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Published on April 25, 2016

How 20 minutes a month could save livesHow 20 minutes a month could save lives

“Keep in touch” isn’t a sentiment most of us associate with the doctor.

New Medicare rules, however, encourage doctors to help manage the health of chronic care patients in between office exams. The goal is to prevent problems that might prompt a visit to the doctor’s office or, worse, the emergency room.

The rules are designed to encourage you and your primary care doctor to work together to not only take care of problems when they arise, but prevent them in the first place.

“Medicine has been more of a reactionary thing: You get sick, you go to the hospital,” said Beth Hamacher, RN, patient care director at Emerald Physicians, a practice that’s now under the Cape Cod Healthcare umbrella. “We’re really moving toward a model of wellness and prevention with this program.”

Chronic care patients [pdf] are those with ongoing issues such as congestive heart failure, cancer, diabetes, or even asthma, high blood pressure, and depression. Chronic care covers any condition that puts someone at risk for declining function, emergency hospitalization, or even death.

Until January 2015, doctors and other professionals could only bill Medicare for responding to a problem. Now, practices can bill 20 minutes per month for creating and managing a coordinated care plan for patients who have at least two qualifying chronic conditions.  At Emerald, that time includes phone calls to check on patients. Those 20 minutes might not sound like much, but Erin Perry, one of the chronic care management nurses at Emerald, says those few minutes, combined with phone chats, have a big impact.

“Our focus is wellness,” she said, “I kind of see us as a lifeline in between visits. It’s a huge thing, those relationships we build with people.”

The Emerald program works like this:

  • To qualify, you must be on Medicare and have at least two qualifying conditions.
  • You then sign an agreement allowing the care team, which includes a doctor and chronic care nurse, to:
  • create and review your treatment plan
  • review and manage medications
  • coordinate with specialists and testing
  • problem-solve and reassure
  • regularly check on how things are going.

Patients are able to reach chronic care staff at night and on weekends.

In a series of videos about the programCormac Coyle, MD founder and medical director of Emerald, said the new program is “taking traditional medicine and turning it on its head.”

Perry described it as keeping people out of emergency rooms and intensive care units and allowing them to enjoy as good a quality of life as possible for as long as possible.

Up to 75 percent of Medicare patients qualify for the program, Hamacher said. There are co-pays, although Congress is debating whether to eliminate them, she said. Those without secondary insurance pay $8 a month.

“I think it’s great for the patients,” said Hamacher. “It allows us to know what’s happening to you when you’re not in the doctor’s office, so when you come in, hopefully, the doctor visit can be more efficient.”

Patients often feel more comfortable chatting with a nurse on the phone than with a doctor in an examining room and may mention something considered too embarrassing or minor for the doctor, Perry said. She described her role as empathizer, listener and educator, and said a phone call is a “gift of time” for a patient who might be confused, lonely, or overwhelmed.

For Sara Henken, 81, and her husband, Milt, 87, the chronic care program has been comforting in the face of complicated care. Milt has a number of conditions, including atypical Parkinsonism syndrome, angina, and prostate cancer. He sees several specialists and is on numerous medications, some of which have their own peculiar side effects. His care is now under Daniel Arnold, MD, and his chronic care team, including Perry. Sara is a big fan of the team and the efforts to make communication smooth. The team gives her printouts of conversations with the doctor after each visit. And she appreciates the calls.

“Someone from his staff calls every few days,” said Sara, “and they say, ‘How is Milt doing? How are you doing? How can we help you?’ I told Dr. Arnold, it gives you reassurance because he’s got a bad disease that’s chronic and progressive and we just feel taken care of and safe.”

The Henkens consider themselves lucky since they have other family close by. But even for Sara, a retired teacher and poet who loves swimming at West Dennis Beach, it was daunting to be chief caretaker and stay on top of specialists and medications. Emerald also connected her with a social worker for support.

“She talked to me for almost an hour and then told me about what was out there in the community to help and how I should take care of myself, being the caregiver,” she said. “And then she gave me her cell phone number and said to call her when I needed to talk.”

Hamacher refers to the new chronic care protocol as touching patients in a “softer, smaller” manner than, say, in a hospital emergency room. It has required a change of thinking for some in the medical world, said Perry.

“It’s hard to switch to focusing on preventive care,” she said. “You have to reframe how you think of your job, from being the person who puts the Band-Aid on the wound to being the person who prevents the wound in the first place.”

Note: As of 5/1/2019, Emerald Physicians joined Medical Affiliates of Cape Cod (MACC), a division of primary and specialty care physicians from Cape Cod Healthcare.