As she was walking into the East Baltimore Medical Center recently, internist Laura Sander received a phone call about one of her patients, a young woman whose diabetes was out of control. The patient had been admitted to another health system’s Emergency Department.
Within a half-hour, Sander was on her way to the ED to persuade her patient to return to the Johns Hopkins primary care clinic for her medical needs. Later, the physician visited her at home. And the following week, the patient came back to Sander’s office for an extended appointment. Between those visits, someone from the internist’s team called the patient to check on her.
Why such VIP care? The patient is one of 70 enrolled in the Priority Access Primary Care (PAPC) pilot, which Sander directs from East Baltimore Medical Center. The pilot is a collaborative effort between Johns Hopkins Community Physicians and the Priority Partners Managed Care Organization, which is jointly owned by Johns Hopkins HealthCare and the Maryland Community Health System.
The program aims to keep Medicaid patients out of the ED and the hospital by providing intensive primary care services that are integrated with behavioral health care and social services. One successful strategy is offering direct access to providers: Patients call, text or video chat with PAPC providers 24/7 for acute needs. Also, PAPC gets a notice within 15 minutes when one of the patients is admitted to any hospital or ED in the state, thanks to CRISP, Maryland’s health information exchange.
The program’s patients are the costliest among Priority Partners’ population, with complex medical and psychosocial needs and a history of ED and hospital admissions. Last year, a study by the U.S. Government Accountability Office found that 5 percent of Medicaid patients account for 50 percent of the program’s expenditures nationwide. The idea behind the Priority Access Primary Care pilot is to identify patients at the top of the cost curve to receive intensive primary care.
When the program was rolling out, Priority Partners provided Sander with a list of patients whose projected costs were higher than expected for their age, gender, conditions and so forth. From that initial list, Sander determined program eligibility criteria, which include three ED visits in the last six months and/or two admissions. Now, Priority Partners looks at its claims data to identify candidates for the program, and Sander makes the final determination of eligibility.
Working side by side with Sander is a team composed of nurse practitioner Kate Shockley; certified medical assistant Sherrell Byrd-Arthur, who serves as a health navigator to help patients negotiate the health system; licensed clinical professional counselor Laura Fukushima; and community health worker Brian Adams, who connects patients to community resources and coaches them in how to manage their diseases.
Since the PAPC pilot began a year and a half ago, ED visits among its patients have dropped by 30 percent and admissions by 41 percent. A key reason for the program’s success, Sander says, is that it provides behavioral health care. When patients come in for a primary care visit, they spend 45 minutes with Sander or Shockley, then another 45 minutes with Fukushima.
Each primary care visit incorporates motivational interviewing and education on disease management. PAPC providers also make time for home visits. New program participants receive a home visit as part of their introduction to the program while patients with chronic conditions will receive periodic visits to help with medication reconciliation. All patients discharged from the hospital receive a home visit as well.
“We work to meet patients where they are, to get to know them and then slowly build their confidence and trust to work on their larger health challenges,” Sander explains.
The program also addresses patients’ social needs. For example, the community health worker helps patients apply for housing vouchers and fill out Social Security documentation.
This kind of attention has not only helped keep patients out of the hospital but has also shown a 2-to-1 return on investment, according to Sander. “We’re happy to say that by doing exactly what we set out to do—to reconnect high-cost patients to primary care—we’ve improved their health and saved money.” The program will run through 2016.