Authors Discuss Benefits of Having Single Doctor throughout Continuum
CERRITOS, Calif.–(BUSINESS WIRE)–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
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
“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
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.
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