Health care executives often say implementing new models of care means having one foot in the old world of health care and another in the new. The transition is slow because of the difficulty of finding evidence that new models work in the real world, both to improve care and cut costs.
In New Jersey, though, a program providing integrated care for 24,000 people is showing results in both areas.
The catch? They're all prison inmates.
Since 2008, the University of Medicine and Dentistry of New Jersey's University Correctional HealthCare arm has been providing both mental and physical health care for inmates at the state's 13 prisons. The program has kept spending at 2008 levels since taking over the contract, and several measurements of health in the population have shown improvement. That success comes despite the high rates of addiction, chronic disease and mental health concerns sported by the prison population.
Jeff Dickert, vice president of UCHC, said the program has won these improvements through the use of tools available to private health care providers. By following the patient-centered medical home model, issues of redundant care and missed opportunities to catch issues early have decreased.
Patient-centered medical homes are generally primary-care practices that take responsibility for the total wellness of a population of patients. The model uses data and population care management to encourage preventative care. For inmates, following up on primary-care recommendations and doing preventative screening can be easier than in private practice, but many of the same chronic illnesses are prevalent.
"The Department of Corrections lends itself to a medical home model in the sense that you can deal with issues of redundancy … and move toward a system where it is integrated, which we have been able to do," Dickert said.
"The more you know about your patients, the better off you are," said Dr. Arthur Brewer, UCHC's statewide medical director. "We know where they live, we know what foods they eat, we actually see what items they purchase. … We can interact with those individuals in regards to some specific medical complaints."
"If we utilize all of our resources, I think it does provide us the best opportunity to provide care for people," Brewer said. "If you look at blood pressure control, control of diabetes and control of HIV disease, and compare it to a general population outside a correctional setting … that speaks to medical home and the ability to help people in this controlled environment."
Dickert admitted that the controlled environment maximizes the effect of medical homes on cost savings, but said UCHC's integrated strategy is not "all that different from a lot of how hospitals are operating." Dickert said UCHC basically imported the system UMDNJ uses at University Hospital, in Newark, to control costs and improve patient safety.
Dr. C. James Romano, the chief medical officer at St. Francis Medical Center, in Trenton, which contracts with the DOC to provide emergency care for inmates, said the care coordination for prisoners is "something that all institutions at this point are striving for, what we call the continuum of care."
"There's more activity from the site where the patient would originate from, getting them into the hospital and getting them back out into the population there with the proper care," Romano said. "It is an approach hospitals are using with long-term care facilities, for example. … Keep the patients healthier in those areas so they come into the hospital less frequently — and when they do, they're not in a catastrophic state — and providing the needed access for them when they leave."
According to UCHC, integrated care has also reduced nursing overtime by 15 percent over the past two years, despite having round-the-clock nursing available, and pharmaceutical spending levels are consistent with 2007 numbers.
Brewer says they use both cost and quality data from the previous provider contracted with the Department of Corrections to benchmark their work.
"We have been able to keep the number of (emergency department) trips statewide less than what the previous provider of that service did," Brewer said, citing one of the top health care cost drivers. He added they've been successful by looking for spikes in the data, and "realizing you need to pay more attention to" them.
When that data showed an increase in orthopedic surgery referrals, Dickert said, UCHC brought in a physical therapist to screen cases and consult. Now, inmates with chronic pain receive physical therapy before moving on to expensive surgical procedures.
Data also are helping UCDC coordinate with St. Francis' provision of inpatient and specialty clinical care to inmates. Corrections and St. Francis have had a relationship for more than 25 years; Romano said the hospital's direct access to the correctional system's health database has reduced hospitalizations.
Dickert said UCDC has reduced hospitalization by 15 percent from the previous provider.
Telemedicine is also used between St. Francis' physicians and the UCHC team as a way to consult without requiring additional trips to the hospital.
"There has been a change with respect to the ability to coordinate care. We get less patients into St. Francis that are seriously ill that may have been delayed in their care in past experiences," Romano said. "The return of the patient back into the prison system, when they get out of St. Francis, is superior than it's been in the past."
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