Programs help seniors stay out of nursing homes.
The following correction was published in the Sunday Telegram on October 21, 2012:
Enrollees in NaviCare's Senior Care Options plan can be eligible for nursing home care, but do not have to be. A correspondent's error in an article in the Oct. 14 Business Matters on Fallon Community Health Plan's NaviCare program indicated elgibility was mandatory.
Roger Wilson calls himself the "poster boy for preventive medicine," but the 70-year-old Oxford resident also exemplifies how NaviCare, a two-year-old program operated by Fallon Community Health Plan of Worcester, helps seniors take care of their health and stay out of nursing homes.
In addition, NaviCare and its counterparts in Massachusetts also help Medicare and Medicaid save millions of dollars.
Mr. Wilson never bothered much with doctors. Most of his life he was a pretty healthy guy - or at least he thought he was. Then came an accident at work that left him legally blind.
Because out-of-pocket medical costs were draining him, Mr. Wilson joined NaviCare, a coordinated care plan with Medicare and Medicaid contracts. Like all new enrollees, he was set up with an initial appointment with a primary care physician. Guess what? Mr. Wilson also had lupus and Type 2 diabetes.
"I felt great, but on the inside I was killing myself," said Mr. Wilson, who never had had a primary care physician. "I would have probably been dead within two years."
Before that eventuality, though, Mr. Wilson would have probably spent the last months of his life in a nursing home.
And the state's Medicaid program, known as MassHealth, would have been looking at adding a few hundred thousands dollars to its already steep bill for round-the-clock nursing home care for seniors and others.
Medicaid pays for the 24-hour care of more than eight out of 10 nursing home residents in Massachuseetts. In 2011, according to MetLife Mature Market Institute, a semi-private room in the Worcester area went for a low of $250 a day, or $91,259 annually, to a high of $385 per day, or $140,525 a year. And the average stay in a nursing home is just about two years.
On the other hand, Fallon's NaviCare program and its Medicare Advantage Special Needs Plan and Senior Care Options program try to either reduce or eliminate that nursing home stay by keeping seniors well and in control of their own lives.
SNP requires seniors, age 65 and older, to have both Medicare Parts A and B and basic MassHealth Standard coverage, while SCO requires only the MassHealth Standard coverage, according to Kristine Bostek, executive director of NaviCare. Clients can be nursing-home eligible, but do not have to be.
So far, NaviCare has enrolled about 1,400 seniors in the geographical area covered by Fallon - all of Worcester and Hampden counties and parts of Middlesex, Norfolk, Franklin and Hampshire counties.
Fallon also operates Summit ElderCare, a program of all-inclusive care for the elderly, or PACE, that is offered to those who are 55 years of age and older living in the community who meet the eligibility requirements for nursing home care. That program, which has 900 enrollees so far, is available to residents of Worcester County and the towns of Marlboro and Hudson.
The SCO model of care combines the efforts of the personal care physician and the SCO care management team, but the key to making NaviCare work, according to Ms. Bostek, is the role of the "navigator."
That's the title Melissa Brousseau has, and she uses her skills to help Mr. Wilson and about 85 other NaviCare enrollees deal with their health problems - in their own homes or apartments.
"I'm like the center point of contact for the members, their providers, primary care physician, VNA (Visiting Nurse Association), etc.," said Ms. Brousseau. "I make sure all of a patient's services are coordinated."
Ms. Brousseau links her patients up with suitable networks of providers who have contracted with NaviCare to care for the needs of the plan's enrollees. The networks are large enough to provide patients with a choice of providers throughout the Central Massachusetts area.
"It's nice for them; it's like they have their own personal service representative to work with," she said.
Instead of paying a fee for separate services - treating a sore throat, prescribing insulin, caring for a rash - Medicare and Medicaid pay NaviCare a so-called "global payment" to care for all the health needs of the patients enrolled. The annual payment is adjustable, with higher payments for patients considered to be of greater health risk.
"Today in Massachusetts, about 26,000 seniors and others get their care through coordinated care provided by SCO and PACE," said Alicia G. Bandy, senior account executive with Solomon McCown & Co.
"Massachusetts PACE programs have helped 88 percent of their program participants to continue living in community settings, despite the fact that all participants must be frail and needy enough to qualify for a nursing home level of care in order to be eligible to enroll in the PACE program and the SCO programs," she said.
The SCO programs have reduced nursing home placements by almost 30 percent, according to an independent study conducted by JEN Associates Inc. of Cambridge. And the six Massachusetts PACE programs, including Fallon's Summit ElderCare, save the commonwealth more than $52 million a year by having frail seniors enrolled in PACE instead of fee-for-service MassHealth.
Next step: Massachusetts has become the first state to receive approval from Washington to develop a health care plan for improved care and cost containment for 111,000 people with disabilities who are eligible for both Medicare and Medicaid.
CUTLINE: Roger Wilson of Oxford talks to "navigator" Melissa Brousseau, who coordinates Mr. Wilson's health care through NaviCare, a program operated by Fallon Community Health Plan of Worcester that helps seniors stay out of nursing homes.
PHOTOG: T&G Staff/JIM COLLINS