QUALITY: Continuity of Care Saves Lives--and Maybe Money

We know that the record on chronic disease management programs is mixed. We need to learn from our disappointments and build on our successes. Here's a success story from Pennsylvania, where 32 medical practices that signed on to Governor Ed Rendell's chronic care initiative have reported a successful first year. Out of 15,000 diabetic patients, the number exercising the ideal level of control over their blood sugar rose from 33 percent to 44 percent in just one year.

Ann S. Torregrossa, the director of the Governor's Office of Health Care Reform told the Philadelphia Inquirer that the diabetes management program (which is similar to the concept of a medical home) transformed  "how health care is provided and paid for at the primary-care level." Under the program, insurers have agreed to pay practices to strengthen the continuity of the relationship between the caregiver and patient. This fosters a more "team-based" care environment. Patient progress is tracked electronically, alerting clinicians to test results, important treatments, and any missed appointments, so that patients can be contacted and offered an appointment slot the very same day. The funding allowed the medical practices to add staff, such as nurse practitioners, so they can provide patients with a more thorough education about disease management and greater encouragement to practice healthy behaviors. Self-care is a big part of diabetes care. The goal of the combination—continuity, quick alerts to problems and risks as they arise, and better education—is to keep them healthier, and reduce complications that can lead to hospitalizations. It'll take a few more years to know how well these programs meet those goals, but the initial indicators are good. Overall, the aim is better health for less money.

Farther north, Massachusetts General Hospital has been striving to use more continuous care to reduce hospital readmissions for the elderly. Started in 2006, the program calls for nurses in primary care practices to stay in close contact with frail, elderly patients and help them arrange the many services they need to stay stable. Nurses' tasks range from scheduling physical therapy and doctors' appointments to encouraging safer behaviors, like cutting back on driving. The savings so far has not been huge, but the patients (who are already quite sick) are doing better. Over three years, Mass. General spent $8 to $9 million and generated an estimated $7 to $10 million in savings—on top of recouping the initial investment. Hospital readmissions dropped an estimated 19 percent between 2007 and 2008, hospital stays fell 17 percent, and ER visits declined by 15 percent. Ideally savings will expand as the program matures, although at least the money is being spent on care that keeps people out of the hospital.

Realigning incentives for care delivery and focusing on prevention and wellness—(or with the people who already have advanced disease, with good community-based management) are strategies that policymakers on both sides of the aisle are currently considering. We need to learn more, but these programs both show promise.