HTCP began in early 2013 as an interprofessional care team created within the University of Arizona Health Network (now the Banner – University Medicine Division of Banner Health) in collaboration with the University of Arizona Health Plans (UAHP), the UA Center on Aging and the UA Health Sciences colleges. The goal — to improve care for vulnerable UAHP dual Medicare/Medicaid eligible members who receive their primary care from a UAHN provider.
An Interprofessional Approach to Clinical Interventions
The HTCP core care team is an interprofessional one, consisting of a nurse practitioner, registered nurse, clinical pharmacist, social work/health behavior partner, and community health partner, supported by a medical and a behavioral health director.
The patient and family-centered clinical interventions include Primary Care at Home for those patients who are most debilitated from their chronic or mental health conditions, care coordination in conjunction with the patient’s primary care provider for those experiencing an acute challenge due to their health conditions, and population-based care for other patients who would benefit from improved preventive services and self-care of their condition. The first two interventions were instituted in early 2013, and a third was instituted in the fall of 2013.
By mid-2014, the HTCP program interventions had resulted in a 41% decrease in emergency department visits, a 33% decrease in hospitalizations and a 27% decrease in hospital readmissions — as reported to the U.S. Centers for Medicare and Medicaid Services and the Arizona Health Care Cost Containment System (AHCCCS).
Better Care and Better Health Outcomes at the Best Value
The HTCP program is modeled after the best practices of established and tested models of care such as the Veterans Affairs’ Home-Based Primary Care Program.
What makes the HTCP program especially unique is the focus on behavioral health issues, from which more than a third of the target population suffers. Recognizing that co-morbidities of mental health and chronic conditions in a socio-economically challenged population leads to fragmented care and overuse of hospital and emergency services, the program aims to:
- Reduce avoidable hospitalization and emergency department use
- Improve appropriate use of prescribed medications
- Enhance the quality of care and connection to the health care system
- Improve self-sufficiency and quality of life
Partnering for Success
The “Healthy Together Care Partnership” refers to a collaboration of the interdisciplinary care team, primary and specialty care providers, and patient and family members.
Here is another patient story showing how the program fulfills its mission of partnering with patients, caregivers and community physicians to deliver care that is accountable and integrates all aspects of wellness:
A 46-year-old woman has numerous chronic conditions including lupus. She suffered for more than a year with an open, bleeding wound encompassing her full lower leg. The Healthy Together Care Partnership team coordinated her care with rheumatology, dermatology, and the SALSA clinic, as well as accompanied the patient to medical appointments and helped her understand and manage her diet, disease, and wound care. The wound is now more than 50% healed after 18 mos. of little progress. When asked what she thought of the program, the patient stated, “thank God you called me. I was so overwhelmed.”
Interprofessional Partners Make the Difference!
The HTCP team model includes students, interns, and residents from the disciplines of Pharmacy, Public Health, Medicine, Nursing, and Engineering, as well as social work interns, peer support mentors, and community health and outreach.
During the first year, a medical student, two clinical pharmacy residents, and two master’s degree candidates in public health participated in program development and clinical initiatives. The expertise and unique points of view the interprofessional partners contribute are critical to the sustained success of a partnership model, such as the Healthy Together Care Partnership.
Additional Resources
Banner Health’s Healthy Together Care Partnership Program [VIDEO]
This is a four-minute video on one of Banner Health’s programs serving AHCCCS and Medicare clients who have complex medical issues. It provides an interdisciplinary team of medical personnel to work together to find the best care for the patients. Staff and patients talk about their role in and benefits of the program. November 2015
“Tales from the Healthcare Village: How a Team-based Collaborative Care Partnership is Uniting Patients, Providers, and Payers to Achieve Better Care at a Greater Value” [PowerPoint]
A presentation by Nancy Wexler and Dorothy Terrazas, FNP-C, at the Collaborative Family Healthcare Association Annual Conference, Portland, Ore., October 2015
“Health Plan Perspectives: Cost of Care, Dual Eligible Populations and the ACA” [PowerPoint]
A presentation by James Stover, CEO, UA Health Plans, at the American Academy of Home Care Medicine (AAHCM) Annual Meeting, Orlando, Fla., May 15, 2014
“Considerations in Dual-Eligible Home Care” [PowerPoint]
A presentation by Jane Mohler, NP-C, MSN, MPH, PhD, at the American Academy of Home Care Medicine (AAHCM) Annual Meeting, Orlando, Fla., May 14, 2014
“Community-Based Programs – Healthy Together Care Partnership” [PowerPoint]
A presentation by Mindy Fain, MD, and James Stover, CEO, UA Health Plans at the Hartford/ADGAP (Association of Directors of Geriatric Academic Programs) Leadership Retreat, Coronado, CA, January 2013