New Hope Care Center pilots new care-delivery model BY SUE WEBBER CONTRIBUTING WRITER A new care-delivery model that encourages doctors to work closely with providers who help people recover after they’re discharged from the hospital is being tested at the Good Samaritan-Ambassador Care Center in New Hope. In August 2011, the Centers for Medicare and Medicaid Innovation (CMMI) invited health care providers to apply to help test and develop four different models of bundling payments. Five skilled nursing centers and three home health agencies volunteered to participate in the three-year study. The goal of the Bundled Payments for Care Improvement initiative is to improve health care delivery, try to avoid readmission to the hospital, lower costs for the Medicare program, and ensure that patients get better care following their hospital stay. “Bundling payments is a care initiative, for care improvement,” said Marie Barta, administrator at Ambassador. At Ambassador, Medicare patients who come to the short-term care rehabilitation center with heart failure or lower joint replacement are monitored for 90 days, from the time they are admitted. Paula Hanson, Ambassador’s client advocate, begins by discussing with the patient his or her health condition and care plan, and then follows through with helping the patient through the system. “Her intervention is to provide patient engagement, education and followup” Barta said. “Her goal is to build a relationship with patients to help them through the transition and to educate them on how to care for themselves.” Hanson makes sure patients understand the importance of monitoring weight and blood pressure, that they set up doctor appointments and see their physicians for follow-up visits. She also
Paula Hanson, left, the Bundled Payments initiative patient advocate at Good Samaritan Society-Ambassador in New Hope, meets with Jean Lindstrom, a client in the program. (Submitted photo) makes home visits after the patients are released from the short-term care unit at Ambassador. In addition to helping patients understand and manage their medications and plan for follow-up doctor appointments, Hanson helps them recognize warning signs that may affect their health and assists them in meeting their personal well-
ness goals. One of the program’s goals is to lessen chances that patients will have to return to the hospital, or have to be seen in an emergency room, Barta said. “If we find that this kind of intervention is successful, it could be a good model of care for this population,” Barta said. Patient feedback so far has been positive, she said. “Patients like the coaching
and one-on-one, and that Paula is there to support and guide them. They like that someone is checking in with them, especially if they live alone and are going home. It’s different from the care they get from family members or doctors and nurses.” MODEL - TO PAGE 4