Rob Mechanic Outlines Initiatives to Deliver Care to High-Need, High-Cost Patients

There's been an increased focus on home-based care and community health workers when delivering care to high-need, high-cost patients, explained Rob Mechanic, MBA, senior fellow at the Heller School of Social Policy and Management at Brandeis University and executive director of the Institute for Accountable Care.

Transcript

What sorts of initiatives do ACOs use to deliver care to high-need, high-cost patients?

There’s a lot of things that are going on, and I’m really excited to talk about them. There’s been a growing movement to do home-based care. For these patients, if you can go into the home, meet them in the home or community, develop a trusting relationship, you learn so much about them and what’s affecting their health that you can bring back and actually develop a plan that’s going to be effective in keeping them healthy and keeping them out of the hospital and emergency department.

There are a number of things. Some programs are doing house calls. This is like Independence at Home, but again home-based primary care. The ACOs that I know that are doing this are think this is really one of the most effective things they’re doing. In fact, there’s 1 ACO out in the Midwest that is exclusively focused on home-bound patients, so their whole model is home-based primary care, and they’ve been extremely successful. They’ve saved over $100 million over the last 3 years. That’s a really important area.

We can talk about other people going into the home. Community health workers: this is another area that I think we're seeing lots of interest in accountable care organizations. The community health workers are trying to build a relationship with people. Community health workers would generally be from their neighborhoods, they would match in terms of race and ethnicity and culture. They can talk to the patients, often times better than the medical professionals who may be not really understanding their life situations.

These community healthcare programs are trying to do 2 things: one is they’re really trying to understand and develop a relationship with the patient. The second thing they’re trying to do is match them to social services, and the most effective programs actually help people sign u for local services. They don’t just say here’s a phone number. They help them sign up. The third thing is to make a much better connection with the primary care team back home. So patients get into the office when they need to. If they can’t get into the office, they workout transportation so they do get into the office.

One of the things we’ll be talking about at this conference are extensivist models. An extensivist model, most people know it from the CareMore system out in California. The idea is you’re identifying your highest risk patients. Typically, these are patients who are in the hospital and who are going to be discharged out. What they do is they have a multidisciplinary team and they follow the patient. So, the same doctor may round on the patient in the hospital. If the patient goes to a nursing home, they will round the patient in the nursing home. They’ll see them in the clinic, and they have a whole team that includes social workers, pharmacists, home health aides, a variety of tings. So, you’re really trying to wrap care around these folks who are at high risk for landing back in the hospital or back in the nursing home, and trying to prevent that. So, we’re having a session talking about those models today.

There are post-discharge clinics. There is a new profession call sniffist, which are physicians that round with their patients in the nursing homes, and that’s growing use in ACOs. More use of remote monitoring and telemedicine. That’s proven very effective for patients in nursing homes—remote monitoring and telemedicine situations. I even talked to an ACO recently. They’re using community volunteers to go out into the community and engage the patients, identify where people are socially isolated talk to them about their problems, get them into the office.

A lot of creativity is needed to do a good job, and I think we’re beginning to see a lot of creativity in this space, both in and outside of the ACO model.