Integrating acute and long-term care for high-cost populations.

The inadequacies of our fragmented acute and long-term care financing and delivery systems have been well recognized for many years. Yet over the past two decades only a very small number of "boutique" initiatives have been able to improve the financing and the delivery of care to chronically ill and disabled populations. These initiatives share most of the following characteristics: prepaid, risk-adjusted financing; integrated Medicare and Medicaid funding streams; a flexible array of acute and long-term benefits; well-organized, redesigned care delivery systems that tailor these benefits to individual need; a mission-driven philosophy; and considerable creativity in engaging government payers. The experience of these "boutiques" illustrates both the obstacles to, and the opportunity for, meaningful, widespread care delivery reform for vulnerable chronically ill populations.

Massachusetts Medicaid and the Community Medical Alliance: a new approach to contracting and care delivery for Medicaid-eligible populations with AIDS and severe physical disability.

This paper discusses the origins and experiences of the Community Medical Alliance (CMA), a Boston-based clinical care system that contracts with the Massachusetts Medicaid program on a fully capitated basis to pay for and deliver a comprehensive set of benefits to individuals with advanced AIDS and individuals with severe disability. Since 1992, the program has enrolled 818 individuals with either severe disability, AIDS, mental retardation, or general SSI-qualifying disability. Under a fee-for-service system, these two groups had received fragmented care. The capitated CMA program emphasizes patient education and self-management strategies, social support and mental health services, and a team approach to healthcare delivery that has reoriented care to primary care physicians, homes, and communities.

Primary care for persons with disabilities. The Boston, Massachusetts model program.

Boston's Community Medical Group (BCMG) was among the first primary care group practices to provide community-based continuous primary care to people with major disabling conditions, the first to rely on nurse-practitioners as primary care-givers, and one of the first to provide care on a prepaid capitated basis. With more than one thousand person-years' experience, BCMG has demonstrated that it is ethically and operationally feasible (1) to provide prepaid managed care to people with major disabling conditions; (2) to share financial risk for that care with providers; (3) to reinforce principles of independent living and consumer autonomy; (4) to assure high-quality clinical outcomes at reasonable costs.

Pneumocystis pneumonia in a prepaid care system caring for a Medicaid-covered population with AIDS.

Pneumocystis pneumonia (PCP) is the most common pneumonia in persons with acquired immunodeficiency syndrome (AIDS) and a frequent cause of hospitalization. The incidence of PCP in patients with AIDS can be substantially reduced when patients comply with standard prophylaxis protocols. However, achieving acceptable prophylaxis compliance in any patient population is difficult, particularly with intravenous drug users (IVDU), homeless, or medically disenfranchised patients. This study defines the rates and locations of treatment of PCP in a prepaid managed care program for a Medicaid-covered population with AIDS, with comparisons to PCP incidence rates in the same population receiving care in the fee-for-service system.

Predictors of medical care utilization by independently living adults with spinal cord injuries.

A prospective study of 87 independently living adults with spinal cord injury (SCI) as a major disabling condition showed the following average annual health care utilization rates: 1.3 hospital admissions, 16.8 days hospitalized, 1.7 emergency room (ER) visits, and 22.4 outpatient contacts (in person or by telephone). Those hospitalized (n = 66) experienced a mean of 22.2 days hospitalized per person per year. Mean length of stay (LOS) was 11.1 days per admission. Stepwise regression analysis indicated no statistically significant (p less than or equal to .05) predictors of hospital admissions. There were three independent predictors of days hospitalized (greater age, fewer years of education, and more days hospitalized during the previous year), three predictors of days hospitalized for those hospitalized only (greater age, fewer years of education, and longer hospital LOS during the previous year), one predictor of LOS (self-assessment of health), three of emergency room (ER) visits (more unmet instrumental activities of daily living needs, lack of organizational memberships, and more ER visits during the previous year), and five predictors of outpatient contacts (greater age, less satisfaction with health care providers' expressions of concern for their health, lower frequency of leaving apartments, lower levels of life satisfaction, and nonparticipation in a managed medical care demonstration project). Many predictors of health services utilization are immutable. However, changes which facilitate social interaction and changes in the organization of health services may reduce certain types of medical care utilization by people with SCI.

The epidemiology of medical care utilization by severely-disabled independently-living adults.

A prospective study of the medical care utilization experience of 205 severely-disabled independently-living adults in Eastern Massachusetts shows that there was a mean of 0.83 +/- 1.26 hospital admissions, 9.9 +/- 22.7 hospital days, 1.5 +/- 2.31 emergency room (ER) visits, and 26.88 +/- 44.4 outpatient contacts per person per year. Among those hospitalized, the mean experience was 16.2 +/- 27.1 days per person per year; mean length-of-stay was 9.3 +/- 14.7 days per admission. Regression analysis indicates that those with spinal cord injuries as major disabling conditions were significantly more likely to be hospitalized. So were those with lower self-assessments of health, higher levels of depressions, and more baseline ER visits. Self-assessment of health is a significant predictor of hospital days for the total cohort (including those with no admissions); so are age at onset of disability (greater age; higher risk), and bed disability days in the month before the baseline survey (more disability days; higher risk). Among those hospitalized, the total number of days hospitalized is significantly related to both age at onset of disability (later onset; more days) and baseline days hospitalized (greater number; more days). Lengths-of-stay are significantly related to two factors; age and age at onset of disability (in both cases, greater age associated with longer stays). Prior ER visits are a significant predictor of subsequent ER visits (more baseline; more subsequent); so are respondents' reported satisfaction with their participation in their medical care (lower reported satisfaction; more ER visits), organizational affiliations, and frequencies of contacts with friends or relatives. Higher levels of social interaction (i.e. organizational affiliation and more frequent social contacts) were associated with more ER visits. Prior contacts with physicians, nurse-practitioners, or physician-assistants was the most powerful predictor of subsequent outpatient contacts (more baseline; more subsequent). There were also significant relationships between subsequent contacts and respondents' assessments of their health relative to others with similar disabilities (relatively worse health; more contacts), age (greater age; more contacts), and baseline ER visits (more visits; more contacts).

A prospective evaluation of the effect of managed care on medical care utilization among severely disabled independently living adults.

We conducted an 18-month longitudinal evaluation of a model-managed medical care program for severely disabled, independently living adults. Regression analyses using an additive model (no interaction effects) suggest that persons in the study group did not have statistically significantly different utilization experiences than members of the comparison group. Regression analyses that include interaction effects suggest that, for certain segments of the cohort, the study group's utilization experience was significantly lower than that of members of the comparison group. Persons in the study group with higher baseline emergency room (ER) utilization had significantly fewer hospital admissions (P = 0.0055). The participants with better self-assessments of health experienced significantly fewer hospital days per person (P = 0.0075) and days per person hospitalized (P = 0.0056), and persons with organizational affiliations reported significantly fewer ER visits (P = 0.0264).

Rehospitalization and spinal cord injury: cross-sectional survey of adults living independently.

A cross-sectional survey of 96 people living independently with spinal cord injuries (SCI) in Eastern Massachusetts shows that 57% had been hospitalized at least once in the year before the survey. Sample means were 1.0 admissions and 16.0 days/person/year. Eight percent of the sample (eight persons) accounted for 22% of admissions and 59% of total hospital days. For those hospitalized, the mean was 1.7 admissions and 45.1 days/person/year. Mean length-of-stay was 34.7 days/admission. Multiple regression analysis shows that three variables appear to be independently related to increased numbers of admissions: self-assessment of health; place of residence; and age (younger respondents at higher risk). One variable is independently associated with total days of hospitalization: leaving home at least once daily (as opposed to less frequently) is associated with lower risk. There were no statistically significant relationships between either numbers of hospitalizations or total days hospitalized and ADL or IADL status, education, employment, medical insurance, household composition, gender, age at onset of disability, time since onset of disability, substance use (alcohol, cannabis, or tobacco), level of SCI lesion, or social supports.

A continuum of care for the inner city: assessment of its benefits for Boston's elderly and high-risk populations.

We describe an approach to health care in the inner city: a multidisciplinary system of physicians and mid-level practitioners that provides individualized care to chronically ill, elderly, homebound, and nursing-home residents of urban Boston who would otherwise be forced into an inappropriate reliance on teaching hospitals. Linked to four neighborhood health centers, three home-care programs, and a teaching hospital, and financially self-supporting except for the home-care component, the system cared for 3000 ambulatory, 280 homebound, and 358 nursing-home patients in the representative year described. In-hospital use, particularly hospital days, was reduced when judged by existing data for comparable (though not identical) populations. Based on stable physician practices, the system offers a workable approach to the related problems of care, manpower, and cost in the urban core.