“They’re desperately in need of something we’re not giving them.”

Three state projects are giving Maine’s biggest medical users more help, and it’s already paying off in a host of ways.

Last year, Tammy Wilson visited the emergency room 38 times.

She knew she went there a lot — too much — but she didn’t know what else to do for her debilitating migraines. In the past she’d seen her primary care doctor and a neurologist, tried over-the-counter drugs and prescriptions. The ER offered the only solution she knew would work, and work fast: an intravenous medication that beat back the agonizing headache enough for her to keep her on her feet as a single mother and the on-site manager for two Travel Inn motels.

“Some days (the ER trip) was two times a day because my migraines were so severe,” she said. “I would try to take care of it at home, but the only thing that worked was going in and getting an IV.”

Then the state took notice.

Wilson is insured through MaineCare, the state-run Medicaid program for the poor, disabled and elderly. The Maine Department of Health and Human Services, which oversees MaineCare, was not happy paying for 38 expensive ER visits for one person in one year.

But in its effort to save money, the department didn’t cut back Wilson’s services.

It gave her more.

Wilson got her own care manager, a state-paid nurse who coordinated Wilson’s care, checked with her after appointments to make sure she was benefiting from them and encouraged her to make herself and her health more of a priority as she dealt with the daily stresses of work and parenthood. Wilson’s primary care doctor saw her more often, working to get her migraines and her blood sugar, which exacerbated the headaches, under control. She got new prescriptions to try.  

It all worked.

Wilson, who averaged nearly one ER trip a week last year, has been to the local emergency room only twice in the past four months. One was for a migraine; one was for a possible broken bone after a fall on the ice.

The change has saved the state big ER bills. And Wilson is both happier and healthier.

It sounds counterintuitive: To save money on health care the state should spend more money on health care.

But that’s exactly what Maine is doing.

Spending more on case managers and nurses. More on medications. More on visits to the doctor’s office.

And not just that. Housing, too. Child care and job training. Transportation. Things that seem to have no impact on a person’s health but actually do.

“We’re not connecting the dots (as a nation),” said Dr. Jeffrey Brenner, a national leader in the effort to change how the country’s neediest — and most expensive — patients get health care. He is working with Maine.

Experts are pleased by early data that show spending more for comprehensive care now may save money down the road and improve people’s quality of life. They are so pleased with the data that Maine is moving forward with not one but three major programs.

One deals with high emergency room use like Wilson’s.

Another gives MaineCare patients a “medical home” that coordinates their health care.

And the third — the newest and potentially most far-reaching — looks at the needs and goals of an entire high-cost family and works to meet them. Better housing? Odd-hours child care? Someone to remind them about prescriptions and medical appointments? All that and more.  

“These are truly the people who are most dependent upon DHHS to do the right thing for them or at least make the right opportunities available to them,” said Kevin Flanigan, medical director for MaineCare Services. 

That third pilot program, Partners in Health and Wellness, is based in Lewiston. Two families are already enrolled.

 ‘In need of something we’re not giving them’

Health care, particularly health care for the very poor and very needy, has traditionally been fragmented. Patients could see an emergency room doctor, a clinic doctor, a family doctor and a specialist — and receive separate prescriptions, diagnoses and advice — without any coordination or follow-up. No one looked into patients’ lives to find out, for example, whether mold was exacerbating their breathing problems at home or whether they could afford the insulin they needed for diabetes.

Several years ago, Brenner, a Camden, N.J., doctor, began researching medical “hot spots,” looking at neighborhoods where residents had the highest hospital costs. That led him to look at the residents themselves.

Brenner’s goal was to help patients get better. The added benefit: high-cost patients who got better wouldn’t be so high-cost anymore.

He found that patients often had several interconnected problems — physical health, mental health, living situation, lifestyle, addiction — but their doctors, social service workers and other providers weren’t collaborating. No one was helping with the patient’s overall situation.

“They’re desperately in need of something we’re not giving them,” said Brenner, executive director of the Camden Coalition of Healthcare Providers and medical director of the Urban Health Institute at Cooper University Health Care in New Jersey.

He started giving people that help. It was intense, highly personalized and often time-consuming, but he saw results. ER visits dropped, expensive care decreased. People felt better.

Brenner’s work has been profiled by The New Yorker and Frontline and touted by the Robert Wood Johnson Foundation. Across the country, others have started using his approach.

It caught the attention of Maine health care experts.

In 2012, MaineCare cost nearly $2.5 billion. According to the state, 5 percent of MaineCare users account for more than half of spending in the program.

“How does that 5 percent group really look outside of just their cost parameters?” MaineCare’s Flanigan asked.

Brenner has worked with the state to find out.

“I’ve had the good fortune to meet Gov. (Paul) LePage and spend a lot of time with (DHHS Commissioner) Mary Mayhew and with her staff, and it’s very clear that increased spending in Maine is a crisis and that the state is struggling with how to reduce costs in Medicaid,” Brenner said. “And also, a lot of the people who are getting the really expensive care are not getting good care.”

About four years ago, the state took the first step toward Brenner’s philosophy. It created the Patient-Centered Medical Home program. 

Medical homes

Medical homes provide a base for doctors, nurses and others to coordinate a patient’s health care. The concept first interested pediatricians in the 1960s and 1970s. In recent years, it’s grown popular with doctors who serve adults and families.

The Patient Protection and Affordable Care Act of 2010, which makes sweeping reforms to health care, encourages the creation of medical homes.  

MaineCare started its medical home pilot program about four years ago with 26 medical practices, then expanded to 75. To qualify, the doctor’s office had to agree to offer coordinated services, meet quality and service criteria and partner with a Community Care Team. 

Those teams help coordinate community services and patient care outside the doctor’s office.

“A private practice might ask that (MaineCare) member to come in to the office and do a pill count in the office and review all the medicines they have,” Flanigan said. “A Community Care Team would be able to go to that person’s house and say, ‘Where are your medicines? How do you lay them out so you know you’ve got them for the week? How do you know you need to get to the pharmacy before that runs out?'”  

Central Maine Medical Center in Lewiston joined the medical home program just over a year ago. Today, 21 of its 24 primary care practices are involved, giving patients immediate access to nurses, counselors and health coaches, along with doctors.

Claire Cote, director of care integration for CMMC, believes the program has helped patients. She recalled one man who had diabetes but said he couldn’t come to the doctor’s office. Rather than simply cancel his appointment and move on, the office — a medical home — sent Androscoggin Home Care and Hospice to check on him. 

“They found out the reason the gentleman couldn’t come to the doctor’s office for his visit was because his car had broken down. And the reason he couldn’t afford to get his car fixed was because he’d lost his job,” she said.

They located a grant that gave him enough money to get his car fixed so he could get to the doctor.

“In the past, we may just not have known about that or had those sort of resources in a physician’s office,” Cote said. 

The statewide program has expanded to about 170 medical homes serving 50,000 MaineCare patients who have at least one chronic condition. It is free to patients. Medical homes receive an extra fee from MaineCare.

Although there’s anecdotal evidence that medical homes are working — such as the diabetic patient — it’s unclear exactly how successful medical homes have been overall in Maine and how much money they may have saved.

A team from the University of Southern Maine’s Muskie School of Public Service is evaluating the program. It is expected to release its report in the coming months.

Maine Quality Counts, an independent health care collaborative in Manchester, has been working with Brenner to better develop Community Care Teams to work with medical homes. It has collected stories from medical homes and expects to release its own qualitative report in the next week. 

But while there is no hard data yet to show the program has saved money, saved lives or improved health care, experts are excited enough that they moved forward this month with phase two: behavioral health homes.

Behavioral health homes help people with severe mental illnesses by coordinating physical and mental health care. About 20 groups statewide have signed up.

It’s a program Flanigan is passionate about, noting that adults with severe mental illnesses die 25 years sooner than others.

“It’s time for a new system to shoot for better results,” he said. “I can’t believe the current state is the best we can do.”

The medical home program was the first one Maine started based on Brenner’s philosophy. The ED Project, the program that helped Wilson with her migraines, was the second. It’s already shown success.

The ED Project

The ED Project looked for MaineCare patients who used the emergency room — also called emergency department or ED — more than they should. Some went as often as 20 times in 30 days and many repeatedly sought help for issues such as asthma and headaches.

“When you go to the emergency department, they always see you,” Flanigan said. “And if you’re showing up at three in the morning every other night, it’s the same staff, they know you by name. They take you in, they give you a blanket and give a warm meal, and it’s the most respect you’ve received from anybody in weeks. Of course you’re going to go back.” 

But the visits cost the state a lot of money, they tie up emergency resources and patients don’t get the kind of long-term care they need. 

“The emergency room is not the place you go for management of a chronic condition,” Flanigan said.

Initially, a pilot program tracked emergency visits to MaineGeneral Medical Center in Augusta. The ED Project later encompassed other hospitals.

MaineCare members volunteered to be part of the program. In return, the state gave them extra attention and greater focus.

“We gave them this case management,” Flanigan said. “We gave them respect. We gave them the opportunity to have their say. And we gave them the support they needed to make sure they could adhere to a care plan.”

He added, “It may mean calling up to make sure that they’ve taken their medicines. It may mean calling up and making sure, ‘I know you’re going to your doctors’ appointments, but have you gotten your labs done?'”

It has meant something as simple as getting a patient a new recliner.

“She had pain in her back. The recliner she was in was old and broken down,” said care manager Mike Damron. “She was mostly chair-bound, so if she’s in that chair all day long and that chair is uncomfortable, well, it’s going to exacerbate every pain that she has.”

With the new chair and help from her care manager, the patient graduated from the program. Graduates receive check-in phone calls every six months or so.

“We are always here; always,” Damron said.

About 1,700 MaineCare patients have gone through or are now enrolled in the program. Before the ED Project, they averaged 13 visits in 11 months. They now average six visits in 11 months.

One patient dropped from 141 ER visits in a year to four or five. Others, like Wilson, dropped to one or two and said they felt much better.

“I just think it’s great,” said Wilson, whose uncontrolled migraines had led to depression, work issues and family strife. “I think it’s going to help a lot of us who do go to the ER because we can’t come up with a different idea to help ourselves.” 

Unlike the medical homes program, which is still being analyzed, the state knows the ED Project has saved money — $8 million in its first couple of years. Primary care costs went up as more patients saw family doctors, but emergency room costs went down.

The program has now expanded to reach users sooner. Today, two ER visits in three months will catch the attention of MaineCare.

“The key is that we engage the member and ask them, ‘What are you looking to get? What do you need? What would help you the most?'” Flanigan said. “(They say), ‘I need a provider who makes me feel this way.’ ‘I need a provider who’s closer.’ ‘If I just had transportation to the medical office I’d go, but I always get an ambulance ride to the ED.'”

Partners in Health and Wellness

Flanigan hopes Partners in Health and Wellness will be Maine’s next success with Brenner’s philosophy.

The pilot program, based in Lewiston, coordinates intense, highly personalized help for families that have high medical costs and human services needs. Where other programs have been largely focused on health care, this program will focus on all of a family’s needs and goals, including health care, job training, child care, transportation and housing. 

The state has been working for more than a year to pull the program together.

Until now, families could be getting help from myriad people — doctors, counselors, case workers, job trainers, housing specialists — but those people rarely shared information or oversaw the family’s needs.

Flanigan’s hypothetical example: A parent overdoses on drugs and ends up in the hospital while the child is sent to a temporary home. The parent goes through rehab and gets placed in a subsidized apartment, and parent and child are reunited. The problem? They’ve been placed in the same apartment complex as the parent’s former drug dealer. 

“You have set that family up for failure,” Flanigan said.

Although many services are done through one state department, DHHS, they’re handled by different offices. Information-sharing was, in some cases, impossible. 

With each office maintaining its own database and confidentiality requirements, it took the state months to give DHHS workers the simple ability to talk to each other about a family. It’s a change that has excited staff, particularly in the Lewiston office, Flanigan said.

“We had a packed room the first time I went down to talk and a packed room for every meeting,” he said. “There’s enormous energy. People have known for a long time, I think, the right thing to do. And it’s just been a matter of recognizing that energy and trying to get a program that would match it.”

Advocates hope Partners in Health and Wellness will address some of the 18,000 people who are both high-cost MaineCare patients and users of DHHS services. The pilot’s participants were chosen based on two criteria: The family had to benefit from more than one DHHS office and at least two family members had to have more than $10,000 in MaineCare medical bills in the past year.

Lewiston was chosen as the pilot city because its two hospitals have worked well in the ED Project, the local Community Care Team is energetic and local providers have a good relationship with DHHS.

“You want to start where you’re more likely to have early success,” Flanigan said.

The department chose its first volunteer family about two months ago. Flanigan declined to reveal much about that family to protect confidentiality, but he said it’s a young, growing family that includes children. He said family members were enthusiastic about the program and were eager to make changes in their lives. They had no idea their help wasn’t already being coordinated. 

A second family was added to the pilot program a couple of weeks after the first. Also young and including children, this family has two goals: education and bringing its health care under one roof.

“This was a family that had providers scattered all over town,” Flanigan said. “You miss an appointment or two with one child, so that child gets discharged from the practice and yet the others might continue to go there. Or mom might be discharged for one reason or another and have to go somewhere else. And you end up with, ‘Well, I’ve got to travel to five different providers. Can we get this under one practice?'”

Although the pilot is only weeks old, the department has already learned one lesson: Listen to the families. Their goals may be things DHHS workers wouldn’t have thought of, but they’re vital to that family.

“Once you understand that, a lot of other things fall into place,” Flanigan said.

The department is interviewing a third family now and is considering a fourth.

The pilot has no additional budget. Workers do their same jobs, but do them more collaboratively.

The department won’t be able to gauge the pilot’s success for months or years. DHHS will likely call it a success, Flanigan said, if it helps bring down spending by the top 5 percent of MaineCare members, if more people are employed or more people are living in stable housing. 

Although the pilot project and the state’s two other projects may save Maine money in the long run, Flanigan wasn’t eager to define that as success.

Like Brenner, his goal is to help people. Savings is an added benefit.

“I’ve cultivated this to be No. 1, very altruistic. Everyone who’s engaged, I tell them that repeatedly. If you hear, ever, any cost-savings assigned to this, that’s not their responsibility. They’re not to think that way,” he said. “We’re looking for people to get more out of DHHS than what they’re getting.” 

ltice@sunjournal.com

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