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Vermont's blueprint for health. Retired IBM engineer Stephen Hennessey of Essex Junction, Vt., is "very, very happy" with his internist, Lucy Miller, especially since she helped him get serious about a lifestyle overhaul by providing him with extra attention, at no cost to him, from a nurse, medical social worker, health coach, and dietitian. Like many of Vermont's primary care practices, Miller's is organized as a "patient-centered medical home," where people build relationships with the doctors and can count on getting quick attention to their acute and preventive medical needs, coordinated care when specialists are warranted, and guidance in taking care of themselves. Last fall, when Miller diagnosed Hennessey, 60, with type 2 diabetes, she prescribed medicine and a better diet plus exercise. She then connected Hennessey with one of the state's new local community health teams that works in conjunction with her practice to coordinate Hennessey's care and cheerlead as he develops healthier habits. So far, Hennessey has lost 30 pounds and soon expects to stop taking two of his four drugs.
Community health teams now dot Vermont, helping to extend the reach and preventive power of primary care practices. You don't have to be served by Medicaid or have particular private health coverage to qualify; the teams take "all comers," says Lisa Dulsky Watkins, associate director of Vermont Blueprint for Health, the state's initiative to transform healthcare delivery. Early evidence suggests that Blueprint is working to contain costs. A four-year review of hospital data showed that the growth in inpatient admissions and emergency department visits has slowed.
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Heart Care at Home. The first month after a hospital discharge is a vulnerable time for many people, since post-hospital care is often chaotic—even if patients are not left entirely on their own. Insurers typically have not reimbursed hospitals or doctors for coordinating care after a person leaves, and frequently have had to pay instead for costly readmissions. Approximately 1 in 4 people with heart failure are back for return visits within a month of being sent home, for example. As of October 1, Medicare starts financially dinging hospitals when certain patients are readmitted within 30 days.
The Cleveland Clinic's two-year-old Heart Care at Home program aims to bring those numbers down. When Richard Jones of Niles, Ohio, 70, was discharged in May, he was sent home with a digital scale to flag any weight fluctuations (a possible sign of fluid buildup), a blood pressure cuff, and other monitoring equipment tied into the hospital system. He was also assigned a telemonitoring support team of nurses, social workers, nutritionists, therapists, and doctors who would check his vital signs daily, remotely or in person, for up to 40 days. In phone and house calls, the team coordinated follow-up doctor visits and counseled the lifelong cheeseburger-and-fries fan on worrisome symptoms to watch for and how to make lifestyle changes stick.
"I've stopped smoking, and all these things they told me to do, I've done," says Jones. "Without them, I don't know how I would have got through this." Cleveland Clinic is not paid directly for Heart Care at Home, and does not charge patients. But so far the readmission rate for participants is running 4 percent lower than for the hospital's Medicare heart failure patients overall. And, says David Longworth, chairman of the Cleveland Clinic's Medicine Institute, it's "the right thing to do."
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