Nurse-Led, Team-Focused Healthcare Inspires Providers in New Jersey
Trailblazer in care-delivery model warns it requires hard work – but it gets results
Healthcare providers and insurers across New Jersey are looking for ways to become more efficient and effective in the way they deliver care to patients – particularly those with chronic diseases who make the most visits to hospitals.
Some are finding inspiration in a small nonprofit across the Delaware River in Pennsylvania.
Doylestown, Pa.,-based Health Quality Partners has gained national attention using a nurse-led, team-based model of providing intense, closely coordinated healthcare.
Medicare patients treated by the organization had significant reductions in hospital admissions, emergency-room visits and overall deaths.
Now HQP is working with a group of organizations seeking to replicate that success in serving low-income recipients of Medicaid, through the Medicaid Accountable Care Organization demonstration project expected to launch this year.
Dr. Ken Coburn, Health Quality Partners’ CEO and medical director, helped launch the organization in 2000, two years before it was selected to be one of 15 groups to join a Medicare project aiming to improve patients’ health through better coordination of their care.
His organization based its approach on research focused on ways of improving the health of patients with chronic diseases.
It then hired nurses who visited patients in their homes and used 30 different medical “interventions” based upon the research.
For example, research had shown that efforts to help frail, older patients to manage their weight and engage in physical activity had a significant effect on delaying the onset of full-blown diabetes.
These interventions also focused on such areas as making sure patients take took their medication and understood their diseases and illnesses.
HQP also tailored its interventions to meet individual patient needs, such as training certain patients in techniques to improve their balance, helping them to prevent falls.
“Our thinking was that a lot of smart people had already identified lots of determinants of health and risk factors that could significantly impact health outcomes, but for which our current medical model of care did not really attend very aggressively to,” said Coburn, who recently spoke at healthcare summit organized by the New Leaders Council, a self-described progressive organization of young adults inside and outside of government.
Risk factors that could affect health include social isolation, mild cognitive impairment and diminished physical performance, he said.
Coburn said it was important that his organization didn’t cut corners, and that it made sometimes-expensive investments of time and money to employ interventions that research had shown to work.
“If it was a 17-week structured program in a group, that’s exactly how we tried to implement it,” he said.
After eight years, Health Quality Partners was the only one of the 15 groups that hadn’t raised costs. It also saw a 39 percent reduction in hospital admissions, a 37 percent reduction in ER visits and a 25 percent reduction in patient deaths from all causes.
“That’s a pretty dramatic impact on health outcomes for something that has no known side effects,” Coburn said.
He said his organization was rooted in learning experiences he had in the 1980s and 1990s.
When he was a doctor at Montefiore Medical Center in the Bronx in the 1980s, Coburn worked with a team of healthcare providers that included social workers and community health workers who were reaching out to patients with AIDS. While the drug treatments available at the time were ineffective, Coburn saw potential for the model as a way to reach a vulnerable population with complex needs.
In the 1990s, Coburn moved to Philadelphia, where he worked at hospitals that were trying to treat Medicare patients through a federal program that was designed to pay hospitals to take on the risk of improving their patients’ health.
Again, hospitals tried to deploy teams of different healthcare providers to coordinate patient care. If they succeeded, then they would keep more of the payments; if not, they would lose money.
Many hospitals in the program came up short in trying to meet those objectives.
“It was just really, really hard,” Coburn said, adding that hospitals didn’t have the capacity to build teams of providers in a way that reliably served sicker patients.
He used the lessons from these experiences to build Health Quality Partners, which now has 30 employees.
On the heels of its success with Medicare, Coburn received calls from insurers looking to replicate that work.
While most decided not to move forward when they heard about the commitment involved, Aetna has used the organization to treat 2,500 patients in its Medicare Advantage program. The effort has led to “excellent” health results for patients, as well as savings for the insurer, Coburn said.
Now that the federal government is again changing how it pays providers, encouraging them to take on more risk in trying to improve patients’ health, Coburn sees a risk of repeating mistakes from previous decades, but he’s excited about the prospect of expanding on his organization’s success.
Providers from around the country continue to ask Health Quality Partners about its program, he said.
“We explain and they say, ‘Huh, that sounds hard. What do you have that’s cheaper, faster, easier and that works?’ And I say, ‘I don’t have anything, a bag of tricks, like that.’ This was a team-based model that took a lot of years to design and develop.”
Coburn said that federal officials are designing potentially important programs to improve healthcare delivery, but he added that they might be seeking to achieve too much too quickly: “I think some of them are really stunningly difficult in sudden ramp-ups.”He added that accurately tracking the data generated from these projects could be as important as doing the work itself. Without good data, projects may be seen as successful when they didn’t actually accomplish their goals, or may be seen as failures because essential data just wasn’t recorded.
“We’ll be doomed to recommit over and over again, testing things that are of dubious value, if we don’t structure … ways of testing things that will give us important, insightful answers as to what really works,” Coburn said.
Joel Cantor, director of the Rutgers Center for State Health Policy, said he is a big fan of Coburn’s work. He asked Coburn if research is available on effective interventions for Medicaid patients that New Jersey’s Medicaid accountable care organizations could draw from.
He noted that many of the social factors affecting the the health of people with low incomes, including homelessness, and the long-term effects of traumatic experiences in childhood, may be challenging for ACOs to address.
Coburn said he doesn’t know about the available strategies, but the goal will be to find them and “bake them into” the ACOs’ approaches. He noted that it might require many different interventions. And he pointed out that some of the other organizations in the Medicare project that weren’t as successful as Health Quality Partners tried only one or two evidence-based approaches, while his organization used more than 30.
“The reason is that people with complex needx change over time and ...what works at any given point in time for one person isn’t necessarily what they need the next month,” he said.
Jeff Brown directs efforts to prepare the potential Medicaid ACOs with the nonprofit New Jersey Health Care Quality Institute. He said Coburn would be working with these organizations “to really ensure that they’re doing the best they can in a very data-drive manner to care for complex and needy patients.”