Maine Shifts Health Focus To Community

Maine Shifts Health Focus To Community

For the last three of the nearly six decades Shirley Estes, 80, has been married to her husband Harry, since his first heart attack and quadruple bypass at age 51, she has spent so many nights and early mornings in the Eastern Maine Medical Center emergency room she has lost count.

Most of the time, Shirley handled her husband's unpredictable heart health by herself. Last summer, she laid slacks and a blouse on her bed each night so she could quickly change out of her nightclothes and rush her 81-year-old, ill husband to the hospital, a few miles away in Bangor.

But last fall, following a stroke that put him in the hospital for nine days, followed by two weeks in a nursing home, Harry and Shirley Estes began receiving extra support from a new team of primary medical care providers rapidly expanding across Maine.

A "community care team" from Eastern Maine Healthcare Systems, which includes a registered nurse and physician, among others, now calls Harry Estes at least three times a week to check his medications, blood pressure, and diet while reassuring his wife that they are only a phone call away. No lines, no waiting for an appointment, and no middle-of-the-night trips to the emergency room.

Less than a year after his stroke, Harry Estes is back on his riding mower, grooming the two-acre lawn around their Brewer, Maine home. He’s also enjoying the company of his more relaxed wife, who no longer has to leave a neighbor in the house with her husband just so she can take a few minutes to go to the grocery store or run an errand.

"After his last stroke, I was going to the hospital two or three nights a week," Shirley Estes says.

"Now, anything to do with his health, I call. I don't want to be a nuisance but they tell me I'm no bother. He has not declined and he has come a long way because these people have helped me as much as it has helped him.” The improved health of Harry Estes and the additional support for his wife comes from a statewide Patient-Centered Medical Home Pilot, launched in 2010 by the Dirigo Health Agency’s Maine Quality Forum, a Maine state agency; Maine Health Management Coalition, a purchaser-led multistakeholder collaborative; and Maine Quality Counts, a regional health care collaborative funded by the Robert Wood Johnson Foundation’s Aligning Forces For Quality initiative.

In addition to improving the quality of life for patients like Harry and their families, the project has also eliminated unnecessary and expensive hospital admissions and emergency room visits from the health care system. That, supporters say, moves providers away from more costly fee-for-service reimbursement that pays no matter the outcome to more accountable payment reform pushed by private employers and insurers, as well as the Affordable Care Act.

At Eastern Maine Medical Center alone, the aggressive attention to chronic heart failure patients from registered nurse care coordinators has helped the 411-bed hospital reduce its readmission rate for Medicare patients to 12 percent last year, from nearly 20 percent just three years earlier in 2009. Such admissions can cost the health care system more than $10,000 a day, and even more depending on the severity of the illness and complexity of the patient’s condition.

Primary care practices are further supported by multidisciplinary community care teams that include nurse care managers, social workers, health coaches, and pharmacists, as well as volunteers who not only coordinate services to patients, but to families of patients like Shirley Estes as well.

"I just think this effort is going to take off," Shirley Estes says of the medical home initiative. "It just has to. It's so much better to have him back at home."


If a collaborative group of businesses, employers, state policy-makers and medical care providers in Maine has its way, patient-centered primary care medical homes and their community care teams will take off and be part of the national solution to improving quality while at the same time lowering health care costs.

Under the medical home model, practices are paid a fee of about $3 per patient, per month from private insurers, though it can vary somewhat depending on patient eligibility to help cover the costs of medical care coordination. In comparison, Medicare began paying $7 a month per patient per month, while MaineCare pays $12 per eligible patient per month. In addition, about $3 per patient, per month from Medicare; 30 cents from private insurers; and the equivalent of $3 from MaineCare.

“There is a potential for a substantial return,” says Lisa Letourneau, MD, executive director of Maine Quality Counts. “We are hopeful about seeing at least a slowing of the rise in health care costs.”

When Maine was selected last year as one of just eight states to participate in Medicare’s Multi-Payer Advanced Primary Care Practice (MAPCP) demonstration, due in part to the success of the medical home effort, CMS set an expectation that the medical home effort reduce by 4 to 5 percent “avoidable inpatient admissions,” reduce by 9 percent “avoidable” emergency department visits and decrease by 5 percent specialty consultations and imaging.

Because Maine is participating in the Medicare effort, its original pilot program has been extended through 2014, which Maine officials say will give its community care teams more time to develope and improve.

If the pilots are successful in Maine, the Obama administration wants to roll them out nationwide to seniors across the country, CMS officials say. Other large care coordination efforts often start first with caring for Medicaid patients or Medicare patients. Others may just work with privately insured patients, industry analysts say. But the Maine effort is working with patients covered by all forms of insurance, or what those involved are calling an “all-payer” medical home project.

"If you are going to manage the medical care of a population, then you have to have all of the population,” says Elizabeth Mitchell, former chief executive officer of the employer-led multistakeholder group, the Maine Health Management Coalition, one of the three “convener” groups that launched the medical home initiative with Maine Quality Counts and Dirigo Health Agency’s Maine Quality Forum.

“You can’t just change medical care for one payer,” added Mitchell, who is now chief executive officer of Portland, Maine-based Network for Regional Healthcare Improvement, a national membership organization of over 30 Regional Health Improvement Collaboratives including Quality Counts and the Maine Health Management Coalition. “You have to have alignment. You have to have true population management and you don’t do something differently for this person and don’t do that for that person.”

The all-for-one and one-for-all approach is a common theme in Maine. The primary care medical home pilot has now grown from an original 26 primary care physician practices and staff to a total of 75 practices to care for new patients from the Medicare award. Those involved say they are now treating and providing care coordination to an estimated 360,000 people in Maine, or more than 25 percent of the state’s 1.3 million people.


Meanwhile, the services medical homes provide are going deeper into the community. For example, all of the practices began working with community care teams in 2012. Some of these teams are based in home health agencies like Androscoggin Home Care & Hospice in Lewiston, Maine, which is located about 35 miles north of Portland and began providing services to patients of four primary care practices in its service areas.

The added feature of community care teams to the primary care medical home has enabled patients to be linked to community resources like food banks, mental health case workers and other social services particularly important to poor people insured by MaineCare, the state’s Medicaid program, because these patients often have limited means and have been unable to work due to health or other issues.

In 2012 - the first full year Androscoggin's home health care workers became part of the medical home project’s community care team effort - the 50 patients it serves had 62 percent fewer emergency room visits than 2011, while hospitalizations dropped by 51 percent, says Julie Shackley, chief executive officer at Androscoggin.

The per-member, per-month fees have helped practices and home care providers like Androscoggin to hire additional nurses, social workers, and additional support staff, Shackley says.

"We just know we are improving the quality of care and saving money when hospitalizations cost the system tens of thousands of dollars," Shackley says. "We are part of the continuum and part of the community. It's not just the physician and not just the hospital."

Androscoggin home health workers say they are typically called by physician practices or the hospital to engage with patients at their homes, often uncovering issues like poor diet that includes shelves packed with high-sodium canned goods like soups.

“You often get a good picture of what is going on in their lives when you enter their home just by looking at the kitchen counter top," says Michelle Couillard, a registered nurse with Androscoggin. "Some patients also have many bottles of pills that can be several years old. You have to go through these medications and help them."


The outreach is the key, those involved say. In Orono, Maine, a rural community nestled among 100-foot tall pine trees a few miles northeast of Bangor and just off Interstate 95, registered nurse Kathleen Bates calls 25 patients a day from the five-doctor Orono Family Medicine health center, making sure they are taking their medications, eating the right foods and generally feeling well.

Bates, a former cardiac care nurse who also has a background in pediatrics, is a troubleshooter of sorts for patients that are elderly or suffer psychological conditions that make it difficult for them to remember to take their medications or even have the confidence to leave their home.

“We imbed ourselves into the patients’ issues,” Bates says. “We are pleasantly persistent. Patients say, 'I can be more accountable because you are calling me.’”

But ultimately, the providers like Bates and Glenn Rampe, MD, at Orono Family Medicine say they are the ones who have to be accountable “or we won’t be paid.” To be sure, reimbursement across the country is moving away from fee-for-service medicine to more accountable models that work to shift care away from treating illness to striving to keep people healthy.

Also emerging are accountable care organizations (ACO), which reward doctors and hospitals for working together to improve quality and control costs and better manage the medical care of populations of patients. ACOs link medical care providers together to improve quality. If the providers in the ACO achieve better outcomes, they divvy up money saved with the health plans.

Eastern Maine Healthcare Systems has integrated its medical homes and community care teams into what is one of the nation’s first ACOs, which launched in January 2012, as part of Medicare’s Pioneer ACO initiative. Throughout the primary care medical home pilot, providers are also reporting their results, which include reduced rates of emergency room visits and hospital readmissions. As the data is collected and more is learned about the health of these patients and why they are entering the more expensive hospital setting in the first place, employers and health policy leaders in Maine believe they will be able to provide higher quality health care at an even more affordable price.

“The data is going to enable providers to perform better,” says Michael DeLorenzo, Director of Health Analytics at the Maine Health Management Coalition, which includes some of Maine's largest employers like the University of Maine system, Hannaford supermarkets, and Bath Iron Works, the giant shipbuilding subsidiary of General Dynamics. "You have to be accountable for quality of care, outcomes, and cost of providing care. To be accountable, you have to know what you are doing. It can't be an internal reporting mechanism to use just to go out and say how good you are."


But those who are a part of the expanding patient-centered medical home project in Maine say it might not work in areas of the country if there isn't collaboration, particularly with buy-in from the providers of medical care.

In the Maine Health Management Coalition, multiple stakeholders from business and labor were the first to get involved, but providers had to be included, particularly doctors and hospitals that are resistant to change, fearing a loss of revenue or autonomy at a time of rapid change in the health care system and how doctors and hospitals are reimbursed.

"If you don't engage providers, you are not going to get traction," Mitchell says. "It's harder than it looks. But you have to get the providers on board."

As successful results come in from medical care providers like Androscoggin and Eastern Maine Healthcare Systems, private and government insurers are enrolling more patients.

Meanwhile, employers are demanding more information to enroll more patients. Mitchell and DeLorenzo say employers want the highest quality care for their employees and want to work with the providers who have the best outcomes, which lead to fewer hospitalizations and lower costs for the companies picking up the tab. An independent, unbiased source of information on provider performance in these areas is crucial for decision-making.

“Shopping for discounts is not going to get employers what they need," Network for Regional Healthcare Improvement's Mitchell says of employers and others paying for healthcare. “The medical home is proving itself over and over to be the right model.”

The initiative in Maine was borne from early collaboration. While other medical home initiatives are just beginning across the country, those involved in the Maine primary care pilot say it might not be easy to replicate if there is not an existing framework where the health care community, government, business and labor are already on speaking terms.

Those involved in Maine’s effort say it might have been more difficult to get their medical home project off the ground if there had not already been a spirit of collaboration among various interests that started almost two decades ago.

"What's happening in Maine only works because the infrastructure was already there and it was driven by employers and providers working together directly," Mitchell says. "Employer support was critical.”

The Maine Patient-Centered Medical Home Pilot has had early success in large part because there has for years been a spirit of cooperation and collaboration that started nearly two decades ago when employers and unions got together in hopes of slowing the growth of worker health costs, employers and provider groups say.

In 1993, the Maine Health Management Coalition formed when business and labor interests came together in an effort to get their arms around rising health care costs. “Maine has always had a long-standing focus on health care and collaboration,” says Ted Rooney, a registered nurse who was a mananger of health benefit programs at the venerable Maine-based retailer L.L. Bean in the early 1990s and a member of the Maine Health Management Coalition board from 1994 to 1999. And that is not always the case, say Mainers who in the early days of forming partnerships between business and labor or doctors and insurance companies found distrust and rancor and often pointed fingers at each other.

Rooney, who is now project director for the Robert Wood Johnson Foundation’s Aligning Forces for Quality initiative in Maine, says the RWJF grants coaxed more collaboration from providers and other groups not traditionally working together in Maine's effort to improve quality and control costs.

“The Robert Wood Johnson Foundation is so white hat that it provided a really safe place for people and groups to be willing to participate,” Rooney says. “We were able to get the public health and consumer sector more engaged. They are aware of RWJF’s efforts with the uninsured, smoking cessation and health disparities."

The initial grant of $182,000 has been renewed and grown over the years, providing more than $2.2 million thus far to convene the three primary stakeholders, education providers, and provide funding for analysts who report and provide feedback on health outcomes.

The grant was like throwing seeds on fertile ground,” Rooney says. “While the grant provided what some may think is a small amount of money, it helped fund Quality Counts and was the catalyst for the medical home project."


The patients helped by Androscoggin Home Care & Hospice’s participation in the medical home program include 53-year-old David Cagulada. In June 2012, Cagulada was forced to make an emergency call for an ambulance after kidney failure and chronic heart failure left him gasping to breathe.

Because he was too sick to work, he says his web-based search engine optimization business collapsed when he was no longer able to provide his clients services. That left him homeless on the streets of downtown Lewiston when he was unable to pay his bills.

“I had to call 911 because I just wasn’t getting better,” says Cagulada, noting he hadn’t seen a doctor for several years before he became ill.

Following an eventual referral to Sabattus Street Family Practice in Lewiston, which is part of the patient-centered medical home project, the physicians and community care team began to connect him to a network of health and social services, including public housing.

Because he had no home, registered nurse Lucie Kelley and social worker Corrie Brown had their first meeting with Cagulada at the Lewiston Public Library. “It’s the only place I could think to meet,” Cagulada says.

In June, Kelley and Brown, part of the Androscoggin community care team, equipped Cagulada’s one-bedroom loft apartment in downtown Lewiston with a “telehealth” home monitoring system that allows them to read his blood pressure, weight and other vital signs remotely so they can detect any problems and help him avoid the multiple week-long hospital stays he experienced in June of 2012 from renal failure and congestive heart failure.

“If he has a problem now, we’re going to know about it,” says Angela Richards, a registered nurse and project manager for community care teams that work with patient-centered medical homes from Androscoggin in Lewiston and several area communities. “We have connected David with a [YMCA] scholarship and transportation because he wants to work on his weight loss.”

A year after his battery of hospitalizations, Cagulada has had no visits to the emergency room or hospital since Androscoggin staff helped him move into his apartment.

“I had no idea all of these services were available,” says Cagulada, who this summer began to reach out for business clients once again after more than a year of being too ill to work. “I’m getting there. I feel like I am becoming healthy.”

Bruce Japsen JOQ

Bruce Japsen writes on health and health policy for Forbes, and also contributes to the New York Times, while offering health policy analysis for several TV and radio outlets, including Fox News and the Chicago affiliate of PBS and CBS. Japsen served as a health policy writer for the Chicago Tribune for over a decade.

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