In this edition of Local Motion, KVNF's weekly public affairs program, we discuss Delta Health's new chronic care management program, ChartSpan.
It aims to better manage patients with chronic conditions like congestive heart failure, COPD, and diabetes.
Our guests include Jonathan L. Cohee, CEO of Delta Health, and Reuben Farnsworth of the Delta County Ambulance District.
Our conversation also covers a collaborative effort between Delta Health and the ambulance district to integrate their services and resources to better support chronic care patients.
Interview transcript
This transcript has been edited for length and clarity.
Lisa Young, KVNF: Jonathan, as the CEO of Delta Health, I'm going to let you kick off today's conversation. What would we like to talk about today?
Jonathan L. Cohee, Delta Health CEO: I think today it'd be great to talk about our new chronic care management program. It's not new to Delta. We've been doing chronic care management for the last two years, but we've really just increased our services. We partnered with ChartSpan, the company that we chose to help us with that. And so chronic care management, we'll talk about the details and what goes into that, but it's really a segue to get us into the value-based care services and providing more and more of those services in the home. Taking care of managing patients, social determinants of health. In the chronic care management program specifically, you take a look at all of the Medicare patients; they need at least two chronic diseases.
There's typically a co-pay. Some insurances don't have the copay, but some do. On average, it's about $15 to $20 a month. But what it does is it allows them to have access. There's about 20 minutes a month that's spent on their case, and they really spend a lot of time with the patients...make sure they're receiving what they need...they have their meds, their vitals, everything they're doing is fine. And then also one of the things we're working with Ruben Farnsworth with DC, also North Fork EMS. We're working really closely right now to try to tie the services in the community together and work. Oftentimes...we don't tie those resources together.
Anybody that has a chronic condition (like) congestive heart failure, chronic obstructive pulmonary disease, COPD, CHF, diabetes, any of those conditions that have been, there's really not a cure for those. Those are going to be with people for the rest of their lives, and they need to manage those conditions. Medicare recognized if there are frequent touchpoints with patients who have those chronic diseases, one, we're able to keep them in the home and better manage that condition. As soon as patients come into the hospital, whether that's the emergency department or they have to be admitted because they are in an exacerbated state, right? So if I have chronic obstructive pulmonary disease, it's allergy season, and I don't have the correct medication, I haven't been taking care of myself, I may have to go into the hospital to treat an acute flare-up. And every time I go into the hospital, it kind of knocks me down, and sometimes it's really hard to get back to that baseline. So every time you do that, you fall a little bit deeper.
Young: Delta Health's been working with ChartSpan, and you've been having phone calls made. These phone calls do not go out to all patients. Correct? They only go out if you're on Medicare?
Cohee: Correct.
Young: And if you have two issues, medical conditions in your life that are chronic, like high blood pressure, heart disease, type one or type two diabetes, I mean, the list could go on, but you have these situations going on in your life, and you're on Medicare. And by the way, Medicare is not about your age. It can be for folks who have other conditions. So we're talking about anyone that qualifies. If you're in Medicare and you go to Delta Health, you more than likely have already received a call from ChartSpan, or you could still receive a call from ChartSpan. Is that correct?
Cohee: Yes, absolutely.
Young: As those calls are going out and people are being contacted, most people are really resistant. What have you done so that folks are already prepared to get that call from ChartSpan?
Cohee: I think hindsight's 20-20. If I were to do the rollout again, I would put a message out in our patient portal (about) expecting this call. Oftentimes, it's hard because the only time you see your provider is annually. And then we put it out in the DCI, the Delta County Independent. But the 'why' behind it, why ChartSpan, why don't we do it just ourselves?
So, for us, when we tried to stand it up, we just didn't have the physical bodies to be able to do that and the software. That's why we partnered with ChartSpan to be that team for us. They really are integrated into it so that their team is dedicated to us. For most people, they'll be talking to the same people. So when they call in, and they have an issue, ChartSpan will call them on a monthly basis. Patients that are enrolled have 24/7 access where they can call and get that nurse if they have questions.
Young: Let's talk about the collaborative work that you want to do here with Ruben. You started that conversation, but I just wanted to make sure people know how they can get more information on ChartSpan.
Cohee: Our grant team said, 'Hey listen, we have this tremendous grant, this opportunity,' but it really lends it to, they'd love something to be done in the community, and they really want to tie some entities together to be able to do it. So when I spoke to the grant team, I said, 'Hey, what about remote patient monitoring? What if we (get with) North Fork EMS? What if we got Delta County Ambulance Service?' We got everybody together to see if we couldn't come up with a plan to be able to present.
Young: Ruben, what excites you about the possibility of working with Delta Health in this area?
Reuben Farnsworth, Delta County Ambulance District: We share a large number of patients between Delta Health and Delta County Ambulance. Our mobile integrated healthcare program already sees a lot of these patients who are probably getting chronic care management. Right now, we don't have a way to get paid when we see Medicare patients because ambulance services are viewed by Medicare as suppliers of transportation. So, currently, the way the legislation is, ambulance services are incentivized to take people to the most expensive destination, the emergency room (and) by the most expensive means of conveyance possible, which is an ambulance. At Delta County Ambulance, we decided we wanted to kind of shift away from that paradigm and we wanted to focus more on providing the most appropriate care through the most appropriate mechanism that was most beneficial to patients. And we found some creative ways to fund it.
We've seen some big differences for some of these patients. And it goes back to what John was talking about of touch points. In this area, we're HRSA, which is the Healthcare Rural Services Administration. So this whole (area), Montrose and Delta counties, we're all health provider shortage areas. There's a shortage of PCPs. So if I go to a physician that works through one of the Delta Health clinics here, if I call and say, 'Hey, I got a horrible chest cold. I don't know if I got the flu or if I got COVID, I don't know, but I'm sick as a dog.' They'll go, 'Cool, we can probably see you in a week or two.'
And I go, 'Well, a week or two, I'll either be better or I'll be dead.' And they go, 'Well, I guess you can go to the ER.' I'm not going to the ER for a cold. What we wind up with is we see a lot of patients that utilize the emergency room or 911 in the ambulance for their chronic health needs, their exacerbations. With our mobile-integrated healthcare team, we started trying to get out in front of those. So whether we get a referral from a physician or a 911 ambulance team or a social worker, we will get that call that says, 'Hey, there's this person that we think needs attention.' We'll try and go see them before it becomes a 911 call.
Their primary care provider reaches out and says, 'Hey, I haven't seen Mrs. Smith in three months, and I'm really wondering what's going on with her?' And I understand she's been transported by ambulance to the ER three times in the last two months. What's going on with that? So we'll go see her, and we say, 'Hey, why aren't you making it to your doctor's appointments?' And what we're finding is a lot of people in this county and in our community are adversely affected by what we call the social determinants of health. These can be things like food insecurity, access to transportation, and access to resources. Sometimes what happens is you start talking to these patients, and they go, well, I don't have a way to get to the doctor's office.
You get the diabetic that they keep having issues with their blood sugar. And so we go out to see what's happening, and you look in their pantry, and you find microwave TV dinners, and you find Snickers bars and a case of Mountain Dew, and you go, oh, no wonder you're having issues. And you start talking to them about their diet. And what you find out is that the healthy part of the grocery store, the outer ring of the grocery store (is) the most expensive part of the grocery store. When you have an elderly person who is on a fixed income with social security, and they're on Medicare, and they may not recognize they qualify for food stamps, the process got complicated on them. This is all they can afford. Or, we find out that they could afford good food, but they can't stand long enough to prepare a meal in the kitchen.
We identify those places where they're adversely affected, and then we can go back with the teams from Delta Health. And a lot of times, there are solutions patients don't realize exist.
Young: I'm getting a really cool vision about the fact that when you're on the ambulance, and you go to their house, you see the surroundings, you see what's going on when they come into the doctor's office, the physician sees them, but they don't see the house, they don't see what's in the cabinets. They don't get the real overall picture of what is actually going on in this person's life. But the catch here is that you need more money to be able to continue to do the services is kind of what I'm hearing,
Cohee: Yeah, I love that you visualize it now because you take that in what Ruben described, what you just described, and that's basically the program. We get people that need this assistance, we get them equipment in their home. The equipment can be just a scale, and the scale sends a signal to us. So we know daily what their weight is. It can be blood pressure. We know what their blood pressure is. So it's putting that equipment in, it's creating the touchpoint and the visibility, the ability to take things because maybe from that information that we gather, we say they just need an antibiotic where right now, for Ruben and his team to get an antibiotic to people.
But we can have a clinical pharmacist in the clinic. We have the means to get that paid for. We just need a route of administration. Now we don't, we still need to have that clinical pharmacist in the outpatient, but this is where that program can go. And then we have the eyes and ears of the provider that can now do a telehealth visit. So when Ruben's team is out there, they can pop on and say, yes, I see exactly what they need. We have a behavioral health team that can help take care of some of the social determinants, but we know if they're not taking their medication and why we know if they can't afford groceries and why, so we can get them the resources that we need.
Farnsworth: Well, to expand on what John's saying, if you think about it from a cost perspective, there's a lot of talk right now in our country about the cost of healthcare for everyone. And if you consider that, I think the last statistic I saw, the average cost of an emergency room visit is $1,800. The average cost of ambulance transport is anywhere from one to two thousand dollars. So when someone calls 911 because they're having an issue with their congestive heart failure, they haven't been to their primary care physician for two months, and their script ran out, and they haven't been able to get their meds refilled...we just easily hit a $4,000 cost for this one event.
They'll manage the acute flare-up and be like, okay, you're stable. You can go home today, and you're not going to die. You need to follow up with your primary care physician. Well, we go back to if they missed their last two appointments with their primary care physician. They don't have a way to get there. That's great. We manage the acute flare-up at a cost of $4,000 to the system, but now they're going to go home and they're still not going to follow up because they can't, they're not capable. They don't have a way. And so if you look at the cost of sending a community paramedic, having these devices in the home, now all of a sudden you're managing this patient for a much lower cost. And if we prevent those ER visits...what a huge difference.
We have patients we follow in Medicaid who, before our team started seeing them, were using the ER, the emergency room, as much as 20 or 30 times a year. We've decreased those numbers to where they're using the emergency room once a year. You do a simple math on that 10 ER visits at $1,800 is 18 grand. You do 30 ER visits, that's $54,000 a year. That's half of what a community paramedic costs me a year.
Young: What was the catalyst that stopped the person from going to the ER? How did that happen? It sounds like there had to have been some contacts that you had contacts with this individual over time.
Farnsworth: We work with Rocky Mountain Health Plans, which has the Medicaid contract for this part of the state. And they sent us a list, and they said, 'Hey, these are our people that are costing the most money that are using the system the most.' We would go engage with them to find out why this is happening. Why are you going to the ER? A lot of times, it was simple things. They'd go, well, my doctor left. I don't have a doctor anymore. Okay, let's get you a new physician. Or they'd say, well, I don't have insurance, and so I can't go to the clinic, but at the ER, they have to see me.
We had a patient who was really struggling, and we said, sir, why aren't you on VA benefits? He'd served 30 years in the U.S. Navy. He was a veteran of, I think, Vietnam and the first Gulf War. So he was a combat veteran from two wars and had served 30 years in the U.S. Navy. We're like, 'Sir, you should have full VA benefits.' And he's like, 'I agree, but I gave up. I can't tell you how many hours and days I spent on the phone trying to get my benefits.' Well, the county has a person that all they do is help veterans with their benefits. We tied that gentleman in with the person from the county and, within a week, had him receive the VA benefits he earned with his military service.
Young: It sounds to me like the big takeaway message, and what listeners need to hear is that there is help. There are people out there already thinking about how to solve the particular problem that you have.
Cohee: Absolutely. Just know that we'll help you no matter where you are in your healthcare journey. If you have one of our providers, you have a question, reach out to the clinic, reach out to the provider. That team will take care of you.
