NORTH BAY -- A pilot program by Partnership Health Plan of California has yielded early positive results in reducing costs while improving care for some of the region's most chronically ill, and thus most expensive, patients, according to health officials.

The pilot, known as the Complex Care Management Project, is currently underway at both West County Health Centers (wchealth.org) and at Santa Rosa Community Health Centers (srhealthcenters.org), two of the region's federally qualified health centers that serve as key safety-net providers.  

Inspired in part by physician Atul Gawande’s oft-cited 2011 New Yorker article "The Hot Spotters," the year-old project initially focused on 100 total Medi-Cal patients, or 50 at each center. Patients were identified as the most expensive to treat for a variety of reasons, ranging from chronic illnesses such as diabetes to patients who suffer from mental illnesses and often end up seeking care at regional emergency rooms, according to Robert Moore, MD, MPH, chief medical officer at Fairfield-based Partnership Health Plan (partnershiphp.org). He called such patients "super challenging" in terms of readmission rates and difficulty in improving health outcomes.

While the pilot is not yet complete, Dr. Moore and health center leaders said they have seen encouraging improvements in health outcomes, reduced hospitalizations and a solid return on investment, although he cautioned that it's too soon to say definitively how successful the pilot will be.

"Early signs show there was a good return on investment," said Dr. Moore, who was formerly medical director at Clinic Ole Community Health in Napa.

Initial funding for the pilot came from two private grants totaling $200,000--$100,000 a year for each health center. After a six-month analysis, savings have totaled approximately $450,000, or about a 3-to-1 return on investment, based on the amount of inpatient hospital stays among the patient cohort, according to Dr. Moore.

The actual cost of the program is around $150,000 per year, and Partnership plans to take over the costs in the future, he said.

The health centers took different approaches in how they stepped up efforts for the selected patients, but both organizations reported improved health outcomes and lowered costs.

At the West County centers, which operates clinics in Sebastopol, Forestville and Guerneville, patients were assigned to a primary care team, typically consisting of a nurse, a behavioral-health professional and others, such as those called patient navigators. All coordinate patient care.

"What we did was put our nurses as the primary contact for our patient," said Mary Szecsey, executive director of West County Health Centers.

Nurses conduct home visits and "very intensive" patient intake evaluation, looking closely at a patient's individual home situation in trying to determine what some of their barriers might be, she said. With that information, the team of providers then worked intensively with the patients to improve health outcomes.

While the primary care, team-based approach worked for West County, the Santa Rosa centers took a different approach, assigning the patients it identified to one nurse practitioner, with a strong focus on home care.

"Our model is a little more based on doing home visits," said Barbara Scherrer, director of nursing for Santa Rosa Community Health Centers. "One of the reasons we chose a [nurse practitioner] model is that they're independent practitioners ... so they can diagnose and prescribe their own medications."

Partnership, a nonprofit health plan that contracts with the state to administer Medi-Cal benefits for a number of Northern California counties, will continue the pilot for probably another year, according to Dr. Moore. It will likely pick up the remainder of the pilot cost, borne initially by the health centers, because it's shown positive results thus far. He said the pilot likely would be expanded across the Redwood Community Health Coalition's network of providers, which includes FQHCs in Marin, Sonoma, Napa and Yolo counties.

"The promise of savings is justified," he said. "We're encouraged. The point is, it's expensive to take care of [this population], but you're getting that money back."

Ms. Scherrer and Ms. Szecsey echoed that point, noting that it's primary care, not late-game, more costly specialty care, that's driving the improved health outcomes.

"It definitely showed a reduction in ER visits," Ms. Scherrer said. "Hospitalizations is where your costs are in these patients. [The pilot] showed an increase in primary care, but a decrease in hospitalizations. Even though they had more primary care, it showed huge savings, and that's really what we wanted to see."

Both West County and Santa Rosa health centers said patient satisfaction also increased, a hopeful sign that patients themselves are getting past their own chronic conditions, or least managing them better.

"It's not just about cost, but also quality of life for these patients," Ms. Sherrer said.