In the last 3 years, Jeff Kline hasn’t missed a day of work. With a special needs child at home — and mounting daycare and medical bills — he can’t afford to.
Jeff also has asthma and diabetes. Two chronic conditions that can sideline him if they aren’t properly managed.
Thankfully, Jeff’s employer offers a health plan that has programs especially for patients with ongoing, chronic illnesses. So Jeff is connected to a team of doctors, nurses, pharmacists, and health plan staff that helps him properly manage his conditions.
In fact, a nurse care manager calls him weekly to ensure he’s checking his blood sugar and taking his medications on time.
The extra outreach and support help Jeff avoid hospital stays and the ER. And they can save Jeff and his employer from paying for unnecessary care.
Jeff’s employer can rest easy knowing its health plan and network doctors are working together to keep Jeff healthy and able to come to work.
What’s so special about Jeff’s health plan?
Complex Care Models Personalize Treatment
Jeff’s plan includes a complex care model.
Complex care models improve outcomes by putting patients with hard-to-manage or chronic conditions at the center of a specially-trained team of health professionals.
These programs tailor treatment to patients’ everyday lives. So rather than going to a hospital, patients are able to manage their conditions at home or in their communities.
Complex care programs improve patient outcomes and help control costs by:
- Educating patients to properly self-manage their conditions and focus on staying healthy
- Ensuring patients get the right care at the right time in the right place
- Ensuring “care transitions” go smoothly (like when patients go from a hospital to a nursing home)
- Identifying any “gaps” in care so nothing is overlooked
- Anticipating and eliminating issues that might lead to unnecessary ER visits and hospital stays
- Managing patient care with a team-based approach
Personalized Treatment Improves Quality
A 2014 Commonwealth Fund study showed care quality can improve with complex care models. The study looked at 18 complex care programs in 14 states. Most plans saw care quality improvements:
- 70% lower hospital admissions in the first year
- 58% fewer emergency room visits in the first year
- 5% lower death rates among diabetes patients over two years
And some saw cost reductions:
- Savings of $352 in monthly care costs per patient
- 33% lower care costs by the third year
- 64% lower skilled nursing facility costs
- 38% lower emergency room visit costs
Care can cost less when it’s delivered efficiently and in the right setting. And when health plans pay less, savings can be passed along to you.
Filling the Gaps in Care
Well-designed complex care plans rely on a nurse care manager to “quarterback” a multi-disciplinary team. The team may include specialty nurses, behavioral health specialists, social workers, pharmacists, wellness coaches, or physicians.
In addition to working with the patient, the care manager might also connect with the patient’s PCP, specialists, and even family members or caregivers. The team-based approach keeps everyone on the same page and focused on keeping the patient healthy.
Nurse care managers typically call patients to check in. And they’ll provide health education, teach the patient to care for themselves, and offer moral support. During doctor visits, they ensure that patients are prepared to address health concerns.
Some complex care programs go a step further. In some cases, they work with clinicians who visit patients in their homes — where health issues often begin. They may also offer digital solutions (like remote diabetes monitoring or digital scales) to provide real-time data and support to patients.
Nurse care managers are available to talk to patients whether they’re sick or well. And patients have someone to reach out to for help and advice at any time. So any red flags — like missed medications or disease symptoms — are identified before they become problems.
For example, patients with heart failure could benefit from this approach. They should weigh themselves daily to be sure they’re not retaining fluid, which can lead to an ER visit or hospital admission. Through a complex care program, the nurse care manager can be sure patients record their weight, and their doctors can adjust medications if they’re retaining fluid.
Under traditional care models, that conversation might only occur during monthly doctor visits. But having those discussions more often can keep patients out of the hospital.
Does Your Plan Include Access To The Best Complex Care?
Unfortunately, there isn’t a database that lists health plans or provider networks that have complex care programs. The best way to find out is to contact your health plan’s benefits administrator or read your plan information.
But if you’re still shopping for coverage that keeps employees healthy, improves productivity, and may save you money, look for health plans that:
- Use complex care models to care for patients with complex needs or chronic conditions
- Work hand in hand with doctors to provide proper care management and coordination
- Focus on improving care quality and providing the right care for the best value
- Reward doctors and hospitals for improving quality and value
As consumers call for better health care, complex care programs are likely to gain even more momentum. Now is the time to find out about these care models and see how they can lead to healthier, more productive workers and a better bottom line.