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How an innovative care program is saving both lives and money.

Danica Rodic of Burlington is 69 years old. She has Type 2 diabetes, hypertension, congestive heart failure, vascular insufficiency, cardiovascular disease, osteomyelitis of her right ankle, and iron-deficiency anemia. She’s been hospitalized frequently for foot infections, a complication of diabetes. Most of her toes have been amputated.

“I have so many different medical conditions,” Danica says through an interpreter. She and her family emigrated to Vermont from Serbia, and she speaks a language other than English. She also has some cognitive difficulties that make it difficult to grasp instructions. Although she lives with one of her adult children his English is also quite limited, and her daughter lives out of state.

“A lot of the time, when Danica would go to her doctor, she wouldn’t know what to tell them or how to describe her symptoms,” says Debby Tate, LPN, one of her caregivers. “So her circulatory problems would go untreated. Then, she’d wind up in the emergency room in a crisis situation, often requiring hospitalization and, sometimes, additional amputations.

A safety net, waiting in the background

The University of Vermont Health Network – Home Health & Hospice’s Longitudinal Care Program was established five years ago for patients just like Danica. This grant-funded initiative offers proactive case management for individuals with complex medical histories, supporting them at home between critical episodes and hopefully preventing frightening, costly hospitalizations from happening at all.

“These are people who have many chronic diseases at the same time,” says Joe Haller, RN, the program’s Clinical Manager and Complex Care Coordinator. “Many of them also have mental health needs, poor social determinants of health – like job or food insecurity – and minimal supports at home. If they don’t have additional support, they’ll likely return to the hospital. We’re there to be that safety net for these patients.”

Unlike many other medical services, the wraparound support provided through the Longitudinal Care Program cannot be paid for by traditional medical insurance. Haller explains that insurance requires a “skilled need” – i.e., Physical Therapy, Occupational Therapy, or nursing – which have a goal of stabilizing a patent and discharging them.

If and when Longitudinal Care patients have an acute-care need that qualifies for skilled care, his team facilitates, through the patient’s Primary Care Office, a referral to have that portion of the patient’s care covered by their insurance. When the patient becomes stable again, the Longitudinal Care team picks up the patient again.

14 Pills in the Morning, 9 At Night.

The Longitudinal Care team consists of two nurses, two community health workers, and a medical social worker. Together, they provide tailored assistance to 35 patients from Chittenden and Grand Isle countries, from medication management to accompaniment on doctor visits, and connections to social services.

For Danica, managing her extensive medication regimen posed a significant challenge. “In the morning, I take 14 different tablets, and at night nine. I don’t know the names, and all of the instructions are in English,” she says. Debby set her up with color-coded packages from her pharmacy: yellow for morning; blue for evening.

The program extends well beyond medical needs.

“Maybe a patient is struggling with food and housing insecurity. Or they don’t have transportation to get to their primary care provider,” says Joe. “A lot of the people on our system can’t use a regular bus. And they need to know how to apply for a service like SSTA [Vermont’s Special Services Transportation Agency]. They may lose that service if we don’t help them.”
Debby puts it succinctly: “When they say it takes a village, that’s kind of what our team is.”

Claire Marton, the team’s Medical Social Worker and Maddie Ruth, one of the team’s Community Health Workers, keep track of available community resources. Because the program is not governed by insurance regulations, Claire says she can meet patient needs in very direct ways. “If a client needs a recliner, we can get that delivered. If someone needs a ride to an appointment, we can just give them a ride. We wouldn’t ever be able to do either of those things under a traditional skilled nursing program. It’s great to be able to just jump in and get things done,” she says.

Dr. Karen Sokol, Danica’s primary care provider, emphasizes the program’s significance in alleviating the burden on physicians. “As a physician, I’m out there providing medical care, but I end up doing a lot of social work, too [Dr. Sokol’s practice is 100% house calls]. When I have the Longitudinal Care team involved, I can just focus on doctoring, and I can see more patients,” she says.

Dollars and sense

Despite its evident benefits, sustaining such programs remains a challenge within the current healthcare landscape. Dr. Sokol believes systemic reforms are needed to prioritize preventative care.

“As people are living longer, there will be more and more complex patients,” says Dr. Sokol. “And getting them in and out of a clinic for a 15-minute appointment just doesn’t work. That disconnect is one of the factors driving up health care costs.” When people can’t manage their own care at home and through primary care, she says, they end up in crisis. “By preventing the expensive hospital and ED visits, we’re actually saving the system money.”

As evidence, Dr. Sokol cites a pilot project run by the Centers for Medicare and Medicaid Services called the Independence at Home Demonstration. The project compared Medicare spending per person, per month, between patients who received at-home care and those who followed the traditional model of care delivery.

After seven years, the researchers had found that home-based care saved, on average, $200 per person, per month. The study is ongoing.

The Longitudinal Care Program originally operated through a OneCare innovation grant that helped build a program that served 26 clients by the end of 2023, with a waiting list more than double that number. “We stopped taking names a year ago,” Haller acknowledges. “At that cadence, I wouldn’t be surprised if we would be able to serve up to 200 patients if we had a larger team,” he says.

The mounting evidence of savings through home-based care and the success of the program helped secure a recent grant from the Vermont Agency of Human Services. The nearly $460,000 has helped to expand the program reach and number of clients served to now 35, with a goal of 40 by then end of 2024. Recognizing the need to build a sustainable model, the grant will also fund a program impact evaluation analysis to build a case to secure long-term funding.

This additional funding will allow the program to serve an additional ten patients in 2024.

“My Joe, my Debby, my Claire, my Maddie”

According to Dr. Sokol, Danica’s situation has notably improved in the two years she’s been in the Longitudinal Care Program. “She’s had fewer ER visits. I think she feels more comfortable reaching out for help now that she understands who her resources are and has that trust in them,” she says.

Danica seconds that statement, albeit in slightly different words. “They are unbelievable, my Joe, my Debby, my Claire, my Maddie. They are all wonderful.”