Getting it together

Call him Samuel. It’s not his real name, but the medical challenges he faces are real enough: Severe mental illness, diabetes and a bad back have left him incapable of living independently. Thanks to Medicaid, Samuel had a family doctor, a family-care home to live in and a team of mental health professionals.

Yet in the year before he became a client of Community Care of Western North Carolina, Samuel logged 16 trips to a hospital emergency room and was admitted six times. Like thousands of other chronically mentally ill Americans, he floundered at the intersection of two trends — both, ironically, intended to improve health outcomes.

Double-edged trends

For most of us, the family doctor is no longer a one-stop health-care shop; we have specialists for everything. Medical tests are often performed outside the doctor’s office or hospital. Insurance companies loom large in care decisions for those who still have coverage. And chronically ill people typically have multiple providers, not to mention bills pouring in from all directions.

Teresa Collins, the nurse care manager assigned to Samuel, deals daily with the fallout from such complexity. “Managing my own health care is difficult,” she says. “For the patients I work with, it’s just overwhelming.” Although the various providers do a good job within their areas of expertise, they may be less successful when it comes to communicating with one another or factoring in what a patient wants.

Fifty years ago, Samuel wouldn’t have had to deal with such issues. He’d have lived in a state psychiatric hospital where his medical, psychiatric and housing needs were dealt with in-house. But the deinstitutionalization trend has changed that. Chronically mentally ill people are being reintegrated into the broader community. And while the change has broad support among health professionals, the process can be rocky for patient and provider alike.

Reintegration

Enter Community Care of North Carolina, an award-winning state program designed to address costly breakdowns in health care for Medicaid patients. CCWNC (the regional branch for eight western counties) strives to reintegrate care for those who have more medical emergencies and hospitalizations than the average for Medicaid patients with similar illnesses. (Yes, there’s an app for that.)

Community Care connects clients with stable, patient-centered “medical homes”: primary-care practices willing to assume the central medical role. Care managers like Collins ask patients about their health-care goals, educate them, ensure that appointments are kept, coordinate treatment plans and get pharmacist advice on sorting out bags of pills. They might even intervene in nonmedical issues. “If you lose your housing,” notes Collins, “it affects everything else.”

Does the addition of yet another health-care professional really do any good? In terms of some common debilitating illnesses, the answer is an unequivocal yes. Community Care clients do better than the Medicaid average on all six outcome measures for which national benchmarks are available. They see their primary-care doctors more frequently than those not enrolled in the program. They visit hospital emergency rooms less and have slightly fewer hospitalizations overall.

But clients whose conditions include mental health or substance-abuse problems haven’t seen the same degree of improvement. In response, a new Community Care initiative reconnects head and body, working with both behavioral and physical health providers to help achieve the patient’s own goals.

That’s welcome news to Charlie Schoenheit of the Western Highlands Network, which manages behavioral health services for Medicaid patients. Schoenheit says CCWNC simplifies the process of obtaining primary medical care for patients who walk through his door first. And for some hard cases, Western Highlands and its contracted service providers may assign a case manager.

Too many managers? Not according to Schoenheit. “These are smart folks,” he notes. “They don’t have trouble deciding who should take the lead in a particular case.”

But how’s it really working?

Collins began her involvement with Samuel by sitting down with him and his providers. Samuel expressed a need to see his family doctor more often. The doctor didn’t think it was medically necessary, but he scheduled Samuel for monthly checkups. The mental health team and family-care home agreed on a unified plan and adjusted the behavioral approaches.

Over the next two years, Samuel’s use of the emergency room dropped to just six visits, with no hospitalizations. Now medically stable and feeling heard, Samuel reduced his doctor visits to a more normal frequency, Collins reports, and she’s been able to step out of his care.

Results like this make her proud to be involved with the program. “I love my job,” she says. “What we do here should happen nationwide.”

All well and good, a skeptic might reply, but how much is this program costing taxpayers?

In a report to the North Carolina General Assembly, Milliman Inc., an independent health-care consulting firm, estimates that in the fiscal years 2007 to 2010, the program actually saved N.C. Medicaid $948 million.

— Asheville resident Michael Hopping, a retired psychiatrist, is a freelance journalist and fiction writer.