The Hospital, Your Care Coordinator

Some centers now take charge of keeping people healthy and at home.

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Hospitals aren't known for making house calls. Once patients get their discharge papers, they take their chances with a family doctor or staffers at a clinic who may or may not know what happened inside the hospital's walls. So Margaret Bennett's experience is pretty rare. Bennett, 84, who had a stroke 11 years ago and colon cancer in 2007, recently spent two weeks at Montefiore Medical Center in the Bronx because of a blood clot in her leg. In many places, such a frail and elderly patient might be hospitalized for weeks or even months, but Bennett's doctor now comes to her.

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Every two weeks or so, geriatrician Mohamed Aniff visits, lingering for close to an hour in the sunny and spotless apartment she shares with daughter Geraldine, 65—surroundings far cheerier (and more economical) than any hospital room. The Bennetts have Aniff's cellphone number, so they can reach him any time of the day or night, and if they had a computer they could query him by E-mail, as many of his patients do. The costs of the visit are covered by Medicare. By coming to Margaret, Aniff can assess the safety of her environment, discuss her care in depth with Geraldine, and develop the kind of personal relationship rarely found between patients and hospital staff. "He's something else," Margaret says of Aniff, as she grabs his hands and smiles broadly. "He's family."

Why this unusual level of involvement for one elderly New Yorker? Montefiore is pioneering a new model of healthcare delivery, endorsed by the architects of health reform, that promises to radically change the current fragmented system in which the family doctor may have no idea what happens during a hospital stay, or a diabetes patient's endocrinologist, internist, and cardiologist never talk to one another. As an "accountable care organization," or ACO, Montefiore, along with Kaiser Permanente in Oakland, Calif., Intermountain Healthcare in Salt Lake City, the Mayo Clinic in Rochester, Minn., and a handful of other medical systems, is experimenting with a novel way to save money and improve patient outcomes by coordinating all of their care, by all of their doctors, whether in the hospital or out.

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The ACO idea was born out of discussions in 2006 between Elliott Fisher, director of the Dartmouth Atlas Project, which documents regional disparities in healthcare, and Glenn Hackbarth, chairman of the Medicare Payment Advisory Commission. "Our early work at the Dartmouth Atlas showed that most healthcare is local," says Fisher. "Patients go to their local hospital, and see doctors that work in networks based around that hospital." He and Hackbarth envisioned a model in which a hospital, a large physician group practice, or a combination of the two would be held accountable for the well-being of a community of patients, most likely all those living within a few miles. The organization would receive a flat fee per year from each person's insurer or employer, based on health and age, and then work to keep all as healthy as possible and out of the hospital. The medical provider should thus be able to come out ahead financially. Home visits would become commonplace, as would such 21st-century tools as electronic medical records and sophisticated home health monitoring systems.

If an ACO patient does end up in a hospital bed, it is in the organization's best financial interest to make sure that the care is of high quality, that hospital-acquired infections and medical mistakes don't happen, and that medications are administered correctly, reducing the need for any extra care. Once the patient checks out, doctors affiliated with the organization follow up to make sure he or she doesn't return in short order, since a high readmission rate could lead to cuts in Medicare payments.

ACOs are rare today; there isn't even much agreement on a definition. But provisions in the health reform law call for Medicare to establish an agency that would set up and evaluate different models of coordinated care delivery, including the ACO and the "medical home," a related concept in which a primary care physician coordinates all aspects of a patient's care. Ideally, proponents say, ACOs and medical homes would join forces for the greatest impact.