JAMA Article Highlights Ideal Health Care System for Older Adults

Authors Discuss Benefits of Having Single Doctor throughout Continuum of Care

CERRITOS, Calif.--()--The future of the health care system might be firmly rooted in its past, according to the authors of a manuscript published in today’s issue of the Journal of the American Medical Association (JAMA).

“For many people, this approach may harken back to the age when their primary care physician came to the hospital to take care of them. In this case, however, organizations have built systems to ensure continuity of care”

The article titled “Delivery Models for High-Risk Older Patients: Back to the Future?” and authored by CareMore Chief Medical Officer Dr. Sachin H. Jain, Brian W. Powers of Harvard Medical School, Harvard Business School and a CareMore innovation fellow, and Dr. Arnold Milstein of the Stanford University School of Medicine, found older patients, in particular, could benefit from a physician who follows them throughout their continuum of care during and following a hospitalization.

“For many people, this approach may harken back to the age when their primary care physician came to the hospital to take care of them. In this case, however, organizations have built systems to ensure continuity of care,” notes Jain, the senior author of the paper.

The JAMA article highlights two systems that use this kind of model: The University of Chicago Health System and CareMore Health System.

The University of Chicago Health System launched its Comprehensive Care Physician (CCP) model in 2012 to align inpatient and outpatient care for high-risk Medicare beneficiaries. Participants are paired with a trained hospitalist who provides both inpatient and outpatient care. Patients are supported by an interdisciplinary team that includes advance practice nurses, registered nurses, social workers and case coordinators.

Patients who present at the University of Chicago Hospital’s emergency department-are assigned to a Comprehensive Care Physician who provides them with direction on their care goals to help avoid unnecessary inpatient admissions. The CCPs visit admitted patients for several hours each morning. In the afternoon, they see other patients in their panel in an outpatient setting, focusing on those who have been recently discharged.

CareMore is a Southern California-based company that operates Medicare Advantage (MA) plans across three states.

CareMore identifies high-risk patients in its MA plans through risk assessments, predictive algorithms and physician referral. For these patients, retrained hospitalists, referred to as “extensivists,” lead a care team that includes nurse practitioners, case managers, medical assistants, a social worker and a nutritionist. When high-risk CareMore patients are admitted to the hospital, the extensivist provides care throughout the admission. Extensivists also oversee discharge planning, either to home or to a post-acute setting. For patients discharged to post-acute sites, the extensivist continues to provide direct care. Patients who go home follow up with their extensivist at a CareMore outpatient clinic in their neighborhood.

CareMore has been able to reduce both hospital lengths of stay (31 percent from 5.3 days to 3.7 days) and 30-day hospital readmissions (from 20 percent to 14 percent).

According to the authors of the JAMA piece, both of these models offer intensive, team-based care for high-risk patients and cultivate a sense of accountability and ownership for preventing health crises for seniors with complex illnesses. The models are distinguished by a single physician responsible for both inpatient and outpatient care.

“Unfortunately, the good information that was gathered in the hospital isn’t always shared at the next point of care,” Jain said. “The University of Chicago and CareMore have designed systems that fill this gap by having a single doctor who follows the patient from the hospital to the skilled nursing facility to home.”

While the results are promising, Jain said further investigation is needed into the effectiveness of these models as they are scaled, including coordinating with providers on effective payment models to support these kinds of structures.

About CareMore

CareMore has developed a model of care that is known for identifying the physical, mental and social needs of older adults and other populations and developing innovative programs to successfully address them. The company serves more than 80,000 Medicare members throughout Southern California, Northern California, Las Vegas, Phoenix and Tucson, Ariz., under federally-approved Medicare Advantage contracts. CareMore also is participating in a dual demonstration project in parts of Los Angeles County, in conjunction with state and federal regulators, to coordinate care for people eligible for both Medicare and Medicaid. It serves Medicaid members in Memphis, Tenn., in collaboration with Amerigroup. Additionally, CareMore offers its proven clinical and health technology models to third parties through various subsidiaries.


Doug Bennett, (502) 889-2103

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