The timing couldn’t have been worse. It also couldn’t have been better.
Helen Bagwell fell in her West Boise house in January and hit her face on a wall. She wasn’t seriously injured, but the 95-year-old was falling more often. She needed to follow up with a doctor.
But in the middle of the Treasure Valley’s infamous winter, Bagwell’s daughter and housemate, Carolyn Duke, dreaded that follow-up visit. Venturing out in the ice and snow was a big risk for a person prone to falling.
At the time, Saint Alphonsus Health System was just a few months into a new program that was created for patients like Bagwell.
The program does away with 20-minute visits and specialists who don’t work together. In their place it offers hours-long initial consultations with a team of specialists, followed by home visits for people whose cognitive or mobility issues make leaving the house a taxing ordeal.
Judy Dunnam’s elderly mother was one of the first patients on the program. She lives in a memory-care center in Meridian and was taking a number of medications for Alzheimer’s disease. The Saint Alphonsus team recognized early on that two of those medications were counteracting each other. The team also made several other changes to her treatment plan.
“It was like, ‘Oh, somebody’s hearing me,’ ” Dunnam said. “I want to be a part of my mom’s care. I don’t want her overmedicated. I want her to have a good quality of life.”
What ‘quality’ means to patients, hospitals
The program runs on a philosophy of care that more hospitals locally and nationally are adopting — and which got a big push from the Affordable Care Act.
The old style of health care, known as “fee for service,” isn’t cutting it anymore, especially for patients with complicated medical needs. Those patients may end up in the hospital more often than necessary and be prescribed too many of the wrong medications, preventing them from developing a better quality of life.
While the Saint Alphonsus program is available to people on all types of health insurance, the hospital is tracking the progress of about 10,600 patients who have Medicare and Humana Medicare Advantage plans. The hospital will learn next year whether the program saves money and helps patients more than the fee-for-service system does.
“This way of practicing is so much more efficient. Even though it takes longer, it’s faster,” said Kara Kuntz, a geriatrician who spends more than half her work week immersed in the program. “When I’m caring for a person in a silo by myself, without a team, with shorter appointments, we make progress — but it takes longer, because I can only do so much and achieve so much as one person in one visit.”
The house-call team includes Kuntz and two other geriatricians, two palliative care doctors, two nurse practitioners, a pharmacist and a social worker.
Saint Alphonsus bills each specialist visit as it normally would, even if the visit happens in a residence or assisted-living facility. But for a cohort of patients, the program is a way to take advantage of new types of insurance contracts that reward the hospital for being more efficient and saving money. That type of arrangement is sometimes called “value-based” or “population health.”
“A lot of people ask, ‘How can you afford to do this?’ ” Kuntz said. “It’s because Saint Alphonsus has recognized that we’re changing the way we provide health care, and we need to, because health care costs are rising and our quality is not. There’s a gap there.”
That’s why Saint Alphonsus and other hospital systems, including Boise’s St. Luke’s Health System, are trying new things.
Seeing the home
When a doctor like Kuntz goes into the home of a patient like Bagwell, she sees the living environment. She notices the step into the house and the walk to the mailbox that might be a health hazard. She gets to see the family relationships. She learns critical bits of information that a patient’s caregiver could have forgotten to mention during a rushed office visit.
During a recent house call, Kuntz listened as Bagwell described feeling awkward when an aide comes to the house to check her feet and sit with her while her daughter, Duke, is away. Bagwell felt obliged to entertain the aide. And after a lifetime of independence, Bagwell felt as though someone was looking after her.
“I don’t feel like I need somebody to sit with me,” Bagwell said. “She’s very nice. I just don’t feel like I need her.”
Kuntz asked Bagwell to think about the aide’s visits differently: “What if it makes Carolyn feel better? Would that be OK? If you do it for your daughter?” And what if the aide helps out around the house while she’s there, instead of just sitting with Bagwell?
That made sense to the bright-eyed 95-year-old, who doesn’t mind wearing a medical-alert necklace but still wants to have her daily Southern Comfort and get the mail on her own.
Kuntz gave a doctor’s order for Bagwell’s family to try giving the aide something to do when she visits.
Since joining the program, Bagwell has regained a lot of her cognitive ability, Duke said. She does the cryptogram puzzle and the Jumble game in the Idaho Statesman. She pays attention to current events. Her concentration is better.
“She has an improved quality of life,” Duke said.