Case Management of Chronically Ill Elderly Dual Eligibles

With chronic illnesses like diabetes and heart disease being cured isn’t the goal; feeling better on average, not going to the hospital as much, living a longer and higher quality life is the goal. The existence of chronic illness is a somewhat ironic demonstration of modern medicine’s success. Three decades ago, many chronic conditions killed you at much younger ages. Today, many like heart failure can be fought off for years or indefinitely.

Kenneth Thorpe, chairman of the health policy and management school at Emory University, estimates that 95 percent of spending in Medicare goes to patients with one or more chronic conditions — with enrollees suffering five or more chronic conditions accounting for 78 percent of its spending. According to Mr. Thorpe, “This is the Willie Sutton rule; If 80 percent of the spending is going to patients with five or more conditions, that’s where our health-care system needs to go.”

This is the basic health profile of full Dual Eligible, a population in the United States of more than 7 million people and in Missouri more than 168,000 of our citizens.  As we’ve discussed in earlier blog posts, dual eligible individuals are using the full benefits available to them under both Medicare and Medicaid. 61% are over 65, 39% are younger than 65 and disabled. Half have dementia or another mental impairment and 55% have three or more chronic conditions. This is the highest cost group of consumers in the American medical system. They are 15% of the Medicaid population and account for 40% of total Medicaid spending. In Missouri we spend in excess of $2 billion annually on this group’s healthcare.

Individuals with chronic conditions, many dual eligible, represent perhaps the best group for home health and community based services (HCBS) generally to demonstrate their biggest benefit to the healthcare system overall.

Many traditional care-management systems rely on nurses sitting in call centers, checking up on patients over the phone. These centers are often housed within insurance companies or subcontracted providers to insurance companies who have capitated contracts with state governments to manage chronically ill Medicaid beneficiaries and, increasingly, the dual eligible population at large.  That model has mostly proven to be a failure where maximizing long term savings to state governments is concerned and, more importantly, where improving the long term quality of life for beneficiaries is concerned. Most savings driven by this model are attained via provider reimbursement cuts and minimization of services which produce early savings that then tend to marginally abate with time.

While many are familiar with the use of home health nurse visits in the days and weeks after a serious hospitalization or nursing home discharge; a much greater benefit to the system can be achieved by sending a nurse to regularly visit chronically ill patients at home. Using home health in this fashion basically redefines the health-care system’s role where the elderly and chronically ill are concerned. It acknowledges that being older and chronically ill is a condition that requires ongoing, professional medical management. In this acknowledgement there is tremendous improvement in quality of life at much lower public expense, especially where the dual eligible beneficiary is concerned.

Many chronically ill patients think of the hospital as a place people go to get better. What providers of Home and Community Based services (HCBS) realize is that, in reality, a hospital is a place where chronically ill seniors get worse. Being in the hospital for multiple days is often the point at which a chronically ill but basically stable senior’s health condition really begins to deteriorate. It’s when the individual ends up in a nursing home and in some cases never makes it back to their own home. It’s also the point at which public health cost absolutely skyrocket. Keeping seniors out of the hospital and out of the nursing home is the core focus of HCBS; they cut cost and save and preserve quality of life; and it saves money, lots of it.

At home is where chronically ill elderly patients spend the time they don’t lose to hospitalizations. It’s where they take their medicine or fail to properly, eat healthy meals or eat poorly, are engaged or become depressed, get around or fall down. This is the key to the power of home health and HCBS; in the home a trained medical professional can see trouble before it becomes too late. As well intended as they may be, clinicians in call centers in O’Fallon and Omaha can’t get the same level of understanding of a situation as can a clinician on-site. It’s just very difficult to build an effective relationship over the phone that makes a lasting difference.

Pyramid Home Health Services has been building these relationships with Missourians suffering from chronic illness since 1972.  We fundamentally believe that where chronically ill dual eligible are concerned, you can’t treat them when they’re sick and ignore them when they’re well. You need to know them well enough and see them frequently enough to catch if they are depressed, if their color is good or bad, if they understand their medications and are managing them appropriately. When you consider that a relatively high acuity dual eligible with multiple chronic illness can be effectively kept out of the hospital and nursing home for approximately $4,000 annually and a very high acuity individual for less than $8000 annually and compare the same to one, three day hospital stay at $5,800, and $125 per day for rehab in a skilled nursing facility afterward, which can often run up to 100 days, the economic benefits of using HCBS to case manage the health of chronically ill elderly become abundantly clear. Further add to that fact that home is where everyone would rather be unconditionally.

If Pyramid Home Health Services can assist you or your organization with case management and/or additional HCBS for a chronically ill loved one or a population for whom you’ve contracted to manage, please contact us at 888-880-6565 or visit us at

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