More than house calls: Why Sacramento doctors are delivering pills to their patients
North Highlands resident Lori Swanson still marvels that her doctor went out of his way to pick up her medication from the pharmacy: “I was not able to get it, and he went out of his way to help me.”
A Medi-Cal patient, Swanson has a foot injury that makes it difficult to get around. She lost her job of 17 years because of the injury, she said, and because she had no income, she lost her home and everything she owned.
Then, last summer, she signed up for a home-based care management program through her insurer, Anthem Blue Cross, she said, and one by one, a multidisciplinary team of caregivers entered her world and helped to restore her to the lifestyle that she had before her medical crisis.
Dr. Christopher Lillis leads that team as the associate regional medical director with Anthem’s CareMore Health division. He was the physician who went by the pharmacy to pick up Swanson’s medication. He described it as “the most natural thing” to do because he was worried that his patient’s recovery could be affected if she didn’t get that medication in a timely manner.
“One of the fathers of American medicine’s quality movement is Dr. Don Berwick,” Lillis said. “He’s got this easy phrase: ‘Right care at the right time at the right place.’ If we give the right care at the right time at the right place, people lead healthier lives, and it costs the system tons less.’
Anthem opened up a CareMore office in Sacramento this summer to begin working closely with roughly 7,000 Medicare and Medi-Cal beneficiaries being served by the insurers’ largest independent physician association, River City Medical Group. Together, the insurer and River City identified the top 10 percent of patients who have complex medical conditions that put them at high risk for hospitalization, emergency room visits and poor health outcomes.
The CareMore team here — composed of a physician, a psychiatric nurse practitioner, a geriatric nurse practitioner, a nurse case manager, a social worker and community health workers — hope to duplicate or beat the success that CareMore had with 105 patients in Connecticut. Over a 10-month period, a home-based care management team reduced hospital admissions for the patients by 12.5 percent, cut their emergency room visits by 27.2 percent and lowered costly visits to specialists by more than 30 percent.
Teaming with River City
The idea, Lillis said, isn’t that the CareMore team will replace the patients’ primary care home at River City. Rather, he said, they work with River City doctors to keep patients from falling through holes in the safety net and to ensure that patients land safely and get guided to the right medical professionals.
In most cases, Lillis said, that’s not an emergency room.
“You’re treated like a number. You’re asked to wait in the waiting room for six to eight hours,” he said. “There’s got to be a more humanistic, patient-centered way. That’s really what bringing the care into their homes is. It’s cutting out a kind of inhumanity of being in the emergency department waiting room and bringing it to a place where they feel comfortable, where it’s safe, and where there’s not the chaos of some folks being wheeled in with gunshots or some folks coming in with a heart attack.”
The primary care system is by far the most efficient and effective system for taking care of most medical problems, Lillis said, but people with complex medical conditions often get caught up in a cycle of ER visits and hospital admissions that never get to the root of what’s holding the patient back from recovery. In Swanson’s case, CareMore’s team found, she needed assistance with the paperwork to get the money that would pay for housing and food.
“We look at the whole person and figure out how we can help restore health and joy in life,” Lillis said. “The pragmatic little things ... can help a person gain momentum and rebuild their health. That’s what I think we’re doing for Lori. And, from the day I met her up through now, she’s smiling a lot more, a lot more encouraged, a lot more hopeful.”
Swanson said that CareMore’s physician-led team goes beyond monitoring her physical condition, charting her medication use or discussing her lab results. They also look for social and behavioral health barriers that could torpedo her recovery. In a matter of weeks, she said, she came to think of the CareMore staff as family because of their commitment to helping her recover from psychological traumas and return to financial security.
“It’s about someone who knows what your needs are and helps you through what your needs are and makes sure you get to that point where you’re able to do what you want to do,” Swanson said.
How CareMore’s approach helps
Swanson said she has daily reminders of just how different the CareMore approach is because her mother, a Medicare patient, had a stroke two years ago and is paralyzed from the neck down. She also has been diagnosed with dementia. Her mom has coverage through a different insurer.
Because of her mom’s medical conditions, Swanson’s father can no longer drive her mother to medical appointments, she said. Every time her mom has to go to see the doctor, the couple must pay $500 out of their fixed budget to pay for it. Consequently, Swanson said, her mom sees physicians only when there’s an emergency.
“Every time Dr. Lillis ... or somebody else from CareMore comes over, my dad sits there and looks at me and says, ‘I wish (my insurer) had this.’ My mom is going downhill because of that. If she had CareMore coming in, I know she would be so much better than what she is now. She’s not getting the care that she needs.”
At first, Swanson said, she didn’t want CareMore to expand to serving more patients because she was afraid they’d have less time for her, but as her health has steadily improved, she’s come to believe everyone in the world should have access to this type of medical attention.
While you might think this individualized type of care would be costly, Anthem’s Dr. Demetria Malloy said CareMore brings a depth of knowledge on how to stabilize patients with chronic conditions and how to guide them back into a medical care home where their needs can be met.
Just as importantly, CareMore’s team sits with people wherever they call home, so they can observe what each individual needs, said Malloy, the regional medical director for Anthem’s Medicaid health plan. Often, she added, family members sit in on the assessments CareMore does, and they provide information that the patient has forgotten or hasn’t thought of. What those sessions also provide, she said, is a picture of just how vital the patient is to the family unit and how the deterioration of their health has affected everyone in the home.
“Sometimes ... we need to be able to give a different resource other than what’s standard,” Malloy said. “Sometimes, there’s just a barrier there that they just aren’t able to get over. We’re trying to just pinpoint that, help solve that for them and bring them back.”
Lillis and Malloy said that CareMore’s community health workers and social workers become experts at knowing the community resources available to patients and how they can be used to knock down barriers.
“Medical costs come down as a byproduct of this process,” Lillis said. “We’re helping someone get their most pressing needs met. What I’ve noticed in health care over the years is that it’s just been very transactional. Patients are told to make appointments. They come into appointments, and they get 15 minutes with a doctor. Maybe they’ll get to talk about one or two issues, and it doesn’t get to the root of what’s holding people back.”
