Patients with cancer, diabetes, heart disease, hypertension and renal dialysis all fall under Cheryl Kram’s purview. She’s not their doctor — and she reminds them that she is not their mother — but Ms. Kram is certainly their advocate.
Ms. Kram is the high-risk care manager for Martha’s Vineyard Hospital’s new integrated care management program. The world of medically complex ailments can be overwhelming and foreign, Ms. Kram said in an interview this week, but knowledge is power.
“There’s no way to prevent someone from being ill . . . that’s just human,” Ms. Kram said. “But we can give them the resources to help them make better choices about health care.”
Funded by a $500,000 state grant received by the hospital in June, the program currently serves 70 patients who are considered medically complex. More patients are expected to be enrolled this fall. As high-risk manager and registered nurse, Ms. Kram calls patients daily, weekly or monthly, depending on the patient, and checks in. She asks if they have been taking their medications, testing their blood sugar, keeping their doctor appointments, and she is available to answer questions or concerns. She is also available for home visits and on some occasions may accompany a patient to the doctor.
This relatively new preventive and accountable care model has proven to both ensure continuity for patient care and also to keep costs down. With a better management of their medical conditions, patients can cut down on visits to the doctor or hospital — especially emergency visits driven by a health crisis.
Massachusetts General Hospital in Boston has run the same program since 2006. The program began as demonstration project under Medicare, during which time the Boston hospital was able to prove that it could decrease costs by active case management for medically complex patients.
“Mass. General found they had made great gains and progress, and continued the program,” Ms. Kram said. The program is now funded by private insurers.
The Boston hospital wanted to expand the program, and the Vineyard seemed like “the next logical piece,” Ms. Kram said. The Island hospital and Massachusetts General Hospital are both owned by Partners Health Care.
The Vineyard program is free for patients, thanks to the state grant from the executive office of health and human services. The grant covers the cost of staffing and software for tracking patient hospital visits.
Vineyard patients who qualify for the program are identified by the hospital here based on their medical history over the past year, including hospitalizations, emergency room visits and the number of diagnoses. Patients enrolled in the program suffer from hypertension, cancer, diabetes, heart disease, kidney disease, cancer or other high-risk medical issues. Once a patient is identified, a physician rates the patient by priority — high, medium or low. Ms. Kram goes through an assessment check list that includes a psychiatric examination and physical. She inquires if the patients have concerns and makes sure they understand their diagnoses. A program through Partners notifies her if patients in the program are admitted to any of the Partners hospitals, or have appointments with their doctors on the Island. Ms. Kram is connected to case workers at Mass. General and she’ll connect with them if patients are in Boston.
“There’s a continuity, even though they’re up in Boston, there’s a piece we can come back to and pick up from here,” she said.
She continued: “If they’re in crisis, it’s not me they want to call — if they want to call me afterwards or maybe I can help prevent it. But they know if they’re not feeling well or their health is in jeopardy, they’re calling their primary care doctor or going to the ER.”
Ms. Kram helps with “just about anything,” from ordering a compression stocking or getting a scooter, to helping patients better understand information given to them by doctors. She also helps connect patients to Island resources, and she praised the many support programs on the Island, including the stroke support group and caregivers support group.
“You’re the daughter at home caring for your mom but you’re my patient, so let’s get you the support group so you don’t feel like you’re doing it on your own,” she said.
Ms. Kram has been in community health care on the Island for 30 years, working at the Vineyard Nursing Association, Martha’s Vineyard Community Services, inpatient care management at the hospital and for primary care physicians in private practice.
“I’ve done a little bit of everything,” she said. “It’s pulling all of my years of experience into one,” she said of her new position. “It’s a great job, it lets me get connected to this person, hook you up here, utilize that.”
The program provides resources for an underserved group of the population, Ms. Kram said.
“For people of Medicare age, there’s a lot out there for them, but for people between 30 and 60 they sometimes need support,” she said. “The program meets the needs of the baby boomers, the sandwich generation, the ones that are in between their parents and their kids.”
Ms. Kram said that the program also encourages patients to take ownership of their health care.
“I’m not asking them to do anything, I’m saying here’s what I can do for you,” said Ms. Kram. “I tell patients, I’m here as often as you need me, Monday through Friday.”
“There are no stupid questions,” she said. “We’re trying to reduce cost and keep people healthy and allow them to use resources that are already in place.”