Improvement Stories:
Taking Special Care: Helping More than 4,000 Medicaid Patients Manage Their Health
Partners HeathCare hospitals care for more than 100,000 Medicaid and uninsured patients each year. We have made major progress in identifying patients with the highest risk of rehospitalization in that group, and giving them special attention at home to help them stay well and to help connect them to the resources they need. In a three-year pilot program, Health Coaches have made more than 10,000 phone contacts with patients with chronic or complex conditions. Coaches, including nurse practitioners and other professionals, help them manage their care and maintain their health so they do not require hospitalization. They are making sure over 4,000 patients annually are taking medications or getting refills, keeping appointments with doctors, and receiving tests. In addition to answering a patient’s questions, Health Coaches also contact the patient's physician to provide medical updates and relay the patient’s concerns. Partners HealthCare offers programs for children and for patients with severe mental illness as well. As 10 percent of all patients account for 70 percent of the nation’s health care spending, the coaching program is part of a major effort by Partners HealthCare to improve care whjle controling health care costs. Our data suggests that even with the added cost of Health Coaches, the overall cost of care for patients has decreased 3.5%, due mostly to avoiding unnecessary Emergency Department visits.
Photo detail: Martha Colon is a Medicaid patient who works with a registered nurse who coaches her regularly by phone to help manage her chronic illness.