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Better care, lower hospital costs through coordinated approach

Better coordinated care for patients improves health and reduces costs. In one such program, focused on Oregon Medicaid patients, hospitalization rates declined by 18 percent since 2008 under the team-based "health home" or "medical home" model. Meanwhile, health measures on things like blood pressure or blood sugar, steadily improved over the same time period.

This model works, says Tammy Dee Ashley. It worked for her.

For nearly a decade after falling ill in 1999, Ashley was a "frequent flyer" in hospital emergency rooms around Portland.

With no insurance or regular doctor, Ashley's primary source of care was the hospital emergency room - the most expensive and least effective place for treating chronic conditions. She was hospitalized dozens of times for illnesses including hepatitis C, kidney & heart infections, heart disease and pneumonia.

"OHSU Hospital - that was my doctor's office.and it was a revolving door," she says. One year, she spent almost as much time in the hospital as at home.

Finally, in late 2008, an OHSU doctor referred Ashley to a primary care clinic in Southeast Portland and started seeing her there once a week.  He set one basic rule: Call the clinic first, instead of automatically heading for the emergency room.

Following this rule, Ashley's health improved, and she drastically reduced hospital visits. During the past year, she has gone to the hospital only three or four times, for brief stays.

Ashley is a challenging patient. She not only has chronic illnesses of the heart, liver, lungs and kidneys. She's also a recovering heroin addict. Now 48, she has been free of drug abuse since September 2008.

"What I like about having a doctor Is that I can talk with him about anything," she says. "The trust is there. And he takes time to explain things to me."

Even her visits to the primary care clinic have become less frequent. "They know me well enough, and I know them well enough, that we can talk over the phone and pretty much make the decision."

Coordinated care is more than medical treatment. "Not just physically, but mentally and emotionally, it has helped me to become so much more stable in my life," Ashley says. Her care team, which includes a social worker, helped her find dental care, an apartment with subsidized rent and a smoking cessation class.

"It changed my life," Ashley says.