Rochester Business Journal

After seeing a significant reduction in repeat hospitalizations for patients enrolled in an experimental health coaching program, area insurers say they plan to expand the pilot.

Patients who were coached in ways to better manage their chronic conditions under the Care Transitions Intervention program had 25 percent fewer hospital readmissions than a similar group that had not been coached, Finger Lakes Health Systems Agency officials reported to the 2020 Performance Commission on Monday.

The results—the first available from the nearly 2-year old pilot—come from an analysis of area private insurers’ claims data.

The reduction in readmissions is significant first because it shows such coaching benefits patients who suffer debilitating chronic conditions, but also because it shows coaching has immediate cost-cutting benefits for providers and insurance carriers, FLHSA associate executive director Thomas Mahoney M.D. said.

The project’s managers have not calculated dollar savings realized by Care Transitions yet but expect to see a significant reduction in costs. Expansion of the program over the next few years would be financed partly with money from a recently won $26.6 million federal grant being administered by FLHSA, officials of the local health planning agency said.

Patients with chronic ailments such as diabetes, congestive heart failure or pulmonary disease require continuing ongoing care and account for a bigger slice of medical costs than a larger and healthier segment of the population.

Data gathered by the Department of Health and Human Services’ Agency for Healthcare Research and Quality in 2002 found the anecdotally cited 80-20 rule—that 20 percent of the population accounts for 80 percent of health care costs—proved to be true in the U.S. health care market. The 5 percent of the population with the most expensive to treat conditions accounted for 49 percent of costs, the AHRQ study found.

In the Care Transitions pilot, 21 trained coaches are assigned to patients hospitalized for complications associated with chronic conditions. Patients who meet a set of standards known as PQI, an acronym for prevention quality indicators, are deemed eligible for coaching. After seeing patients in the hospital, coaches follow up with home visits and phone contacts.

The focus of Care Transitions coaching is not to ride herd on patients to see that they follow post-discharge regimens but to help patients develop their own strategies for coping with and managing their conditions, and to recognize when they should and should not seek medical help, Mahoney said. 

Begun in fall 2010, the pilot is being supported by Excellus Blue Cross Blue Shield and MVP Health Care, both of which agreed to not let extra Care Transitions coaching systems count against participants’ home-care benefits. Medicaid managed care insurer the Monroe Plan Medical Care also participated. Grants from the state and the Centers for Medicare and Medicaid Services more recently have financed a Care Transitions expansion to Medicaid enrollees not in a managed care plan, Mahoney said.

Care Transitions coaches were hired and trained by two local home health companies—Lifetime Care and Visiting Nurse Service of Rochester and Monroe County Inc. Lifetime is a sister company to Excellus. VNS is part of the University of Rochester Medical Center.

Excellus’ pilot has been limited to Rochester General and Unity hospitals. MVP’s pilot is at Strong Memorial and Highland hospitals. Spokesmen for both insurers said the companies plan to expand their Care Transitions coverage to other local hospitals and other regions.

Under new rules promulgated by CMS, hospitals are penalized financially if they readmit patients for the same condition within 30 days of discharge, making the coaching effort a potential money saver for hospitals, which under payment reforms underway by CMS face other reimbursement cuts.

The cost of providing coaching amounts to a few hundred dollars, while a hospital readmission would cost some $10,000, said James Redmond, Excellus vice president of community relations.
 
A single disappointing result was that the hospital staff too often identified patients who were not eligible coaching as meeting PQI criteria, Redmond added. But while that made administration of the program less efficient, it did not affect coaching of patients who did qualify and the pilot met its pre-set goal of achieving a 25 percent reduction in readmissions.

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