Patient Care Connect

UAB has been one of the pioneering organizations, along with Genesis Health System, in the development of the Medical Concierge patient navigation program. Started with help from a 3-year, $15 million grant from the Centers for Medicare and Medicaid Innovation (CMMI), our Patient Care Connect program has trained and deployed teams of non-clinical (“lay”) navigators (non-nurse, non-social worker) in 12 communities in a five state region of the deep south. All of our teams use the Medical Concierge software, which allows us to aggregate data centrally for reporting purposes.

UAB’s Patient Care Connect program was started in July 2012 and is currently serving a patient population of approximately 20,000 Medicare patients. UAB designed and developed all of the care protocols and pathways for the program, including a significantly enhanced distress assessment tool, built into the Medical Concierge software, that forms the basis of the navigator’s patient interview and assessment process.  Navigators receive extensive training in the continuum of cancer diagnosis, treatment, and survivorship, as well as in health issues in geriatrics and complicating co-morbid conditions. Medical Concierge has been custom designed to track all patient encounters. The system tracks levels of patient distress, creates work lists as stressors are identified, assists with referrals to other care providers, provides follow up intervention reminders, and serves as a team communication tool. It is very easy to use and provides excellent support to all of our navigation teams. We like the system and highly recommend it.

These navigation teams consist of a nurse leader surrounded by well-trained lay navigators. The lay navigator concept is based on more than 15 years of experience using community health advisors in a variety of community screening, low income resource support, and clinical trial navigation programs at UAB. The Patient Care Connect program pairs a lay navigator (think, “patient advocate”) with a new patient, with the goal of empowering patients’ to overcome barriers to care, make the most appropriate and informed choices for their treatment, avoid the use of the emergency room, reduce the use of ineffective therapies, and maximize the appropriate use of health-care resources. Navigators follow patients through the entire continuum of their cancer journey. Specific program goals include: 1) reducing unnecessary emergency room visits, which lead to high utilization of inpatient resources; 2) encouraging the use of evidence based treatment plans by empowering patients with the knowledge they need to ask the appropriate questions of their care teams; and 3) promoting the earlier adoption of palliative and hospice care by preparing patients in advance about choices available to them should they face advanced stages of their disease.

Medicare provides comprehensive claims data on the entire study population. We observed decreases after implementation from 13.4% to 11% for hospitalizations (18% decrease, p < 0.01), 8.0% to 7.1% for ER visits (12% decrease, p < 0.01), 2.9% to 2.5% for ICU admissions (14% decrease, p = 0.04) and an increase of 3.9% to 4.3% for hospice (9.2% increase p = 0.37). Costs decreased about $158 per quarter per beneficiary over the analysis period. A significant pre-post decrease of $952 per beneficiary (p < 0.01) lead to an estimated total reduction in Medicare costs of $18,406,920 for the 19,335 beneficiaries in the UAB CCN for the five quarters post-implementation. Current savings rate is in excess of $1000 per beneficiary (patient), per quarter.

Warren Smedley, MSHA
Service Line Director, Cancer & GI Services
University of Alabama at Birmingham Comprehensive Cancer Center
 Birmingham AL

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