BUSINESS FIRST: Population health programs expand care, while cutting costs

Health Care Focus

Tera McIlwain is a pharmacist for Millennium Collaborative Care but works directly with patients from a Horizon Health Services site.

By Tracey Drury – Reporter, Buffalo Business First

It’s been a few years since “population health” became a common phrase in the health care world.

But what does it mean? The Centers for Disease Control and Prevention have a concise explanation that points to nontraditional partnerships among different sectors of the community – public health, industry, academia, health care, local government entities, etc. – to achieve positive health outcomes for a group.

The idea is to identify significant health concerns and then come up with ways to allocate resources to overcome problems that drive poor health conditions.
In Western New York, programs were introduced in recent years to improve the region’s population health. Providers said they work, with collaborative programs helping to expand access and reduce barriers to care.

Two programs detailed below were funded as part of a $7.3 billion statewide Medicaid waiver program known as DSRIP (Delivery System Reform Incentive Payment). The waiver program intends to cut costs in the system by reducing unnecessary emergency department visits and avoidable hospitalizations by transforming systems, boosting clinical outcomes and improving overall population health.

Community Partners of WNY
The community health worker program was launched by Community Partners of Western New York, one of the region’s two performing provider systems created through DSRIP. The organization partnered with the Buffalo Urban League and Catholic Charities of Buffalo to embed these workers at community health provider sites to work directly with patients in the areas of behavioral health and maternal/fetal health.

Amy White Storfer, director for Community Partners’ project management office, said these workers connect with patients outside the four walls of a health setting and help them overcome whatever obstacles they face in getting to their doctor.

“It’s about helping those patients with obstacles they may have for access to care,” she said. “We know there are patients who have a primary care provider but may not have been seen for their annual (exam), but we know they are at risk maybe for early-onset diabetes or asthma.”

As both a physician by training and CEO of Catholic Medical Partners, Dr. Thomas Lawrence said the program helps address the needs of a patient on a more global basis.

“It’s more than just good medical care in the traditional medical sense: It’s addressing the very important basic needs of people, like housing and good nutrition and transportation needs, things that we know significantly influence state of health,” he said.

The community health workers (CHW) are often in the field, tracking down patients and helping to identify what keeps them from making it to an appointment.
Megan Lostracco is project coordinator for the program at Catholic Charities, where three CHWs maintain a caseload of 50 to 75 patients. She recounted a situation that involved a patient who has severe anxiety and hadn’t had an annual physical in years. His assigned CHW accompanied him several times before finally getting the patient into the office for his exam.

“Each step he got a little closer,” Lostracco said.

Other times, the task is about educating people about resources available to them that they might not even know existed. That could include how to access and call for a cab paid for by Medicaid, connect with a nutritionist or what to do if they face eviction.

“It’s about figuring out what the barrier is, help people cross those barriers and empower people to become independent,” she said.
Grace Tate, executive vice president of the Buffalo Urban League, oversees a team of nine people in its CHW program who work out of Catholic Health clinic sites. She said the reason the program works is many of the workers are from the same community and faced similar challenges so they’re able to connect on a different level than a doctor might.

“They have a certain level of trust and intervention, so they really expand the provider bandwidth for what goes on in the clinic,” Tate said. “They become the foot soldiers for part of the health care team and it really increases the quality of health care the individual receives.”

The organization is thoughtful about whom they hire in the program, as well, recognizing that not everyone will succeed at a job that requires persistence, tenacity and compassion. Sometimes the employee must call family and go house to house tracking down someone who changed their phone number or address.

“It could take six or seven interventions before they get someone to come in. They have to hunt down some patients,” Tate said. “You can’t be squeamish. The level of care that it takes and insight and patience is extraordinary in some cases.”

Tera McIlwain, a pharmacist and Michelle Curto, Horizon vice president of administrative operations speak about a patient at Horizon Health.

Millennium Collaborative Care
Millennium Collaborative Care, the region’s other performing provider system, introduced an enhanced patient services program in November to address gaps in care, increase access to community resources and help make sure patients take the proper medications while decreasing the likelihood of a bad drug interaction.

In April, the program expanded by embedding a pharmacist at Horizon Health Services to meet directly with high-risk patients before or after their appointments for behavioral health and counseling. Michele Mercer, chief clinical integration officer for Millennium, said the program was designed to make sure that patients filled and took their meds, known as medication adherence.

That’s typically a problem for people with depression, schizophrenia and other mental health conditions.

“We know that 5 percent of our population is expending 50 percent of the resources and costs,” Mercer said. “We start at that highest level to identify those highest-risk patients. Then we drill down to those who would benefit the most and then look at what’s driving their behavior or condition.”

Tera McIlwain, the Millennium pharmacist and care manager, works from Horizon’s office on Bailey Avenue, often without her white coat on, to help make patients feel more comfortable. The meeting starts with a dialogue to find out if the patient understands why they were prescribed each medication, what it does for them and what happens if they don’t take it.

“I want to know what the patient knows about the medication and fill in any gaps,” she said.

McIlwain goes over with the patient other medications prescribed for other chronic conditions, and with the physician, too. She plans some sessions with staff so they understand how each medication might increase or affect the risk of other chronic conditions common in that patient population.

Sometimes they know why they take the meds, but they might not know about potential side effects and how they can alleviate those issues.

In the first month of the program, McIlwain had 16 successful patient interactions. That included a woman who was living with her mother and, because of a financial situation, the daughter began using her mom’s medication when hers ran out. That left them both at risk for more serious illness related to hypertension and diabetes.

A few phone calls later, McIlwain had ironed things out with the physician’s office and the pharmacist so both women had the correct meds.

“It’s more of an open conversation with the patient to find out what their needs are, and also what are the solutions or different routes,” she said.

Michelle Curto, Horizon vice president of administrative operations, said the shared resource provides an extra layer of care in behavioral health offerings that also benefits staffers.
McIlwain also shares information about resources that staff and patients may not have known about, and she’s accessible via email to staffers at Horizon’s 20 other sites, too.

“Our patients are always on medicine, but they’re not always good about telling us all the medicines they’re on,” she said. “It’s even knowing how to ask the question.”



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