GRAND RAPIDS — The success of a collaboration that set out three years ago to improve care for seniors with an array of health problems shows what can happen when cooperation trumps competition.
It also demonstrates the potential benefits for health insurers that are willing to put up money to try something new.
In three years, Tandem365 reduced emergency room visits among its 1,000 clients by 52 percent. Inpatient hospital stays declined 38 percent and visits to specialty physicians decreased 46 percent.
The declines came by better coordinating care and addressing issues such as medication adherence and by organizing assistance for household chores or errands, meal preparation, shopping and transportation to a doctor’s office.
From a financial standpoint, the program resulted in a 35 percent per-member reduction in the cost to treat people.
Meanwhile, individuals with multiple chronic medical conditions enrolled in Tandem365 realize a better quality of life by alleviating some of the emotional toll related to their illnesses.
“You look at the dollars, but look at the people,” said Steve Zuiderveen, president and CEO of Sunset Retirement Communities and Services. “The dollar savings is wonderful, but the people cost is much more significant.”
Sunset Retirement Communities is one of four Grand Rapids senior living and long-term care providers behind Tandem365, along with Life EMS Ambulance, whose professionals are on the front line of responding when a patient calls 911 for assistance.
The Grand Rapids-based collaborative coordinates medical, behavioral health and social services for people 55 and older who have multiple chronic conditions such as congestive heart failure, emphysema, dementia, kidney failure, Parkinson’s and diabetes. Oftentimes, the patients are in frail health, lack a social support network, and could use daily or weekly assistance at home.
The goal is to keep them out of the hospital or ER by coordinating teams of case managers, nurses, social workers, paramedics, therapists and aides.
‘BETTER FOR THE PATIENT’
The key to the service is a partnership with Grand Rapids-based Priority Health, which in 2014 agreed to reimburse for the kind of care, services and coordination that Tandem365 provides.
Health insurers historically haven’t paid for those kinds of non-traditional services to members. That changed when Tandem365 went looking for a partner and approached Priority Health, which signed on to reimburse the organization a certain amount per client for coordinating care.
The high acuity level and high cost of the patient population Tandem365 targets led to Priority Health’s willingness to invest in the program, and to help craft a new care model for the people who cost the most to insure.
“We all knew and we know now that the traditional model of care doesn’t work for this group of patients,” said Dr. Greg Gadbois, medical director at Priority Health. “It makes sense for us to fund it. It’s better for the patient.”
The money spent up front by Priority Health more than pays for itself through reduced medical claims on the back end, Gadbois said. The net savings comes to about $300 per member, per month.
The program’s cost savings exceeds the amount of medical claims and the total Priority Health pays Tandem365 for services, which Gadbois describes as a “lifeline that can keep them out of the hospital.”
“That’s significant (savings), potentially, over a long period of time,” he said. “That’s an admission we don’t have to pay for because we saved someone from having to go through the hassle, and having to go through the pain and suffering that got them into the hospital again. That’s the way it should be.”
SETTING THE STAGE
The seeds for what became Tandem365 were planted in 2012 when Mercy Health Saint Mary’s approached the four senior living and long-term care providers — Sunset, Clark Retirement Community, Porter Hills and Holland Home — for help in reducing a 22-percent 30-day readmission rate for Medicare patients. At the time, the federal Centers for Medicare and Medicaid Services was preparing to begin penalizing hospitals for high readmission rates.
In agreeing to work with Saint Mary’s, the long-term care providers needed to set aside their competitive instincts and instead cooperate with one another.
“We were very much independent and looking out for our own, trying to carry our own weight with the hospitals and get referrals,” said Teresa Toland, the CEO at Tandem365 who previously ran the home care division and was vice president of business development and quality at Porter Hills.
As staff from the four organizations began to get together and talk, they soon came to a realization, she said.
“We all had the same issues,” Toland said. “Every one of us had the same struggle.”
The biggest barrier to overcome was a lack of coordination and communication between care providers when a patient transitions from a hospital to a long-term care setting or to his or her home. By addressing that and a “laundry list” of other issues, the group was able to reduce the 30-day readmission rate at Saint Mary’s from 22 percent to 4 percent within a year and a half.
That initial success laid the groundwork for what became Tandem365.
“We said, ‘Why stop here?’” Toland said.
The group went back to work and “defined everything in the health care system that would cause” a failure by a patient and lead to an ER visit or a hospital readmission, she said.
They largely identified social issues that get in the way of proper care for the so-called “at-risk” patients who often have little or no social support at home to help manage their medical conditions. As a result, they showed up frequently in the ER. The group concluded that the kind of help needed for the targeted patient population could come from social service agencies in the community.
But they still faced a major challenge in determining who pays for the service.
“All of the things they require, insurance doesn’t pay for it,” Toland said.
So the group approached Priority Health, which was willing to support a pilot program. The four long-term care providers and Life EMS also collectively put in $1.5 million that provided the financial support needed to launch the pilot.
ADJUSTING THE MODEL
Under the pilot, Priority Health selected the patients for participation in Tandem365 from its Medicare health plan enrollees. Under the program, when members have issues, they are to call Tandem365, where a dispatcher is trained to triage their situations.
If the call is for a medical issue, Tandem365 dispatches paramedics from Life EMS to the home to assess the situation. The paramedics can transport members to the ER, if needed. If the members do not require transport but still need assistance for another issue, they are connected with a person or organization that can help.
“We’re coordinating the village,” said Life EMS CEO Mark Meijer, noting that he — like the executives at the four long-term care providers — had to adjust his thinking when joining the group.
If an ambulance isn’t transporting a person to the hospital, Life EMS isn’t billing for it, Meijer said. He got over that issue by focusing instead on how Life EMS could provide a new service by participating in Tandem365 and improving care for patients.
Meijer concluded the new organization could reduce the number of times that Life EMS transported someone to an emergency room when they actually did not need the service.
Sometimes, for instance, people can feel ill because they do not take their medications properly. Through Tandem365, responding paramedics or nurses can work with the people to get them back on track.
“We intuitively knew this makes sense,” Meijer said. “We intuitively knew by experience this would work.”
FINDING THE MOST IMPACT
Tandem365 initially asked Priority Health for 20 referrals of patients who received care at home. The program has steadily expanded and today serves about 600 people monthly in Kent, Ottawa and Allegan counties.
Tandem365 now is expanding into Kalamazoo County and recently signed a contract with Blue Cross Blue Shield of Michigan for reimbursement. Final details of the deal with Blue Cross Blue Shield have yet to be worked out, Toland said.
While Tandem365 has generated strong results in the first few years, partners say there are limits to the program’s expansion.
A new market needs to have the social service and structure in place to properly execute the program, as well as a large enough eligible patient population to justify the investment and the willing participation of long-term care providers.
The model works best where there’s a higher concentration of patients.
“That’s where we make the most impact,” Meijer said. “We’re expanding at a pace that is kind of sensible.”
Priority Health would “love” to see Tandem365 expand into more markets outside of the Grand Rapids area, Gadbois said, although he recognizes the limitations, particularly for rural counties.
“You need a certain number of patients to support that team,” he said.