Seniors with more than one chronic condition who are susceptible to frequent hospitalization will be enrolled in a patient-centered medical home pilot program in Florida with hopes that the year-long program will improve outcomes and reduce costs.
Metropolitan Health Networks, Inc., a West Palm Beach, Fla.-based provider of healthcare services, is partnering with New York-based SeniorBridge on the pilot program, SeniorBridge Care Management for Metcare. The program will involve 100 pre-selected Medicare Advantage members in Florida who are served by Metcare, have multiple chronic conditions and are frequently hospitalized.
Through the program, each participant will be assigned a specially trained nurse and social workers, who will meet with the participant and caregivers in his/her home. The team will conduct home safety assessments and evaluations of medical, functional and psychosocial status and develop an appropriate care program that goes beyond phone calls. Other services that may be included in the program are health education and counseling and on-call management support.
In addition, the program will create an electronic medical record for each patient.
"With this program, SeniorBridge and Metcare are taking leadership to address a critical need to improve the health and function of the fastest growing segment of our population while reducing unnecessary and costly hospital admissions," said Eric C. Rackow, MD, president and CEO of SeniorBridge and immediate past president of NYU Hospital Center. "We expect our proven model to be a catalyst for improved care, to show significant return on investment and to be a healthcare reform standout."
"SeniorBridge Care Management for Metcare responds to the clear need for highly trained advocates to help patients at risk for multiple hospitalizations navigate the complexities of their care with a highly personalized approach," said Jose Guethon, MD, MBA, president and COO of Metropolitan Health Networks. "We believe this type of initiative has the potential to build on Metcare's patient-centered medical home care model, to further empower primary care physicians while improving health literacy, quality of life and care of our customers."
According to Metcare executives, recent research published in the New England Journal of Medicine indicates one in five seniors are rehospitalized within 30 days of being discharged from a hospital, and only half recall receiving self-care instructions or seeing a doctor after their initial discharge. Medicare beneficiaries, meanwhile, account for 15 percent of the U.S. population but 37 percent of hospitalizations and 47 percent of total hospital costs.
"Comprehensive assessment and ongoing in-home care management is the groundwork for improved compliance and quality care," said Guethon. "By providing timely and reliable insights about the challenges, preferences and home environments of our customers, SeniorBridge Care Management for Metcare has the potential to minimize the time our doctors spend chasing medical information and empower them with an even more comprehensive understanding of their customers' needs so they can continually provide higher quality care to those often considered the most difficult to treat."