When patients suffer acute care episodes that lands them in one of the 12 clinics Hidalgo Medical Services operates in the remote, mountainous deserts of southwest New Mexico, diagnoses for hypertension or diabetes are not uncommon — nearly half of the 34,000 residents of the sprawling region where the nonprofit health care and community development organization operates are overweight or obese.

All patients with diagnoses for hypertension and diabetes, or who exhibit signs of developing those conditions, are automatically enrolled in a family support program that includes a long-term care plan and a referral to a community health worker. Over the course of their care, the health worker they're assigned to will drive hundreds of miles to visit them in person and check on their health and compliance, instead of waiting until they end up back at one of the clinics.

"Sometimes, the patients don't wind up in a clinical setting," Charles Alfero, M.D., who founded Hidalgo Medical Services two decades ago and now runs its Center for Health Innovation.

Improving the treatment of chronic disease is a critical front in national efforts to improve overall health and reduce health care utilization. According to the Centers for Disease Control & Prevention, 75 percent of all health care costs are linked to chronic conditions. The human toll is striking: the CDC reports that heart disease, cancer and stroke together account for half of all deaths in the United States each year. The Agency for Healthcare Research and Quality estimates that 23.6 million U.S. adults, or 7.8 percent of the entire population, have diabetes.

In 2010, heart failure afflicted 5.8 million Americans — including 670,000 new diagnoses — and cost a staggering $39.2 billion in health care services, medications and lost productivity, AHRQ reports.

In response, a growing number of hospitals and communities have begun developing detailed care plans for patients with the warning signs of chronic disease. The programs are typified by regular primary care, behavioral health services that target the linkages between depression and other chronic conditions, and routine phone calls or visits from dedicated disease managers or, as is the case at Hidalgo Medical Services, a community health worker.

These efforts rely on a range of competencies, including strong internal referral systems to track patients and coordination among providers, local governments and social service agencies to reach patients in their communities or homes. And increasingly, providers are looking to start those relationships well before patients end up in the hospital.

"We're trying to create a model of community and family support services for populations along the spectrum, from prevention models and early intervention to care coordination at the highest end of the cost curve," Alfero says. Ideally, he says, "a person with a first-time diagnosis is in the system before they get sick."

Often the early adopters of these strategies have relatively high proportions of uninsured or low-income patients, says Carol Beasley, the director of strategic projects for the Institute for Healthcare Improvement.

"If you look at where the energy's likely to come from, for hospitals, the interest in this [is] if they're providing a lot of charity care," Beasley says. "It's frustrating to be caring [for this population] themselves."

Yet the delivery system is rapidly entering an era when the Centers for Medicare & Medicaid Services and private payers expect all providers to demonstrate improvements in population and community health, and penalties for readmitting patients are mounting. As such, a broader range of organizations are taking notice as partnerships between providers and payers demonstrate the financial value of better treating their most regular patients.

Jason Dinger, CEO of Mission Point Health Care in Tennessee, an accountable care organization aligned with Saint Thomas Health, says successfully treating high-frequency patients with chronic conditions will be key to the ACO's success. Mission Point was selected to participate in CMS's shared savings program earlier this year.

"You have a very small number of patients generating the good portion of the cost. We give them a real big bear hug," Dinger says. "We visit them in the hospital. We visit them in their home. We often join them at their physician office visits, really making sure they're getting a great experience in what is typically a really challenging time of their lives. We work with … the folks with chronic diseases and their families who are struggling to maintain and respond to those needs."

Working across the community

Treating high-frequency patients, providers say, often means bringing together not just health care institutions but also other community resources to reach patients in their everyday environments. In Cincinnati, a coalition of local groups, including Cincinnati Children's Hospital, have coordinated a number of projects targeting high-cost diseases that often are associated with socioeconomic factors — including asthma, preterm birth and gun violence. For instance, Beasley notes, the hospital has worked with the United Way locally to create a "web of services" for expectant mothers to reduce preterm births.

"All of these reach outside the edges of the delivery system to get the job done," she says.

Another example: the North Colorado Health Alliance links systems like Banner Health, a number of behavioral health providers, the United Way of Weld County and several county public health agencies to share information on patients in the hope of raising overall community health one referral at a time. The network of relationships gives the group a chance to reach populations that might otherwise fall off the radar screen — from migrant farmworkers to inmates in local correctional facilities.

"It's a partnership alliance of both providers of services and other community entities along the Triple Aim model," NCHA President Mark Wallace says, referring to the Institute of Medicine's Triple Aim of improving the experience of health care, improving population health and controlling per capita costs.

A 'concierge' model of care

At Mount Sinai Hospital in Chicago, all new heart failure patients are entered into the Project Red readmissions reduction program. A multidisciplinary team monitors everything from sodium levels to medication adherence — which sometimes means figuring out if the pharmacist has access to the prescriptions patients need.

Behind the scenes, the team stands poised to monitor patients' medication adherence, review their diets and pass along suggestions for grocery shopping to key family members. It also takes a bit of creativity.

"None of these patients belongs to a gym," says Jennifer Weiss, Mount Sinai's director of rehabilitation services. And suggesting that patients go for a walk or exercise in a nearby park can be unrealistic because of safety concerns in the neighborhoods they live in. Instead, Weiss advises patients to "park your car as far as you can from the entrance to Target."

In the first 11 months of the program, the hospital saw the readmission rate for the enrolled patients drop by 55 percent. That's a key indicator; the average Medicare payment nationally for an episode of care with no hospital admissions is $11,162; the average payment jumps to $28,377 for one admission and $46,394 for two admissions.

High-frequency patients also often have checkered histories in their interactions with providers, notes R. Corey Waller, who runs the Center for Integrative Medicine for Spectrum Health, Grand Rapids, Mich., which focuses primarily on high-cost patients who are often suffering from one or more chronic diseases. In fact, he says, "a lot of these patients have been fired by their primary physician."

Waller's program won't do that — instead, new enrollees receive several months of what he calls "concierge care," with the center taking complete responsibility for their health care over that time frame. That gives the center unique insight into patient lives, Waller says, by melding high-intensity medical interventions with case management tactics more typical of a social service agency.

"If a patient calls and says 'I'm in trouble,' we may know the electricity is out again," Waller says.

Mental health care is key

Many providers also offer a complement of mental health services to support primary care interventions, inspired in part by groups like the IHI, whose Triple Aim initiative targets patients who suffer from both chronic conditions and associated comorbidities such as depression or substance abuse.

The IHI's Beasley calls for the "integration of realms of … medical care and behavioral health care."

"Unaddressed needs in that domain can get in the way of other medical conditions," Beasley says.

A 2012 AHRQ study, "Practice-Based Interventions Addressing Concomitant Depression and Chronic Medical Conditions in the Primary Care Setting," analyzed 11 chronic disease studies, finding that patients receiving collaborative care interventions with mental health components had greater improvement in depressive symptoms than their counterparts, reported higher quality of life scores and saw a moderate improvement in mortality rates.

"We found that recipients of collaborative care had significantly greater improvement in depression outcomes as compared with patients receiving usual care for people with arthritis, cancer, diabetes, heart disease and HIV," the report found.

At Hidalgo Medical Services, there are mental health workers in every primary care facility ready to take referrals from physicians. The North Colorado Health Alliance takes a similar approach, embedding some of its primary care clinics within mental health facilities.

"It's our belief that there should be no wrong door in establishing a medical home," the NCHA's Walker says.

From passive to positive

By emphasizing wellness across a broad range of primary care and behavioral health interventions, providers ultimately hope to change chronically ill patients' perspectives and behaviors — and ultimately their overall health. It's a strategy that relies heavily on the creation of a detailed care plan with specific, day-to-day instructions for patients and their clinicians.

"We have a menu of things that support patient decisions around how they're going to take care of themselves," Alfero says. "It's all those things that don't happen all the time in a brief exam visit."

At the Southcentral Foundation in Alaska, new patients and their physicians develop a wellness plan that shows up in the system's records any time they enter an emergency department or clinic, says Douglas Eby, M.D., the system's vice president of medical services. "Initially people say, 'Why are you putting a label on me?' Are you telling me I'm lazy or stupid?' That's where trust becomes so important."

Over time, the system has used the care plan and other key interventions to achieve a reduction in ED use of 50 percent. In the best outcomes, Eby says, the hospital is able to transform not just a patient's behavior and health, but also their overall outlook on life.

"If someone's highly dependent and highly passive, at the beginning you're directive," Eby says. "As you gain trust and you partner with them, what you're gradually doing over time is getting them to be more positive and optimistic."

Next month: The final installment of the series will explore the national implications of high-cost patients, highlighting experiments to reduce costs and improve care for Medicare and Medicaid beneficiaries.

4 Common Causes of Chronic Disease

Four modifiable health risk behaviors are responsible for much of the illness, suffering and early death related to chronic diseases. They are:

1. Lack of physical activity
2. Poor nutrition
3. Tobacco use
4. Excessive alcohol consumption

More than one-third of all adults do not meet recommendations for aerobic physical activity based on the 2008 Physical Activity Guidelines for Americans, and 23% report no leisure-time physical activity at all in the preceding month.

More than 43 million American adults — approximately 1 in 5 — smoke.

In 2007, 20% of high school students in the United States were current cigarette smokers.

Lung cancer is the leading cause of cancer death, and cigarette smoking causes almost all cases. Smoking also causes cancer of the voice box (larynx), mouth and throat, esophagus, bladder, kidney, pancreas, cervix, and stomach, and causes acute myeloid leukemia.

In 2007, less than 22% of high school students and only 24% of adults reported eating 5 or more servings of fruits and vegetables per day.

Excessive alcohol consumption contributes to more than 54 different diseases and injuries, including cancer of the mouth, throat, esophagus, liver, colon and breast, liver diseases, and other cardiovascular, neurological, psychiatric and gastrointestinal health problems.

Source: Centers for Disease Control and Prevention, 2012

Coordinated care on the frontier

The area served by Hidalgo Medical Services sprawls across 7,400 square miles in the deserts of southwest New Mexico — a region roughly the size of Connecticut and Rhode Island combined. Within that area, there are 34,000 people and no acute care hospitals.

Starting with a single National Health Service Corps trailer in the 1980s — and after a nine-year period in which there were no health care providers at all in Hidalgo County — Hidalgo Medical Services has grown to 12 clinics, serving 60 percent of the population of southwest New Mexico with primary care, mental health, dental services and family support.

"We're a primary care, integrated health system," says Charles Alfero, M.D., who founded the organization and stepped down from his leadership role earlier this year to launch the system's Center for Health Innovation.

With limited resources, funding the clinics and caring for a vulnerable population with high rates of hypertension and diabetes takes constant effort and ingenuity. Over the years, the nonprofit has relied on grant funding from groups like the National Institutes of Health, state Medicaid contracts and funding for federally qualified health centers to create a system of care in an area with few other options.

"We've put clinics in places that never had them before," Alfero says.

But despite the challenges of providing health care to an extremely dispersed population, Alfero said there are some advantages to the frontier-like setting where Hidalgo Medical Services operates.

"We're not seeing 35 visits a day," Alfero says. "We're seeing half of that. At the provider-patient level, better relationships are possible." — Haydn Bush

Executive Corner

Head off hospitalization

Partner with local social service groups to reach out to the chronically ill in the community. These entities make daily contact with vulnerable populations that have a range of health and social service needs, and can identify potential patients before hospitalization is necessary.

Integrate care

Build care plans for patients at risk of developing chronic disease that integrate primary care, behavioral health services and regular contact with a key clinician, such as a disease management worker or community health worker.

In case of depression

Integrate disease management with mental health interventions to reach patients who also may suffer from depression.

Empower your patients

Patients with extensive interactions with the health care system are often passive participants in their care. Leading-edge hospitals are working to empower patients to make better decisions for themselves, which they hope will lead to lasting behavioral change.

Get creative

Encouraging patients to adopt healthier lifestyles that include regular exercise can be tricky, especially if the patients don't have access to gyms or safe parks. Suggest simpler strategies, like parking in the back of parking lots to increase walking time.