Weather Forecast


Patients love new 'coordinated care'

Kim Schossow is one of three registered nurses who work in the Essentia Coordinated Care program. A doctor and a nurse practitioner are also on the team. Photo by - Brian Basham1 / 2
Anna Schlauderaff, right, talks to her Essentia care coordinator, Kim Schossow. Photo by - Brian Basham2 / 2

The way Medicare and Medicaid health care is delivered -- and paid for -- is changing, and Essentia Health is in the thick of it.

It's the beginning of a change (from fee-for-service to payment based on patient outcome) that bodes well for both patients and the federal pocketbook.

A new approach

Basically, the coordinated care program involves keeping a close eye on the most vulnerable patients -- poor and elderly people who qualify for both Medicaid (for the poor) and Medicare (for the elderly).

"These are very complex, frail patients -- a very high-cost population because of high-cost needs," said John Smylie, chief operating officer for Essentia Health.

These patients tend to be on the edge of having to move to a nursing home or repeatedly be hospitalized, he said.

That costs the federal government a lot of money, and it doesn't provide the best health outcomes for the patients, who would be better served staying healthy and at home.

By managing and coordinating their care -- via nurses who keep in contact with them between doctor appointments -- a program run by Essentia Health gives these patients the extra support they need to catch minor health issues before they become major ones.

"These nurses are like care managers," Smylie said. "They're staying very close to what's happening."

They do this in part simply by staying in telephone contact with patients, making sure they don't miss appointments and are staying healthy between visits.

A change for the better

At Essentia Health-St. Mary's in Detroit Lakes, Joyce Holm and Anna Schlauderaff like the way the program works.

Anna is now in her 80s, and Joyce serves as her mother's health advocate, taking her to medical appointments and trying to help her stay healthy.

"It's been a year and a half -- it's great, what a difference," Joyce said. "Care coordination, it's exactly what we needed."

Both women are fond of Kim Schossow, a register nurse who serves as Anna's care coordinator.

"My sisters said, 'Where did you find this Kim?,'" Joyce said. She looked at Schossow and teased: "You're never going to get rid of me."

Three registered nurses at Essentia Health-St. Mary's split a caseload of about 120 patients in the dual-eligibility coordinated care program.

Staying healthy at home

Perhaps a third of those patients are nursing home residents. Others live on their own or in assisted living apartments. Some are caring for spouses with dementia or other ailments.

"Our goal is to help older adults succeed in the environment where they live," said R.N. Ashley Kolstad, a member of the St. Mary's team. "We try to identify potential problems and link the right services to the need."

There's a lot of flexibility in the program. The basic idea is that nurses stay in touch with their patients by phone or in-home visits. They get to know patients well, and the nurses can sometimes tell just by listening that someone needs to see a doctor.

When in doubt, they don't hesitate to drop in and see patients in person.

And sometimes, the nurses go beyond phone calls and home visits -- they help with federal paperwork and sometimes take patients to doctor appointments themselves, serving as advocates and memory aides.

Sometimes they are just a friendly ear on the phone. Other times they help far-away relatives understand their loved one may be in danger because of memory problems or being frail.

They know the system and they know the players, and that alone can be helpful to families.

"Sometimes it's just finding the right person (to help the patient)," Joyce Holm said.

The coordinated care program at St. Mary's is headed by Dr. Bill Henke and includes R.N. Julie Erickson and nurse practitioner Clarissa Dumdei.

Helping the taxpayers

Hospitals obviously don't make money by keeping patients away, but this experimental program --  funded through the Affordable Care Act (Obamacare) -- changed the way hospitals are compensated.

Now when hospitals save the federal government money, they share in those savings.

In other words, hospitals are paid for quality, inexpensive care that provides good patient outcomes.

The old fee-for-service model pays hospitals based on tests or services performed, regardless of patient outcome.

The change provides a great incentive for hospitals to change the way they do business.

"We used to get a 'Thanks,' if that," from the federal government for programs that saved federal dollars," Smylie said.

"In the past, if we did things to save the government money, it was just shooting ourselves in the foot," he added. "Now they share savings."

If health care providers succeed in keeping patients healthy and out of the hospital, there will be more open hospital beds, which will be a challenge for hospital finances.

The answer to that is growth, and outperforming the competition.

"We'll need to grow to be efficient and effective," Smylie said.

Bringing more people in

Essentia Health is betting on coordinated care. It is expanding the program beyond the federally funded dual-eligibility program.

The Detroit Lakes care coordination program is modeled on one that has been in effect at Essentia Health in Duluth for several years. That started with dual-eligibility and later expanded to cover other populations.

Likewise, staff at Essentia Health-St. Mary's is in the beginning stages of identifying the target population and creating a wider care coordination program.

In Duluth, that has meant using electronic patient records and technology to help monitor patient health.

A patient with congestive heart failure, for example, can weigh themselves at home daily, and that information goes electronically to the hospital.

Because water retention is a critical symptom of problems in those patients, a noticeable weight gain will trigger a call from a nurse, who can "tell them they need to watch it or they will be in the ER the next day," Smylie said.

Blood pressure and other vitals can also be checked that way, allowing nurses to keep an eye on patients at home. "It's almost like an ICU (intensive care unit)," Smiley said.

The greatest cost for these patients is re-admittance to the hospital.

With this program, "if they need care, they're getting it -- be it routine office visits or intervention needed by their physician or admittance to the hospital -- that's really where the investment results in higher care and lower costs," Smylie said.

"It's about doing it right the first time," he explained. "Doing the right care in the right place by the right provider of care is ultimately the best care, and the way to save money."