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Roadmap to person-centered care

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Bruce Chernof, M.D., president and CEO of The SCAN Foundation, Long-Term Care Commission member
Bruce Chernof, M.D., president and CEO of The SCAN Foundation, Long-Term Care Commission member

I recently experienced a minor glitch with my phone and dropped by the local Apple store for help. The employees at the Genius Bar took their time with me, asked a lot of questions and performed a few diagnostic measures to figure out what was going on. It was a great experience in receiving targeted service that met my particular needs. In medicine, we have sophisticated diagnostic measures and all types of cutting edge technology, yet our approach to caring for individuals is often far less responsive than the level of attention given to getting a smartphone to work.

It's time for us to scrap the old model of medicine and adopt what we're calling “person-centered care,” which focuses on the whole person, and not just the disease. Instead of using a one-size fits all approach, care teams must first identify which individuals are a good fit for this kind of care, and then find the right interdisciplinary team to care for the whole person. Insurers, drug counselors, dieticians and others outside the normal orbit of care who provide essential services can be brought together to work seamlessly on behalf of the person in the center of care. 

For starters, person-centered care could focus on the oldest and sickest among us – those with the highest needs – especially those with multiple chronic conditions. These individuals stand to benefit the most because they use the system the most, and are the most complicated to treat.

To support interested health organizations in adopting this approach, The SCAN Foundation partnered with Avalere Health Inc. to develop a roadmap outlining not only how to build a person-centered care model, but also highlighting two organizations that have built and implemented their programs while demonstrating that the model is cost-effective.

Sutter Health is a good place to start. The nonprofit Northern California health system is integrated; it's comprised of hospitals, physician groups and a home health agency. Sutter launched its person-centered, multi-disciplinary care model for individuals with advanced illness, with a long-range goal of building it to scale and expanding to entities outside of the system. But first, Sutter needed to evaluate the internal return on investment to see if expansion was economically viable.

The sustainability analysis looked at a variety of factors, including health care utilization, quality of care and the experience of the person. To effectively measure the data, Sutter, with Avalere's support, compared their patient set with a Medicare population outside their system which had similar demographic and clinical characteristics when it came to high-intensity services. Based on the results of the sustainability analysis, Sutter applied for and received $13 million in funding from the Innovations Center to scale the program throughout its system.

Person-centered care models can also be used by government agencies. For example, Aging and Independence Services in San Diego works with medically and socially complex populations to support effective transitions between the hospital and community. AIS is providing Care Transitions Coaches to work with individuals and their caregivers to ensure a smooth transition when they leave the hospital with the goal of reducing future readmissions. 

Like Sutter, AIS with Avalere crunched the numbers to make sure this model works. To get the best analysis, they compared readmission rates of their patients with those of a Medicare fee-for-service population. The Medicare population is not under the AIS umbrella, but they share the same mix of age, condition, etc.

Now, AIS can articulate to hospitals how to target the care transitions intervention in order to achieve the most positive return on investment. Plus, there are expansion opportunities, like with Sutter. AIS is pursuing contracting arrangements with health plans that do not have in-house care transitions services, work that AIS can readily provide.

Sutter and AIS are two examples underscoring the success of person-centered care models in action today. Both organizations conducted analyses about the long-term sustainability of such a model and each found it was the right fit for their organization, and for the individual receiving care.

Person-centered care models are a financially viable option for health care organizations, both public and private. And with no shortage of chronically ill patients in the health care system, adopting alternative models might not only be the road less traveled, but the right road.  Our health care delivery can and should be at least as targeted to the individual as the services provided to our smartphones.

For a copy of the Person-Centered Care Sustainability: Road Map, please visit: http://www.thescanfoundation.org/person-centered-care-sustainability-road-map.

Bruce Chernof, M.D., is president and CEO of The SCAN Foundation, an independent, non-profit public charity devoted to transforming care for older adults in ways that preserve dignity and encourage independence.

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