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New OHSU Senior Care Program Gets $2.5 Million Boost

The John A. Hartford Foundation grant supports expansion of Care Management Plus: Information Technology Tools for the Care of Seniors

A $2.5 million grant to Oregon Health & Science University will expand Care Management Plus, a technology-intensive, innovative primary care model that reduces hospitalizations, lowers costs, and improves health outcomes for older adults with chronic illnesses.

The four-year grant from The John A. Hartford Foundation will make Care Management Plus available to dozens of rural and urban clinics across the country.

"By marrying clinically supported technology and personalized, one-to-one care, Care Management Plus has helped primary care teams enhance care for patients with complex illnesses," said David Dorr, M.D., assistant professor of medical informatics and clinical epidemiology, OHSU School of Medicine, and the project's principal investigator.

In initial studies of Care Management Plus, seniors with diabetes in the program had better control of their blood sugars and were more likely to be regularly tested. They also had 15 to 25 percent fewer long-term complications, a 20 percent reduction in mortality, and a 24 percent reduction in hospitalizations, compared to a control group.

"We are optimistic that the program could also improve treatment and lower costs for the care of other chronic diseases, such as depression, cardiovascular and end-of-life care," Dorr said.

This would represent an important step forward, as patients with chronic illness account for 75 percent of health care expenditures in the United States. Sixty-five percent of the Medicare-funded population have two or more chronic conditions and represent 95 percent of Medicare costs, and this group has up to 98 times the rate of preventable hospitalizations than the rest of the population.

Cherie P. Brunker, M.D., co-principal investigator, Intermountain Healthcare and the University of Utah Division of Geriatric Medicine, describes Care Management Plus as "giving providers the tools they need to improve care and meet the increasing needs of older adults - all with a focus on the goals of the individual."

At the heart of Care Management Plus is a robust tracking and reminding system that takes advantage of medical informatics innovations developed at Intermountain Healthcare and OHSU, and well-trained, "technology-enhanced" care managers. Together, they help patients and caregivers self-manage their conditions, prioritize health care needs, prevent complications through structured health care protocols, and navigate an increasingly complex health care system.

For example, an elderly woman with diabetes, high blood pressure, mild congestive heart failure, arthritis and memory problems would have a care manager, such as a specially trained nurse or social worker, assigned to her. The care manager would work with her to create a care plan, act as a catalyst to ensure the plan is followed, and remain a point of contact for the care team, including specialists and the primary care physician. Information technology is used to store and update the care plan, remind the care manager and others about protocols and best practices, and facilitate and document communication among the care team.

"The frail elderly are at high risk of avoidable complications, and the system - information technology with a trained care manager - has been an effective solution for them," said Linda Leckman, M.D., CEO of Intermountain Healthcare Medical Group, and an early proponent of the system.

The care manager also collaborates with the patient, the family and physicians to adjust the plan as needed. The goal is to prevent problems rather than treating them after they occur. The care manager is most frequently a nurse, and the grant will foster collaboration with the OHSU School of Nursing and its John A. Hartford Center of Geriatric Nursing Excellence, led by Heather Young, Ph.D.

Building Patient Relations, Improving Clinician Productivity
Care Management Plus is a "proven model" that emphasizes face-to-face time with patients, rather than the common model of telephonic care. As a result, care managers "develop really strong relationships with the patient. Sometimes patients just need education, but a lot of times they need this ongoing care," Dorr said.

Care Management Plus also can help physicians be more productive by making the care of patients with complex illnesses more efficient, and it pays for itself after the first year. In the pilot study, productivity increased by 8 percent to 12 percent among 50 physicians who used the program compared with 72 control physicians who did not use the program, which meant a savings of $99,000 per clinic in additional revenue that paid for the cost of the care manager.

"If a patient is in crisis, the ability to refer them immediately to the care manager who can sit with them and talk with them about issues, do some formal assessment and get them to a specialist the next day really saves me as a physician time to do more complex things with the patient that ultimately affects my bottom line," Dorr said. "By helping patients help themselves through self-management, they're better prepared and they don't go to the hospital as much."

Overall health care costs decrease, Dorr said. At the end of the grant period, his team estimates a $9 million savings for Medicare. Based on these results, dissemination has already begun at 26 clinics through this grant and through a Geriatrics Teams in Practice Dissemination grant, also funded by the John A. Hartford Foundation, and led by Eric Coleman, M.D. He adds, "These outcomes speak volumes to both chief clinical officers and chief financial officers alike."

Looking Ahead
Dorr hopes Care Management Plus reshapes health care practice in the care for elders and those with multiple chronic diseases, which has been described as mediocre, fragmented and inefficient in the United States.

Care Management Plus "establishes a medical home by overcoming the problem of complexity of follow-up," Dorr said. "Patients don't get forgotten."

Persons interested in benefiting from the training and technology supported by the program can visit the project's Web site at

About OHSU
Oregon Health & Science University is the state's only health and research university, and only academic health center. OHSU is Portland's largest employer and the fourth largest in Oregon (excluding government), with nearly 12,000 employees. It serves 189,000 patients, and is a conduit for learning for more than 3,400 students and trainees. OHSU is the source of more than 200 community outreach programs that bring health and education services to each county in the state. As part of its multifaceted public mission, OHSU strives for excellence in education, research and scholarship, clinical practice and community service. Through its dynamic interdisciplinary environment, OHSU stimulates the spirit of inquiry, initiative, and cooperation among students, faculty and staff. OHSU is made up of the schools of Medicine, Dentistry, Nursing, and School of Science & Engineering. For more information about OHSU, call (503) 494-8311.

About The John A. Hartford Foundation
Founded in 1929, the John A. Hartford Foundation is a committed champion of training, research and service system innovations that promote the health and independence of America's older adults. Through its grant making, the Foundation seeks to strengthen the nation's capacity to provide effective, affordable care to this rapidly increasing older population by educating "aging prepared" health professionals (physicians, nurses, social workers), and developing innovations that improve and better integrate health and supportive services. The Foundation was established by John A. Hartford. Mr. Hartford and his brother, George L. Hartford, both former chief executives of the Great Atlantic & Pacific Tea Company, left the bulk of their estates to the Foundation upon their deaths in the 1950s. Additional information about the Foundation and it programs is available at

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