Success in the Face of Reform

Abstract

We hear repeatedly that health reform will dramatically affect the way postacute and long-term care (PA/LTC) will participate in the U.S. health care system. New models of care delivery include accountable care organization, medical homes, and demonstration projects that combine Medicare and Medicaid dollars. All have core principles of accountability, integration of care, emphasis on long-term health outcomes, and better transitions. So, where do physicians look for guidance in the postreform world? Many of us immediately think of innovative centers such as the Cleveland Clinic and the Mayo Clinics. There is certainly much to learn from them, but how transferable are their practices? How dependent are their models on concentrated populations and resources? What do they offer to rural or suburban practices? At the same time, some independent physician practices are trying to chart their own paths through the changing environment without sacrificing physician leadership. One such model is Chappel Health and Wellness in central Florida. It's led by Chris Chappel, MD, CMD, and includes three other physicians and six physician assistants. They operate three clinics and provide medical direction to 25 PA/LTC facilities in the three counties around Orlando. What makes Dr. Chappel's practice model unusual is that it incorporates “discharge clinics” in cooperation with local hospitals. These clinics streamline transitions from the acute setting by giving patients on-site access to a pharmacy, a home health agency, and a durable medical equipment provider. The discharge clinics also set the immediate follow-up appointments with primary care physicians and specialists. The pharmacy's presence alone mitigates what is a major contributor to hospital readmissions, medication errors. Each Chappell clinic also has a wellness program incorporating diet and exercise coaching in a 5,500 square-foot gym. In a final twist, Chappel Health and Wellness has a clinical research arm staffed by a pharmacist and two physicians. Dr. Chappel has been working with Florida's Quality Improvement Organization on a project to reduce hospital readmissions. The collaboration includes four nursing homes, two home health agencies, and a patient-advocacy and coaching organization. The project targets seven of the leading readmission diagnoses, including heart failure, chronic obstructive pulmonary disease, and sepsis. The linchpins of the project are two: immediately offering a health coach to a patient at hospital discharge and use of the Interventions to Reduce Acute Care Transfers (INTERACT) program for improving long-term care transitions. The results have been dramatic. Nursing homes have become more comfortable treating patients with complex diagnoses and talking with family members about care-setting choice. Hospital admission rates of residents in the four nursing homes have decreased from 26% to 17% and are still falling. Thus, Chappel Health and Wellness is firmly planted in both community-based and facility-based long-term care. Dr. Chappel describes the model as a medical village concept within a clinic. He and his colleagues strive to follow the Institute of Medicine's advice on how to give appropriate and affordable care: “Deliver the right care at the right time by the right provider in the right setting.” Is Dr. Chappel naïve in trying to go it alone in the post–health reform world? He says that he is striving to let primary care do what it does best and eliminate or reduce the need for the administrative middle man of an accountable care organization (ACO), for instance. “I think we are years away from bundled payments for physician services in the outpatient world. If it happens sooner, our concept will be ready for it and will have a track record, especially when it comes to decreasing 30-day readmits,” Dr. Chappel said. Maybe he's not naïve. He says that physician groups partnering with hospitals, nursing homes, insurance companies, and other entities is inevitable. “We are starting small to work out the bugs, then expanding in whatever direction it takes us.” The handwriting is on the wall. Governmental payers, employers, and health insurance companies are all pushing for more integrated health care systems, where physicians and hospitals are held accountable for the overall cost and quality of care. It is likely that all physicians will need to participate in systems requiring more communication, care coordination, and quality-data reporting. The Chappel Health and Wellness model strives for coordinated services that are rooted deeply in a profound respect for patients. In Dr. Chappel's view, hospitals, LTC facilities, and physicians' practices can and must work together effectively.