in March, six months after moving to Stoughton from Marinette to be closer to her children and grandchildren.

When Kamin's vision got blurry, she went to Stoughton Hospital Urgent Care, where she learned she has diabetes and her kidneys were starting to fail.

She started seeing Dr. Christopher Harkin at Meriter's clinic in Stoughton, initially for weekly visits and then every three months. Harkin put her on diabetes medications, connected her with an eye doctor and encouraged her to lose weight.

Now, Kamin walks three times a week and eats fewer sweets and more fruits and vegetables. She has lost 35 pounds.

"They explained what would happen if I didn't change my diet and exercise," she said.

Terry Halverson, 73, of Lone Rock, has had 11 heart attacks in 30 years and twice underwent triple bypass surgery.

He has high blood pressure and kidney disease, and takes about 20 medications and supplements.

After spending three weeks in the hospital this spring, he enrolled in UW Health's adult complex care program, which started last year.

A nurse called him every day for a month and still checks in weekly, monitoring his conditions and trying to keep him out of the hospital.

"She keeps your feet to the fire," Halverson said. "Without it, I might not be here."

The program, which has nearly 170 patients, is on track to prevent about 100 emergency room visits or hospitalizations a year, Jaffery said.

Another UW Health program, for people who have one or more chronic diseases but are otherwise healthy, focuses on managing blood pressure, diabetes and depression. Of 128 patients, the proportion of those with high blood pressure dropped from over half to about 30 percent in five months.

A third program, for people with no chronic diseases, has boosted screening rates for osteoporosis and breast, cervical and colon cancers.

Not only do the programs improve care and help avoid Medicare penalties, their reliance on nurses and medical assistants frees up doctors to spend more time on complex issues, Jaffery said.

Caring for children with complicated cases

UW Health's pediatric complex care program, which has 35 patients, started in March with the $9.5 million federal grant awarded to the Wisconsin Department of Health Services.

The program expands an effort in place for more than a decade at the Children's Hospital of Wisconsin in Milwaukee, where it has reduced inpatient costs by 50 percent, officials say.

One component of the grant, which helps pay for a doctor, a nurse practitioner, a nurse and a social worker, is to develop a payment model that would make such a program financially sustainable.

"These things are not incentivized by the U.S. health care system's traditional payment model," Jaffery said. "If anything, they're disincentivized."

Liz Alford, who lives south of Whitewater, hopes UW Health maintains the coordinated care helping Jackson.

He was born with a rare chromosome deletion that makes it difficult for him to swallow and breathe. He uses a feeding tube, wears a breathing machine at night and sometimes requires oxygen during the day.

He has low muscle tone, vision impairment, high blood pressure, fluid on his kidneys and legs of unequal sizes, his mother said.

Seven months after he was born, he had surgery to wrap the upper part of his stomach around his esophagus to reduce reflux.

A few months later, he started vomiting. Alford had to bring him to three specialists, who saw him separately over two months, before the doctors decided to redo his reflux surgery this January.

This July, after he was in the pediatric complex care program, Jackson started vomiting again. Alford's call to a program nurse led to one visit, with two specialists, and a quick decision: Doctors exchanged his stomach feeding tube for one that goes to his intestines.

"I just call and they already know who I am," she said. "You get care based on them already knowing your child."

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(c)2014 The Wisconsin State Journal (Madison, Wis.)

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