Community-Based Teams Deliver Better Health Care to Maine Patients

Jun 5, 2015

LEWISTON, Maine - Life circumstances, as many of us know, can have a huge effect on personal health. But uncovering those circumstances in a 15-minute doctor's visit or trip to the emergency room is unlikely. A pilot program in Maine aims to provide holistic health in a new way - community care teams visit people in their homes to better understand what's preventing them from achieving better health.

The goal is to help them improve their lives and lower health care costs.

Lucie Kelley is the eyes and ears for more than two dozen doctors in Androscoggin County. She's a nurse for Androscoggin Home Care and Hospice's community care team. When a doctor has a patient struggling to manage health issues, Kelley visits the patient in their home. Today she knocks on Christine Bilodeau's door. "Hi it's Lucie!"

Bilodeau has multiple sclerosis. She also has cardiomyopathy - a disease of the heart - and depression. Kelley has worked with her for six months. She's returning today because the MS is making it harder for Bilodeau to get around. She fell recently, and Kelley wants to check on her. "All right, so I'll just pull up your goals to see where we're at."

The primary job of community care teams is to help patients set goals to achieve wellness. Those goals can range from losing weight, to managing medication, to finding reliable transportation. That's one of the more common ones - and it's a problem for Bilodeau, who missed a recent appointment to get her blood checked. "I should've gone over to get my blood done, but it's hard getting a ride," she says.

Bilodeau usually uses a medical transportation company, but long wait times for rides mean a quick prick-of-the-finger appointment can take hours in travel time. Lucie Kelley says medical problems are often rooted in other life factors. But a lot of times, doctors don't know what they are.

"When you go to the doctor's office, everybody looks alike," Kelley says. "They all are, usually, well-dressed - clean, anyways. So you don't know what they're coming from. When we go out, we know what's at home - we know if that refrigerator has food in it. We open fridges and cupboards to see if they're really eating."

"As a concept, we never even thought this was going to be possible, because it's something that's totally different from anything we've ever done before," says Dr. Carl DeMars.

DeMars is a primary care physician and medical director for the community care team in Midcoast Maine - one of 10 teams in the state that serve a total of about 140,000 people. He says the team helps him get a more complete picture of his patients.

"By having all this pre-work done, I can really understand what's going on in the home," DeMars says, "and it allows me to really get at the heart of the matter in the visit, and stop just worrying about why their blood pressure is out of control, when it's really that their housing is falling apart, or that their medication is not being taken correctly."

Since the Midcoast community care team started a year-and-a-half ago, DeMars says emergency room and hospitalization rates for patients dropped 25 percent. The Androscoggin community care team says its ER and hospitalization rates have dropped by between 40 and 50 percent. Success often depends on connecting patients to community resources, but Lucie Kelley says that's proved more challenging than she thought.

"It's been eye-awakening to see there's not a lot of resources out there," Kelley says. "And you really have to be on the ball to follow through, because the biggest thing for me is other agencies don't follow-through."

After the initial visit in patients' homes, Kelley spends a lot of time on the phone - contacting agencies and organizations, and following up with patients. Once those patients meet their goals - typically within three months, they graduate. About 30 percent re-enter the program because of changes in life circumstance or a new diagnosis.

At the end of Kelley's visit with Bilodeau, she writes reminders down for Bilodeau about next steps. Church used to be an important part of Bilodeau's life, so Kelley will try to connect her to a church that can offer social support and help with tasks around the house.

Bilodeau says ever since Kelley started working with her, she doesn't feel so alone. "I don't have family in the area. Don't have a lot of friends anymore. So yeah, she's changed my life quite a bit."

Bilodeau's MS is a daily struggle, but she says so far she's been able to achieve her goal to live on her own. "I still get my low times. They don't last as long."

Community care teams are paid for by commercial insurers, MaineCare and Medicare as part of a multi-payer pilot program funded through 2016.  The hope is that at that point, new payment structures that emphasize health outcomes versus fee for service will ensure community care teams continued use.