What it means to care for the health of a population
A patient wanted to express gratitude for the care he received at Fairview’s coordinated care delivery system (CCDS) clinic. So he recently presented clinic staff with a cake
|Making a difference for patients|
Here are three examples of patients who were treated through Fairview’s coordinated care delivery system clinic. Their names have been changed to protect their privacy.
John: ‘Worth something’
“John” came to the clinic with MRSA—an antibiotic-resistant infection that had been very difficult and costly to treat and control. He’d been ostracized for his condition, feeling that he didn’t belong anywhere. The clinic physician and the behavioral health consultant welcomed him and told him he was to come to the clinic whenever he had concerns. With the medical-behavioral model, staff focused not only on his medical conditions but also his depression and sense of isolation. In one of his many follow-up visits, John told staff that, at the time he first came to the clinic, he had planned to kill himself. Staff asked what made him not carry through with his plan. The patient stated it was because staff cared about him and helped him feel he was worth something.
Lyle: A man with a plan
“Lyle” had diabetes, chronic pain and chemical dependency issues. He initially came to the clinic seeking pain medications. Through a team medical-behavioral model, staff helped wean him off his pain medications. Our pharmacist worked with him to better control his diabetes. Overall, Lyle made significant strides to turn his life around—stopping his chemical use and addressing significant anger management issues. He even enrolled in school with a goal of eventually becoming a chemical dependency counselor.
His sweet gesture of thanks was particularly meaningful to clinic staff because, six months earlier, he’d been upset and very frustrated about getting treatment for his six chronic health conditions. Clinic staff had worked hard to meet his needs and to build his trust through innovative, respectful and compassionate care—and it had clearly paid off.
Stepping up to a challenge
Last spring, Fairview Health Services stepped forward to take part in developing a new way to care for low-income adults, many with complex health diagnoses. This new structure, called a coordinated care delivery system (CCDS), hadn’t been done before in Minnesota. Fairview—as one of only four health care providers in Minnesota willing to take on this challenge—had only a few weeks to plan and prepare.
“We felt very strongly that participating was the right thing to do for our patients—despite the significantly low reimbursement and the incredibly short timeframe to create a program,” says Marge Page, R.N., vice president for adult acute services at University of Minnesota Medical Center, Fairview and a leader for this work.
Fairview opened a primary care clinic on June 1—Riverside Primary Care Clinic on the West Bank of University of Minnesota Medical Center, Fairview—to exclusively serve as the “medical home” for our CCDS enrollees. Patients were low-income adults who had qualified for health care under General Assistance Medical Care (GAMC) and who elected to receive all their care through a CCDS.
From June through February, Fairview cared for several thousand CCDS enrollees. These patients had unique and complex health care needs. Up to 85 percent of them had both medical and mental health diagnoses. About 60 percent had three or more different diagnoses and virtually all of them had challenging socio-economic conditions in their lives.
What does their care look like?
To meet the needs of these patients, Fairview evolved a well-known, integrated medical-behavioral care model. Here are key elements:
• A physician and a behavioralist (a trained mental health professional) assessed all new-to-the-clinic patients and, together with the patient and with other providers, developed a “plan of care.”
• Physical, mental and social needs were addressed at each visit. “Each patient is treated as a whole person,” says Sandra Eliason, M.D., medical director of Fairview’s CCDS clinic. “They are given respectful and thorough care.”
• Patients were cared for through an on-going, team-based model. For example, the medication management pharmacist might see a patient weekly for a period of time to help ensure the patient had an optimal medication regimen and was able to follow it. Meanwhile, the RN care coordinator might track a patient for several weeks between clinic visits. Care was focused on using the right person for the right job at the right time.
• Fairview’s CCDS used a tight network of providers, largely relying on our partnership with University of Minnesota Physicians for specialty care. All the care and services were managed through the clinic and provided by referral only. Because the CCDS patients remained in our network, we had the opportunity to really coordinate their care and improve their outcomes in the most cost-effective way.
Early results and future plans
Fairview has been working to measure the quality and cost of our CCDS care. Some early indications are telling. “For example, we saw a steady reduction in Emergency Department utilization by our CCDS enrollees throughout the months we’ve been in the CCDS model,” says Dr. Eliason.
Minnesota moved to an expanded Medical Assistance (MA) program on March 1. Fairview supported this expansion, which improves access to care for eligible individuals who live outside the seven-county metro area. As our CCDS enrollees transition to MA, Fairview wants to continue serving as many of them as possible.
Meanwhile, we’ve been applying what we’ve learned through the CCDS structure to other patient populations and settings. In the private insurance market, Fairview has signed shared-shavings contracts that align the financial incentives to improve quality and reduce the total cost of care.
“The team we’ve created to serve our CCDS enrollees has done impressive work to build relationships and deliver outstanding care,” says Page. “This CCDS model gave us the flexibility to deliver the right care at the right time to manage the total cost of care. We plan to continue these innovations and spread them to other patient populations.”