Obamacare-based program gives high-risk patients better care, saves money

Spokane woman works toward better health with Health Home program’s support

Hilary Edmondson needed an advocate after the amputation of her leg, and thanks to the Health Home program, she had one.

About two years ago, the Spokane woman entered a hospital with an ulcer under her toe. As a result of her diabetes, it had become necrotic. Because she had gone so long without receiving care, sepsis, a potentially life-threatening condition, had developed in her leg. It was amputated at the mid-calf.

Five days after the surgery — with the wound-closing staples still in her leg — the hospital discharged Edmondson to her home because staff could not find a physical rehabilitation center to take her.

Hilary Edmondson

Back at her apartment, she managed on her own for one night. She was still experiencing some shock from the loss of her foot, and because her apartment was not wheelchair accessible, she had to crawl to get around. When she had trouble administering her antibiotics intravenously, she called for help and was taken back to the hospital by ambulance.

That is when her advocate, Sharon Miller, a care coordinator through the state’s Health Home program, discovered the hospital had discharged Edmondson and stepped in. Miller is a nurse with Frontier Behavioral Health who contracts with Molina Healthcare.

“I was just so shocked that she was already discharged from the hospital. I called to follow up and she was already back at the ER,” said Miller, who had been working with Edmondson for about two years at that point. “I explained that being discharged home was not OK from a safety perspective.”

Miller realized that although the hospital had checked for beds in rehabilitation facilities, it hadn’t checked with skilled nursing facilities. She worked with the hospital’s discharge team and found Edmondson a bed in a nursing facility, where she was able to receive follow-up care such as physical therapy and to learn the skills to become more independent.

“At the same time I lost my leg, I was also dealing with compound loss in my family,” Edmondson said. “I found out my mom had cancer.”

Through the Health Home program, Edmondson gets more than an advocate. The program provides highly coordinated care, including comprehensive care management, health promotion, follow-up, individual and family support, and referral to community and social support services, as needed.

$67 million in savings

The program began in 2013 as part of the federal Affordable Care Act, sometimes referred to as Obamacare. It’s one of the programs to help states find innovative ways to improve patient care while cutting costs. In Washington, it is a partnership among the Health Care Authority, the Department of Social and Health Services and the federal Centers for Medicare & Medicaid Services (CMS).

Health Home is available for certain patients who are eligible for Medicaid or both Medicare and Medicaid. Selected by HCA, these patients must have at least one chronic illness and be at risk for another. By focusing comprehensive care on high-risk, high-cost patients, the program actually saves money. Health Home resulted in a preliminary gross Medicare savings of $67 million over two years, according to a new report by CMS.

The program encourages patients to interact more often with their primary care provider, thereby reducing avoidable trips to the emergency room and inpatient facilities. It also strives to coordinate care among various providers who all strive to work in the patient’s best interest and promote patient independence.

The program allows patients to determine, in collaboration with a doctor, what they want to work on, such as quitting smoking, said Rena Cleland, a Health Home program manager for Molina Healthcare, Edmondson’s insurance provider.

“If a client is willing, (Health Home) helps them learn self-management skills,” Cleland said. “It’s whatever the member chooses to work on that’s going to make their lives better, easier and more enjoyable to them. Telling the member to do something results in them getting defensive. We work with members on their goals, to build a relationship of trust, so that we can ultimately impact their health care decisions.”

‘Care coordination on steroids’

Through Health Home, Edmondson has taken meal preparation classes to help manage her diabetes. She works with a mental-health therapist. She has learned to take notice and speak up when she encounters a potentially serious health problem. Miller attends some of her doctor appointments, making sure that Edmondson asks all the right questions and gets answers.

“This is like care coordination on steroids,” said Alice Lind, HCA’s manager for Medicaid grants and program development. “We require very detailed assessment, including a person-centered care plan, which means the client sets goals that are meaningful for them. We provide the care coordinators access to DSHS’ data, which shows historical use of services, where there are gaps in services and which conditions contribute to the clients’ risk level.”

All her providers “talk together,” Edmondson said. “Everybody knows what meds I’m taking. Everybody knows what I’m working on. Everybody’s informed.”

Through it all, Edmondson said she’s grateful to have an advocate like Miller in her corner.

“She’s really informative,” Edmondson said. “If I miss something, and she catches it, then she lets me know — and I love it.”