ME-Cares Executive Summary

ME Cares

Nurse-Physician Care Support for
Cardiovascular Health in Maine

Executive Summary

ME Cares is a statewide, provider sponsored, community based care support (disease management) program for patients with congestive heart failure and coronary heart disease. Work on the program began in 1998, building on the following beliefs:

The care of ambulatory patients with chronic illness is aided by building systems to extend the scope and reach of traditional, office-based care.
Physician support of clinical programs increase the likelihood that programs will be effective.
Physician support is more apt to occur when programs originate in local provider organizations and when programs apply to patients regardless of their payer status.

Further, we believe that positioning programs in communities encourages community resource development beneficial to patients with disease and to individuals without known disease.

To advance these ideas, stakeholders were assembled (including representatives from physician and hospitals organizations, health plans, Medicaid, and the PRO) and key program elements were defined, modeled after a successful program in Farmington, Maine. Subsequently, as a coalition of interested providers emerged, a governing structure was established, a license to use a common information system was embedded, clinical content was obtained, common outcome measures were adopted by all participating provider organizations, and a credentialing process was begun.

The basic care support intervention involves outgoing phone calls to enrolled patients from nurses employed by participating hospitals. Guided by the care plan developed in conjunction with the supervising physician (usually a PCP) and the clinical content in the information system, the major interventions are education and support for behavioral change. Patients learn about their disease, their symptoms, and their treatment. They learn to monitor their condition including when and when not to call their physician. They are both challenged and supported in their effort to change unhealthy behaviors that are known risk factors for disease progression (smoking, sedentary life styles, unhealthy diets). National treatment guidelines are followed and variances are discussed in a collegial manner with the treating physician.

Working under the auspices of the Maine Cardiovascular Health Council, Medical Care Development (MCD) facilitates the project. The Maine Health Information Center manages data and information (protecting patient and provider confidentiality) and the Maine Medical Assessment Foundation is contracted to help with an overarching quality improvement program. To encourage consistency across provider sites, the ME Cares Steering Committee sets policy and has developed a credentialing process with an explicit criteria set. Consistency is also encouraged by the common information system with clinical content and the common outcome measures reported by all participating provider organizations.

Patient participation requires a physician order. Currently over 800 patients are enrolled and 22 hospitals are participating. We envision enrollment periods of one year for CHD and an indefinite period of enrollment for CHF patients. Initial program results, with six months of data, suggest a positive impact on a number of process and outcome measures.

In January 2001, HCFA awarded MCD and the ME Cares program a grant to serve as one of fifteen demonstration sites as they evaluate the effectiveness of "coordinated care." This will allow reimbursement to hospitals and supervising physicians for their care support and supervisory roles. The Medicare reimbursement model anticipates payment of $124/enrollee/month to facilities and $20/enrollee/month to supervising physicians. In addition, Cigna, Harvard Pilgrim, and Medicaid will be reimbursing hospitals and supervising physicians. Discussions are ongoing with Anthem BCBS.

We believe that the ME Cares program offers hospitals the following opportunities:

To play a leadership role in developing and implementing clinical programs for patients with chronic illnesses that improve clinical quality and avoid unnecessary costs (building non-brick and mortal infrastructure).
To develop an efficient, nurse-physician team model to support care through education, encouraging behavioral change, and care coordination.
To improve hospital-physician relationships by collaborating on a major clinical initiative.
To foster the development of community health resources by advocating for community based programs rather than centralized, national programs.
To simplify the interface with managed care organizations by advocating for clinical programs that apply to patients regardless of payer status.
To receive reimbursement for care support services.
To influence Medicare reimbursement policy by participating in a national demonstration project.

For more information about the ME Cares program, please contact either: Claudette Bean, RN, at 207-622-7566, ext. 260 (cbean@mcd.org) or Richard Wexler, MD, at 207-622-7566, ext. 226 (rwexler@mcd.org).