Stephanie Celani not only knew the phone number of her patient John Pantalone, she also knew his weight to the half-pound when asked one day this month.
That's because Celani, a registered nurse at Advocare L.L.C., a 380-member physicians group in Marlton, has been Pantalone's care coordinator for the last five months, since he was laid low by a serious infection acquired at a rehabilitation hospital.
Celani calls Pantalone, 70, of Marlton, almost every day for information, such as his weight, blood pressure, and a figure that shows how his transplanted kidney is working. Celani reports any deviations to Pantalone's doctor.
During the most intense period of Pantalone's recovery, "Stephanie was becoming like a family member. She would call me every morning" and ask for the "magic number," his weight, Pantalone said.
The purpose of all those calls is to keep Pantalone, whose health problems spiked in the fall when he had renal failure and collapsed lungs after heart surgery, from landing back in the hospital.
Pantalone is experiencing firsthand a push by
Advocare and Horizon Blue Cross Blue Shield of New Jersey - in accord with national efforts - to trim spending and improve quality by proactively approaching care, especially for high-risk patients.
Under the program, which Advocare started in August, the practice has a strong incentive to cut the total cost of care: Horizon lets Advocare keep half of any saving.
The program represents a major shift for doctors.
For a long time, physicians have known the costs of their own services, said John M. Tedeschi, a pediatrician and founder of Advocare, "but they never added the other piece."
"What was I spending on hospitalizations? What was I spending on radiology? What was I spending on specialty referrals? What was I spending on five million other things that go into health-care costs? Now we're going to have that whole picture," Tedeschi said.
An early focus at Advocare, which has doctors in all of New Jersey and in Southeastern Pennsylvania and which is among the nation's largest independent physicians groups, has been reducing the frequency of hospital readmission of its patients within 30 days of discharge, an area of health care under laser focus nationally now that hospitals are being penalized by Medicare for excess readmissions.
Advocare is not a hospital, but its Horizon contract gives it a financial incentive to reduce readmissions under the insurer's most advanced shared-savings program, said Jim Albano, Horizon vice president of network management and Horizon health-care innovations.
Horizon measures Advocare's performance against its entire network.
"For example, if Advocare goes from 10 readmissions for every 100 to eight for every 100, but the rest of the network is still at 10, they get rewarded," keeping half the saving from two fewer hospital stays, Albano said.
Financial results from 2012 for the program, known as "patient-centered medical home," were not yet available, but practices using the model were spending less than those that are not, Albano said.
Susan Day, a clinical associate professor of medicine at the University of Pennsylvania's Perelman School of Medicine who has studied patient-centered medical homes, said financial results from the model were mixed.
"When care is all inside of a system, it's easier to show benefits from cost reductions," she said. What's clear is that the model cuts down on emergency-room visits and hospitalizations, she said.
That includes readmissions, the prevention of which has become a top priority for Michael Renzi, an internist in Haddon Heights and Advocare's chief medical officer.
Every Advocare patient, "the minute we understand that they are in the hospital, we start care-coordinating them. We collaborate with the inpatient physician. We collaborate with the on-site care managers," Renzi said.
"The minute they leave the hospital, they are our highest priority. We make sure all their medications are reconciled, and they have access to the medications," Renzi said.
Then the patients are back in the office within 48 hours of discharge. "If the schedule's booked, we make more slots available. Whatever it takes," he said.
Then the patients have a nurse, such as Celani, assigned to them, who will follow them until the doctor decides they don't need such close attention.
Pantalone is not quite there yet, but he said he had hope.
"The very close and tight follow-up is what's helping me stay healthy, recover quicker, and, I really hate to say this, but stay the heck out of Dr. Renzi's office," Pantalone said.
"I was going there much, much too much."