Can care coordinators expand access to primary care?

As more people become eligible for healthcare under the Affordable Care Act, the question of access will become paramount.

Missed appointments can have a three-fold negative effect, hitting provider revenue, affecting the health of patients who miss appointments, and limiting access for other patients who could have filled missed slots.

“We’re a self-serve society, but it doesn’t translate to healthcare,” says Lynne McCabe, director of the community care coordination program at Mercy Health in Cincinnati, Ohio. “Patients need someone to help them navigate.”

Fortunately, a handful of studies and pilots show promise for the personal touch to not only help patients make appointments but also to raise awareness of the importance of managing chronic conditions to improve overall health. The latter is a critical consideration as physicians and other healthcare professionals as well as payers assume more financial risk in accountable care organizations, Patient-Centered Medical Homes (PCMHs), and other emerging care models.

Reminder calls work

A study published in the American Journal of Medicine in 2010 showed a correlation between reminder calls and fewer missed appointments. Nearly one in four patients at an outpatient multispecialty clinic who did not receive a reminder call missed an appointment. That number was reduced to 17.3% through the use of automated calling and 13.6% when a real person made the call.

The job titles and descriptions vary widely, but many large practice groups, health systems, payers, and others are looking to embed patient navigators or care coordinators at the point of care. These people help guide patients through the care delivery process, resulting in fewer missed appointments, more effective use of healthcare services, and lower overall claims.

A recent year-long pilot at MetroHealth Cancer Care Center in Cleveland, Ohio, for example, resulted in a dramatic improvement in the patient no-show rate through the use of two full-time navigators. In just 3 months, the reduction in no-shows for those receiving radiation therapy equaled a navigator’s yearly salary.

Accenture, the global management consulting firm, helped fund the Cleveland pilot and recently signed on to provide pro bono support for a program from the Highmark Foundation to implement patient navigator programs at three rural western Pennsylvania hospitals. The foundation has committed $254,500 to fund two patient navigators each at Allegheny Valley Hospital, St. Vincent Health System and Jameson Health System.

Goals of the program include increasing access to care, improving outcomes, saving money, and developing the workforce, says Yvonne Cook, president of the Highmark Foundation.

“We’re looking for significant return on investment,” Cook says, citing the Cleveland pilot. “Patients will not be the only ones who benefit. Hospitals will, too, because of lower costs. But the benefit has to be at the individual level.”

Mercy Health is expanding its navigator program after a pilot program brought a return of $5 for every $1 spent, McCabe says. The system’s 1-year pilot, which ended in May 2012, brought hospital admissions among the high-risk pool down by one-half. Readmissions were cut by one-third, with a similar reduction in emergency department visits.

The system is in the midst of certifying its 35 primary care offices as PCMHs, and the 30 case managers either on the payroll or part of the expansion will become part of the staff at each facility. Some case managers worked at multiple practices with an ideal maximum patient load of 150.

Minimize patient effort

McCabe says the pilot showed that a personal touch with high-risk patients means that patients are more connected to their care. Each patient is contacted at least once a month, with the most at-risk patients being contacted as often as three times a week. Having a single point of contact means that medication reviews, referrals and other healthcare needs can be met with a minimum of effort on the patient’s part.

And that’s the ultimate goal: finding the shortest path to the best care for the neediest patients.

Nurses and social workers who play a navigator-type role will be critical in the near future as more people gain coverage through Medicaid expansion and insurance exchanges. A majority of the new enrollees will be previously uninsured people who could be unfamiliar with the healthcare delivery system.

In addition, certain areas of the country could experience physician shortages, longer patient wait times, and delays in securing appointments. Reducing no-shows could help avoid unnecessary waste.