Effectively managing a frail elderly population in a managed care setting

The U.S. spends more per capita on health care than any other country, with much going toward treating chronic disease. The large aging population makes the effort to prevent/control chronic conditions increasingly imperative. Disease management is one popular option, though one size does not fit all. The frail elderly population in particular represents a diverse group with multiple co-morbidities and varied health needs. Given these complexities, caring for this population requires more than traditional disease management.

Since 2000 Physician Health Partners (PHP), an MSO with 250 PCPs, has implemented a care management program for frail elderly members enrolled in Secure Horizons (FEP). Through ongoing quality improvement efforts the FEP program has evolved from a telephonic to a co-located model. The current FEP process includes case finding or referral, assessments with best-practice tools, care planning and case management, systematic data tracking, communication with PCPs and ongoing monitoring and reporting. Characteristics of the current program include: 1. Co-location of care manager teams in PCP offices, 2. Same or next day home visits, 3. Comprehensive assessment for medication adherence, fall and nutrition risk, financial, legal and family support, environment and safety, re-hospitalization risk, and psychosocial and cognition, 4. Immediate access to PCPs, 5. Weekly case conference with PCPs, and 6. Care coordination with the patient's family. The unique structure and program content of the current FEP will be further discussed as part of this case study to showcase the collaborative, tailored approach to effectively meeting the complex needs of a frail elderly population.