 |
ME Cares Nurse-Physician
Care Support for
ME Cares is a coalition of 30 Maine hospitals that offer community based, care support (disease management) programs for patients with heart failure (HF) and coronary heart disease (CHD). Work on the program began in 1998, building on the belief that:
Further impetus for the coalition came from the expectation that community based programs will encourage community resource development benefiting patients with disease and individuals without known disease. To advance these ideas, stakeholders gathered
(including representatives from physician and hospital organizations,
health plans, Medicaid, and the QIO) 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 with embedded clinical content (CMS® Pfizer Health
Solutions) was obtained, common outcome measures were adopted by all
participating provider organizations, and a credentialing process was
implemented. 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 whom to call for help. 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 transfer (protecting patient and provider confidentiality) and
Pfizer Health Solutions provides data analysis.
To encourage consistency across provider sites, the ME Cares
Steering Committee sets policy and has credentialed the participating
sites using an explicit criteria set. Consistency is also
fostered as each site uses a common information system with clinical
content (CMS®), reports program outcomes using the same measurement
set, and participates in shared learning sessions. Patient participation requires a physician
order. Over 2,000 patients have enrolled in the program to date. Typically, patients with CHD participate for one year while
those with HF remain enrolled for a variable time depending on their
progress. Program-wide results show improvement in a wide
array of clinical measures when baseline and follow-up values are
compared. Heart failure
patients (a progressive illness) show symptomatic improvement, better
self-monitoring, improved mental health scores (SF 12), and medication
use conforming more closely to current clinical guidelines.
Similarly, CHD patients have improved mental and physical
health scores (SF12), better adherence to clinical guidelines, a
reduction in their cholesterol levels (total and LDL), and improved
control of diabetes when present.
Individual hospitals receive reports allowing comparison of
their results to the program-wide results. In order for the ME Cares program to continue,
a sustainable financial model must be developed, reimbursing hospitals
and supervising physicians for the services provided. Progress in that direction is well underway.
In January 2001 the Center for Medicare and Medicaid Services
awarded MCD and the ME Cares program a grant to serve as one of
sixteen demonstration sites as they evaluate the effectiveness of
“coordinated care.” As
participants in the project, hospitals receive $124/enrollee/month
(inclusive of monitored exercise) and supervising physicians receive
$20/enrollee/month. As of October 1, 2002, CIGNA HealthCare is also reimbursing
hospitals and physicians for services provided to patients with heart
failure. Medicaid offers reimbursement to hospitals on a cost basis. For
further information about the ME Cares program please contact either: Claudette
Bean, RN Or Richard
Wexler, MD
HOME
| Who
We Are | Programs
| Resources
| Newsletters
| Contact
|
