Remington Report spotlights the role of the SeniorBridge Model in the Patient-Centered Medical Home 

Remington Report - May 5, 2010

SeniorBridge is a ten-year-old company that provides in-home care management for persons with chronic health concerns. The SeniorBridge model integrates the best features of a geriatric care manager and a home healthcare company with web-based technology to deliver coordinated quality care to its clients. This model of service delivery can inform the current health care debate about how to implement a medical home model that improves both health and quality of life.

History of the Medical Home Concept

The concept of the "medical home" was originally used in the specialty area of pediatrics as a way to describe the necessity of having a central location for the maintenance of medical records for children with complex chronic health concerns. The lack of a comprehensive medical record available to all of the treating physicians was a major deterrent to providing quality care to these young patients. This term first appeared in 1967 when the baby boom generation created a swelling population of young people some of who had chronic complicated health care needs that were being treated largely in outpatient and community settings.

The term "medical home" has evolved to describe a system of service delivery that enables the provision of primary care in the community and that takes into consideration the needs of the patient, the family and the environment, including health, educational and social support systems. Some of the first legislative initiatives to facilitate provision of comprehensive care occurred in Hawaii in the mid-1980's and described the following characteristics:
Family centered
Offered in the community
Comprehensive, coordinated and having continuity
Utilizing community resources to support the child and family in meeting their needs (Sia C, Tonniges TF, Osterhouse E, Taba S. Pediatrics. 2004; 113: 1473-1478)

The evolution of thought about the provision of complex care for young people moved from a place to maintain the medical record to a system of services that focused on primary care in the community. This was the start of the person-centered, coordinated medical care movement that is still being debated today, largely around care for an expanding aging population.

Ironically, person-centered care is really only "new" within the construct of a reimbursable, acute care medical environment. In the fields of social psychology and social work, the emphasis has historically been on a whole person-in-environment approach to addressing social, economic and health and mental health issues. Client/patient empowerment through a trusted relationship that builds on the strengths of the individual and his/her support system is a hallmark of community-based practice in these professions. Although there is general acknowledgement of the impact of psychosocial factors on health outcomes, there has been no reimbursement stream for these services, so they have become marginalized and somewhat alienated from the healthcare system.

Additionally, the initial and continuing design of the Medicare system did not anticipate the advances in medicine and technology that has resulted in our increased longevity and the concomitant necessity of managing chronic health issues over many years. Therefore, the program design and the design of most commercial insurance programs do not recognize the need for both younger and older populations to have access to chronic custodial care in the community and within a family setting. The needs of those children from the 1960's has evolved into the need for chronic care among both young and older populations, who have similar needs that include:
Intense treatments over a long period of time
A centralized medical record to facilitate communication and coordination of care
Help with the impact on the family including the economic costs to it, the healthcare system and the community
Psychosocial aspects of the care that have the potential to either enhance or inhibit the outcomes of care
The need to address a restructuring of health care delivery becomes more acute as we face the aging of the baby boomers, most of who expect to be able to age in the community. In 2006, an AARP survey showed that 89% of respondents of older adults prefer to be able to remain in their own homes even when having health concerns.

According to the Partnership for Solutions (Anderson G, Johns Hopkins University and The Robert Wood Johnson Foundation, 2004), approximately 50% of the Medicare population has both functional deficits and chronic health conditions. This makes care increasingly challenging when these individuals need help on a daily basis just to maintain routine functioning that would enable them to remain stable and independent in the community. Additionally, patients with five or more chronic diseases fill more than 50 prescriptions each year and typically have 12 physician visits each year. In this scenario, it becomes apparent that there is a need for the "medical home" that facilitates the structure of the home environment to meet the daily needs of the patient. 

It is the disconnect between what happens within the physician office or the healthcare system and the daily lives of patients that can lead to increases in exacerbation of chronic illnesses due to complex medication management routines, lack of appropriate nutrition and hydration, rehospitalizations, and preventable falls. Each of these outcomes leads to increased cost of patient care and a concomitant reduction in the quality of life that the care recipient experiences in their home setting.

Defining the Patient Centered Medical Home (PC-MH)

In 2007, the "Joint Principles of the Patient-Centered Medical Home" were published as the result of a collaboration of the American Academy of Family Physicians, America Academy of Pediatrics, American College of Physicians, and American Osteopathic Association. These principles seem to recognize the need described above to address the issues of daily care even when they occur in the home or community setting. Furthermore, these principles seem to emphasize the need for recognizing that patients need to be at the center of treatment. This is a dramatic paradigm shift from the traditional emphasis on meeting the needs of the healthcare system or the payer source.

The principles described by this 2007 publication define the PC-MH as having the following characteristics:
A personal physician to provide continuous and comprehensive care
A physician directed medical practice that takes responsibility for the ongoing care of the patient
A whole person orientation, which recognizes that there needs to be a partnership with the patient that respects their wishes, preferences and lifestyle and enables education and support for individualizing care and decision making
That care is coordinated and/or integrated across settings and even into the non-medical community based settings that support people in obtaining the needed care in a culturally competent manner
That quality and safety are key to success, including advocacy for optimal treatment outcomes
Enhanced access to care and to communication with the provider
That payment mechanisms recognize the value that is added to the patient's care through this approach
With doctors having an average of seven minutes to spend with each patient in the primary care setting, it is unrealistic in our current payer system to expect the physician to engage each patient in order to understand their personal goals or wishes for their care. Physicians are often unaware of what the patient understands about their diagnoses or daily treatment routines. Lastly, with little access to the home setting physicians usually are unaware of issues that are impacted by lifestyle, the environment or the patient's ability to access prescription and over the counter medications, and appropriate nutrition. This means that we need to develop teams of health professionals who can help with patient education, accessing care, in-home coordination of treatments, preparing other providers to receive the patient and coping with behavior health and mental health issues that arise for both patients and their care givers.

The SeniorBridge Model: Moving Toward a Medical Home

SeniorBridge is a care management company that provides personalized healthcare services to help people stay at home. SeniorBridge has developed a model of service provision that incorporates a multidisciplinary professional team of health providers that offers care management, care giving and care monitoring services for those with chronic complex health illnesses. 

The care managers who lead the SeniorBridge model are highly trained nurses, medical social workers and allied health professionals who provide continuous, customized, hands-on care management in the home to assure that the physician's plan of care is appropriately implemented. "This approach allows people with complex chronic illnesses and functional deficits to remain in the community with much less need for acute care and with an improved quality of care," according to Dr. Eric Rackow, SeniorBridge CEO. 

The combination of multiple chronic illnesses and functional deficits has to be recognized as a barrier to assurance of the optimum plan of care. Even patients who are motivated to participate in care may find it a challenge to organize and comply with a confusing regimen of care in the home. Nurses, medical social workers, therapists, and paid caregivers need to support the strengths of those individuals and families who can become empowered to participate in their own care and to provide on-going support for those who do not have the resources to become self-managing. 

Individuals with entrenched mental health diagnoses or with dementing illnesses can also be managed in the community when they are provided with a safety net of health and health related professionals who are able to collaborate with the patient in a manner that is most consistent with the individual's lifestyle, preferences and resources. 

The SeniorBridge care manager communicates with the physicians, the Medicare home care provider and community agencies to assure continuity of care and fill gaps in the care plan to support patients. Likewise, the family is supported with education, emotional support and help with future planning. Mediation among conflicted family members helps the family to resolve their developmental issues and focus on the care needs of the vulnerable patient.

The care management team utilizes a unified medical record to track issues of medication reconciliation, home modifications for safety, physician and treatment appointments and changes in health status. The comprehensive biopsychosocial assessment tool facilitates tracking of client plans of care and outcomes over time. 

In a review of SeniorBridge client records that were on service for a year, health outcomes were considerably better than those reported in the general Medicare population. SeniorBridge clients with chronic illnesses who are 65 years and older have 82% fewer hospitalizations and 92% fewer visits to the emergency room, as compared to Medicare beneficiaries with chronic illnesses (Peikes D et al. Effects of Care Coordination on Hospitalizations, Quality of Care, and Health Care Expenditures Among Medicare Beneficiaries:15 Randomized Trials. JAMA 2009; 301: 603-618 and Anderson T et al. High-Cost Medicare Beneficiaries. Congressional Budget Office, May 2005). Additionally, SeniorBridge clients have 46% fewer re-hospitalizations than reported in the recent study published in the New England Journal of Medicine (Jencks FS et al. Rehospitalization in the fee-for-service Medicare program. N Engl J Med 2009; 360: 1418-1428). These outcomes demonstrate that there is both a quality of life and economic benefit to the high-touch approach to in-home care that is provided by a team of healthcare professionals, coordinating care with the physician and the family support system. 

Conclusion

A primary barrier to the provision of the medical home as a system of service delivery for older adults with complex chronic health issues is the lack of a reimbursement mechanism. While Medicare has been successful at creating a cost effective health insurance plan for acute episodes of care, few individuals or families are prepared for the financial and physical toll of living with chronic illnesses. Even Medicare Advantage programs, which provide benefits above the traditional Medicare offering such as telephonic case management, have not been able to successfully address the growing need for community based complex care. 

The SeniorBridge model demonstrates that providing care management services in the home by a team of health professionals will improve the health of Medicare beneficiaries, while at the same time decreasing emergency rooms visits and hospitalizations, thereby reducing the overall cost of healthcare. This care management model should inform the current health reform debate about the potential for more successful outcomes in caring for the chronically Ill. A move toward this model of care will require collaboration between physicians and community based providers of chronic care. At the same time, this model must recognize the central role of the patient and his/her support system in the process.

By Rona S. Bartelstone, LCSW, MSW, CMC, Senior Vice President of Care Management and Eric C. Rackow, M.D., President and Chief Executive Officer at SeniorBridge