Landmark Report: “The Promise of Care Coordination” in Medicare

Download a copy here .  Excerpts from the Executive Summary:

Effective Interventions

Three types of interventions have been demonstrated to be effective in reducing hospitalizations for Medicare beneficiaries with multiple chronic conditions who in general are not cognitively impaired:

• Transitional care interventions in which patients are first engaged while in the hospital and then followed intensively over the 4 – 6 weeks after discharge
• Self-management education interventions that engage patients for 4 -7 weeks in community-based programs designed to “activate” them in the management of their chronic conditions
• Coordinated care interventions that identify patients with chronic conditions at high risk of hospitalization in the coming year, conduct initial assessments and care planning, and provide ongoing monitoring of patients’ symptoms and self-care working with the patient, primary care physician, and caregivers to improve the exchange of information. …In-depth analysis of program details has revealed that six
  key components distinguished the successful…programs from the ineffective ones:

• Targeting
• In-person contact
• Access to timely information on hospital and emergency room admissions
• Close interaction between care coordinators and primary care physicians
• Services provided
• Staffing

Potentially Promising Models

No single program has yet combined all three types of interventions, but doing so should further reduce hospitalizations and costs.

[There are] a number of other models with promising results from small pilot studies or with creative designs

• The Guided Care model developed by Chad Boult and colleagues
• The Patient-Centered Medical Home (PCMH)

Evidence presented in this paper suggests that if “medical homes” participating in the Medicare demonstration are expected to generate savings that equal or exceed the monthly fees paid, they are unlikely to be successful because they will be serving too broad-based a population.

Costs of Effective Care Coordination Programs and Approaches to Financing

How and at what level care coordination services should be reimbursed under Medicare are key considerations. Evidence to date from the Medicare Care Coordination Demo suggests that effective, ongoing care coordination programs were able to generate savings in total Medicare costs, before program fees, of about $120 per member per month over the 2002-2007 period, if properly targeted. This finding suggests that program fees paid for care coordination should not exceed that amount, on average. The savings estimate is roughly consistent with the 15 percent reduction in hospitalizations observed in these programs.

Policy Recommendations

The current evidence regarding effective care coordination supports the following recommendations for Medicare policy:

• For the Patient-Centered Medical Home, be very prescriptive about what services are provided and how they are provided in specifying the requirements for the Patient-Centered Medical Home Demonstration
• Offer vehicles for physicians in small practices to participate in an effective care coordination intervention
• Target both medical homes and care coordination interventions on beneficiaries who are at substantial risk of hospitalization in the coming year
• Create incentives for hospitals to participate in a transitional care intervention.