Throughout Western New York and across the country, community leaders and elected officials often discuss the need to transform health care by improving quality and stemming rising costs.

The consequences of the Covid-19 pandemic have made this necessity even more apparent than ever. Even still, health care facilities continue to face unprecedented staffing shortages, and unmitigated burnout remains a serious concern among health care professionals.

How do we address these mounting challenges?

No single solution or “quick fix” exists. However, any possible solution will require better alignment and more coordinated care among providers and health plans to reduce the need for hospitalizations and provide care in alternative settings when appropriate. It may seem obvious, but this requires a fundamental adjustment in managing health care and how it is paid for in this country. We stand in the middle of a shift toward value-based and proactive care instead of reactive health care. It’s essential we advance this trend, but our health care system requires further transformation.

One could argue our health care workforce shortage won’t disappear when Covid subsides. This likelihood illustrates the need for more efficient delivery models, which by necessity may involve fewer hospital beds, with physician assistants, nurse practitioners, RNs, LPNs, and other health professionals working to the maximum scope of their training and licensure. Easing the pressure on hospitals will require moving more care to community settings and eliminating care that does not add value.

These new, advanced care delivery models must promote proactive health care, address the day-to-day needs of patients to keep them healthy, and support individuals in managing their own care. Caring for patients’ health through a holistic lens and addressing social determinants of health will lead to better outcomes and ultimately lower costs.

“Patients with complex chronic conditions need and deserve help that goes beyond what the physician’s office can provide. That may be advice from a pharmacist, help from a social worker, in-home evaluation, or connecting with community agencies. This program enhances medical care, is patient-centered, and benefits patients and their physicians.”

Nancy H. Nielsen, M.D., Ph.D., Clinical Professor, University at Buffalo Jacobs School of Medicine & Biomedical Sciences.

Patients with multiple chronic conditions require specific and extensive care, presenting a significant challenge to primary care physicians’ time and resources. Care for You involves a dedicated care team of physicians, physician assistants, nurse practitioners, registered nurses, social workers, dietitians, and community health workers who work with patients to develop individualized, proactive care plans in concert with their primary care physician. When patients receive care in one of four settings – in the home, hospital, nursing home, or clinic – Care for You staff support accessibility and efficiency and manage preventable admissions/readmissions.

Components of Care For You

24/7 Access to Care. Individuals can access care at any time to care specific to their personal health needs.

In-Home Care Team. The care team includes Nurse Care Manager, Licensed Social Worker, Nurse Practitioner, Registered Dietitian, Physician, Community Health Worker, Pharmacist

In-Home Urgent Care Visits. The care team can provide in-home urgent care visits 7 days a week, including evenings and weekends to help avoid urgent care or emergency room visits.

Personalized Care Plan.  The care team develops a care plan shared with everyone involved in the member’s care, including their doctors.

Aligned Support. The Care For You team communicates regularly with the member, their doctors and caregivers to ensure coordination of care that meets the needs of the personalized care plan.

The program supports alignment among physicians and care personnel, providing a single point of support through centralized services. Patients also undergo an assessment of social determinants of health so the care team can link patients with applicable community resources and educate and promote medication adherence.  

Care for You offers promise beyond Medicare Advantage patients with multiple chronic conditions. Over time, the program will expand to Independent Health’s other lines of business. Additionally, Independent Health is partnering with providers on a number of initiatives to achieve better outcomes and quality across the region, such as value-based care and reimbursement models for primary care physicians and transition processes for individuals discharged from hospitals. Ultimately, these advanced care models like Care for You can move us toward what we call the “Quadruple Aim” of health care – better care, better health, lower costs, and provider vitality – and help address the systemic challenges our health system faces as we continue to grapple with the impacts of Covid-19 and beyond.