Cone program designed to keep chronic disease sufferers out of the ER

Greensboro News and Record, June 14, 2015

Joe Richardson was in a tailspin, smoking cigarettes every day and not always able to afford his meds. The combination of those factors sparked chest pain so excruciating it sent him to the emergency room every couple of months, when he was sure he was about to have a heart attack.

“I took a nitro,” Richardson said recently of the nitroglycerin tablet he took the last time searing pain sent him to the ER, about 18 months ago. “My wife was in the bedroom, and I said, ‘Hey, we got to go.’ ”

Richardson, 52, belonged to a high-risk population that Cone Health and other hospital systems across the Triad, state and nation are working hard to identify and get back on the right track — patients with serious, chronic diseases who, for one reason or another, can’t always do what’s needed to keep themselves out of the hospital.

With the help of a Cone Health program aimed partly at frequent emergency-room patients, Richardson left those ranks. He no longer smokes, but he does take his heart and diabetes medicine religiously now and even works out at the local YMCA five days a week. The program through Cone’s Triad HealthCare Network, or THN, saves this health system from red ink at the same time it saves patient’s lives.

Indeed, care management nurse Julie Farmer said she wonders whether Richardson, a resident of Eden, would be alive today but for the program that helped him stop smoking. Her job with Cone’s Triad HealthCare Network focuses on helping 35 to 40 folks at a time who are walking in the shoes Richardson formerly filled — basically, medical crises just waiting to happen. Farmer began working with Richardson in late 2012 to help him cope with diabetes, heart problems and poor circulation, and he stopped smoking once and for all early last year.

“I kept saying to Joe, ‘If we could just get you to stop smoking,’ ” Farmer recalled recently. “This was very hard for him, extremely hard. He put forth the effort. When a patient puts forth the effort, it’s a win-win.”

Helping patients

In the case of Richardson, who was disabled by the loss of a leg to diabetes, Farmer arranged to lower his costs for the specialized inhaler that helped him break free of cigarettes. On disability income, he could not cover the roughly $90 a month in supplies needed to activate the inhaler.

“It gives you the nicotine your body is craving without the smoke and other additives from the cigarettes,” said Richardson, a former textile worker later employed by the U.S. Postal Service until he was disabled. “I was able to lay down the cigarettes and walk away.”

The care management program through Cone’s THN program is free of charge to the patient. But it benefits society as much as the patient by preventing avoidable, costly hospitalizations that might end up as bad debt on health-system ledgers. THN fields a staff of more than 20 to support the program, including 11 care management nurses such as Farmer, along with pharmacists, social workers and other support staff. Their aim is altruistic, to give vulnerable patients the best possible shot at productive and pain-free lives.

Saving hospitals, too

But care coordination also makes sense on the bottom line: In these days of “accountable care,” hospitals often must eat the high-dollar cost of repeated admissions flagged as excessive by federal health officials. It’s easy for people not trapped in a cycle of escalating medical woe to be judgmental toward those who might need help from the program, said Rhonda Rumple, the executive director of care management for the Greensboro-based network.

“You might think, ‘Here is somebody who is just not doing what we’re telling him or her to do,’ ” Rumple said. “But many people in our community often don’t know how to access the resources. And that thing that might seem so simple to you and me is very hard for them.”

The problem also stems partly from modern medicine’s reliance on savvy patients as well as skilled physicians and nurses, Dr. William Hensel said. To stay out of the emergency room and avoid repeated hospitalizations, patients with chronic conditions such heart failure, diabetes and severe lung problems must be able to understand their disease, the medicines that keep the illness at bay and the various trigger points that aggravate it, Hensel said. That’s a stretch for some people and the consequences of lacking that basic understanding can be serious, said Hensel, the director of Cone Health’s family medicine residency program.

“A lot falls back on the patient’s shoulders. … This is a move for us to take a more active role,” Hensel said of the THN care management initiative.

Avoiding hospital stays

Hensel referred one of his patients, Georgia Martin of Greensboro, to the care management team early this year with the aim of helping her gain better understanding and more control over a constellation of health issues, similar to those Richardson faces.

“Since I’ve been in the program, I have not been in and out of the hospital like I was,” Martin said last week.

In fact, THN care management nurse Pam Faulkner said Martin, 58, has not been hospitalized at all since joining the program in January. In the six months before that, she visited the emergency room six times, each visit resulting in a hospital stay of about a week.

“So she was living at home about three weeks a month,” Faulkner said last week during one of her periodic visits to Martin’s apartment on Phillips Avenue. “Miss Georgia has really embraced the teachings of our Triad HealthCare Network,” Faulkner said. “She’s changed her diet, weighs herself daily and checks her blood sugar.”

10 visits to the ER

Patients usually come to the program’s attention by one of two, major routes: They are referred to the network by one of roughly 1,000 THN-affiliated providers of medical services, or they visit the emergency room 10 times or more in any six-month period. Cross the 10-visit threshold and members of the care management team get an alert from the hospital that you might need their help.

When someone comes to the attention of Rumple’s staff as needing a boost to manage his or her chronic disease more effectively, the care management staff consults with the patient’s physician and then contacts the person by phone, Rumple said.

Team members focus particularly on three common causes of repeat hospitalization: heart failure, diabetes and chronic obstructive pulmonary disease, or COPD, a breathing disorder. The program is completely voluntary, and there are no penalties or repercussions for the patient who declines help, she said.

“Patients are ready for us at different times,” Rumple said. “We’re not going to drag you around by your toes to participate.”

At any one time, the THN care management team works by phone or in person with a roster of about 600 Medicare patients and several hundred others across Cone Health’s five-county domain.

Hands-on care

The obstacles they help people circumvent range from the strictly medical to basic problems of daily life that can interfere with a patient’s efforts to cope with his or her condition. For example, people confined to a wheelchair by a disease might be living in a house that’s only readily accessible by foot. But that person resists asking the landlord to help out, Rumple said. So a care manager intercedes on the patient’s behalf to get the place wheelchair accessible, she said.

“Almost every landlord that we have requested to build a ramp for their tenant, they have built the ramp,” Rumple said. “But sometimes, people don’t make those requests on their own out of fear for what the repercussions might be.”

Care managers work as intensively as needed with new patients, then less frequently as the person gets a better handle on chronic ailments and knows how to use the THN safety net that includes telephone counseling and pharmacy consultants.

Enjoying life again

Farmer touches base with Richardson occasionally now, but she worked with him more frequently when they were trying to stabilize his situation. She helped him get some of his medicine at more affordable prices. And she even played a key role in helping him ward off medical complications by increasing his level of physical activity.

“I said to him one day, ‘Joe, are you getting any kind of exercise?’ ” she recalled. No, Richardson said, adding that he would like to join the Eden Family YMCA but couldn’t afford the initiation fee and monthly dues. So Farmer called the YMCA and asked an administrator if there were any options for someone in Richardson’s position. “She said, ‘We just happen to have a scholarship program’ at a lower monthly rate,” Farmer said. Now, Richardson goes to the gym most weekdays to tackle the elliptical machine, dumbbells and weight machines in a routine that probably would have landed him in the hospital not all that long ago.

“I work at my own pace. I don’t try to blow it out of the water,” he said. Then he goes home to pursue a newly energized life that includes volunteering with Meals on Wheels, baby-sitting nieces and nephews “when needed,” and dressing up to portray Santa Claus during the Christmas season.

“The main thing is to enjoy life,” Richardson said. “I really enjoy life.”