The Care Coordination Program: a virtually integrated care delivery model for complex, high-needs patients

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Background The South African healthcare sector is fragmented. The increasing prominence of non-communicable, or chronic, diseases in both the private and public healthcare sectors contributes to the country’s complex and costly “quadruple burden of disease” (the others being HIV/AIDS, tuberculosis, maternal and child mortality, and violence). These chronic diseases, once they have progressed, are inherently difficult to manage due to their underlying psychosocial components and their characteristically complex co-morbidities. High costs, without the desired improved clinical outcomes, are common. Elsewhere in the world, such as in the United States, where similar fragmented systems exist, new care-delivery models have emerged to better manage patients with complex conditions. These include vertical payerprovider integration, patient-centered medical homes, and accountable care organizations. Enablers of similar structural reforms are lacking in South Africa, however, where regulatory rules bar the employment of salaried doctors by hospital networks. Moreover, a looming nation-wide dearth of healthcare professionals diminishes the potential for systemic structural changes to the status quo. Discovery Health (DH) is the country’s largest private healthcare payer, providing health insurance coverage to over 2.5 million people. The Care Co-ordination Program (CCP) is DH’s response to the fragmented care received by its members who present with complex healthcare needs, including psychological and social vulnerabilities. Methods The target DH population of members likely to benefit in the CCP is identified geographically using the Johns Hopkins Adjusted Clinical Group tool. This tool categorizes members into Resource Utilization Bands. Further, a Disease Burden Index (DBI) is employed to narrow the focus of the CCP to DH members with the greatest complexity and highest disease burden. The DBI for the CCP population is 17.071 compared to a significantly lower DBI for the general DH population of 1.024 (see Figure 1). Sub-acute service providers in the identified highneeds geographic areas who meet structural, service and management criteria are contracted with DH to participate in a CCP network. At the time of a patient’s admission into an acute facility, a DH care recruiter employs pre-set clinical, social, and psychological entry criteria combined with a FIM (Functional Independence Measure) score to identify patients at risk of sub-optimal quality of care associated with repeated costly admissions. The identified patients are voluntarily enrolled in the CCP and, at this point, a DH care co-coordinator joins the care team of the contracted service provider. The care co-coordinator ensures that the patient’s unique needs are carefully and methodically addressed by the service provider’s interdisciplinary care team. Integrating the family into the care plan is central to ensuring a successful transition to the home. The care co-coordinator shares the transition plan and the patient’s electronic medical record with all involved providers, thus ensuring the co-ordination of care following discharge. The co-coordinator is a valuable resource for the patient, managing vulnerabilities during the transition to home and community. * Correspondence: roshinin@discovery.co.za Risk and Quality Management, Discovery Health, Sandton, 2146, South Africa Naidoo and Steenkamp BMC Health Services Research 2011, 11(Suppl 1):A18 http://www.biomedcentral.com/1472-6963/11/S1/A18