Project transforms patients' lives, slashes costs

Sep. 1, 2014

Project transforms patients' lives, slashes costs - Multicultural Health Foundation

SAN DIEGO, Calif., Sept. 1, 2014 – An innovative project is transforming the lives of the neediest patients while cutting health-care costs. Early results offer a powerful prescription for communities and the health care system struggling to care for the long-term ill.

The three-year project is being funded by a $1.1 million Healthcare Innovation Challenge Grant, just one of four awarded by the federal government in 2011. It was won by a San Diego group of independent physicians, the Multicultural Primary Care Medical Group, in partnership with the San Diego Organizing Project and other national and local partners.

The project targets chronically ill patients reeling from one medical crisis to another, frequently landing in emergency rooms, racking up expensive bills. These patients are generally stabilized and sent home alone, unsure how to manage their multiple ailments, often facing other serious problems, such as inadequate housing, a lack of transportation and depression. Some are referred to government agencies or non-profit organizations to seek help.

The San Diego project turns this cycle on its head.

An entire care team works closely with each patient for up to 12 months to meet his or her immediate health needs and tackle the major social problems affecting their health. The idea is to make a long-term impact on the individual’s quality of life, which in turn helps their families, caregivers and the health care system.

This approach sounds expensive but the preliminary data is showing the opposite. The 105 participants enrolled so far have reduced their visits to the emergency room by 31 percent, hospital admissions by 22 percent, and hospital stays by 49 percent, compared to the period before enrolling.

Of those, a cohort of 21 participants who belong to one health plan saved nearly $660,000 in health care costs in a year, down from $1,625,000.

In all, the data show that for every dollar spent on the project, $5 is saved.

The goal is to enroll up to 160 patients in the project, which is known as the Patient Health Improvement Initiative. They come mostly from the underserved neighborhoods of Southeastern San Diego, City Heights and National City, which have the highest rates of diabetes and hypertension and early deaths in the county. The diverse team members in charge of their care have long worked in these areas, giving them an understanding of their patients’ challenges.

The team includes a nurse case manager, a social worker, community health workers and faith-based volunteers. They work intimately with each patient, including visiting his or her home, to help manage the chronic diseases, to coordinate medications and therapies and to accompany them to their appointments, all the while offering emotional and spiritual support.

Along the way, they teach patients how to navigate the complicated health-care system, empowering them to advocate for themselves. When they encounter a health problem, they know who to contact to get immediate help, usually a nurse familiar with their case. This way, they solve a problem early before it spirals into a crisis that ends with a trip to the hospital.

This approach is having a profound impact on the patients.

One looks forward to returning to work after learning how to control his severe kidney disease at home. Another one is learning to manage his diabetes and is literally taking his first steps toward a more independent life as he learns to use a prosthesis. No longer homeless, a third now shares a house with his daughter and grandchildren – and a new outlook on life.

The project’s director is Dr. Rodney G. Hood, who founded Multicultural Primary Care Medical Group more than 20 years ago and is a national leader in the fight for equal access to quality health care, regardless of skin color, socioeconomic status or zip code.

“Beyond stabilizing their health, these patients have been empowered to help themselves,” Dr. Hood said. “That’s a dramatic achievement when you consider this population.

”These patients are generally part of a small population that cost the system a disproportionate amount, sapping all players in the health-care arena. By one measure, the costliest 5 percent of Medicare patients account for 38 percent of all Medicare spending, according to 2012 federal government statistics.

“Based on our early results, this project’s approach can be used to slash health-care costs in communities nationwide,” said Paul Hernandez, the project’s manager.

The project team may be reached at (619) 266-3664.

“I felt all alone before I joined this project,” said Lavelle Picou, a 48-year-old participant battling sickle cell anemia. “They gave me my life back.”

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