“I didn’t choose it because I wanted to be involved in national politics and national health care activities. I saw it was the only way to solve the problem.” – Peter Boling

Medicare is a large, complex, and sometimes unyielding system that covers nearly 50 million Americans. It takes a special kind of person to see a better way to do things, prove that it’s better, and then take on that vast system to improve it for everybody.

Meet Peter Boling, MD.

He is interested in a lot of things. He majored in English. Then came science, anthropology at one point. “There wasn’t room on my shelves,” he says. He’s an energetic guy.

Boling is chair of geriatric medicine at Virginia Commonwealth University (VCU) Medical Center, an essential hospital and Richmond’s only academic medical center. It is the teaching hospital for VCU medical students. Boling is also a professor of internal medicine at VCU. Since 1984, he has been focused on building – and validating – the VCU House Calls program.

To understand Boling’s passion for this program and in-home care, imagine a common experience for geriatric patients.

An elderly female patient lives with her children and grandchildren. She has numerous health issues: diabetes, dementia, hearing and vision problems, heart disease. Her family “was starting to come apart at the seams,” Boling says. “She was having some behavioral issues and some other things that were making it difficult to care for her. They were ready to put her in a nursing home.” It was a costly, devastating solution that likely would not have improved the quality of her life.

By going into her home and gaining a better understanding of all of the issues involved in her care, Boling was able to change her care plan to meet her needs – including her medical and social services needs. And now, a year later, “she’s sitting there in her living room, happy as could be. They’re [all] happy … because here’s a three-generational family that’s committed to taking care of their grandma and now they’re able to,” he says.

So what if a doctor could show up at her door, administer her primary care, on a regular basis? And if she gets sick, provide intensive care at her home? Could her future be changed? Could she and her family have better options? These are the questions that started Boling’s quest – now more than 30 years in the making.

Focused on Primary Care

Boling attended medical school at the University of Rochester, which followed a unique curriculum called the biopsychosocial model of clinical care. “We were trained much more extensively in interviewing techniques and understanding the whole person,” he says, “as opposed to a series of organs and diseases.”

He went on to do his residency at VCU Medical Center, specializing in primary care – a less common choice among medical students at the time, he remembers. Just as he finished up in 1984, VCU leadership decided to invest in its primary care medical school curriculum and at the same time, focus on patients who were being left behind in primary care.

Boling landed a job that was part of this effort, spending half of his time teaching med students and the other half making house calls.

A strong primary care workforce is critical for an effective health care system. These doctors keep people healthier, saving the entire system money.

Patients Respond to House Calls

Traveling up and down the East Coast, Boling began his work by researching what few house calls programs already existed. He liked those that focused on continuity and comprehensive care – where patients saw the same nurses in their homes, in the clinic, wherever they needed care. With a base idea in mind, Boling set out to find his patients.

I looked at the [outpatient] clinic … at the people who were there on stretchers, and I would ask them if they would want to have somebody come see them at their home rather than coming to the clinic. Pretty much everybody said yes. After a little while, the waiting room was empty of stretchers. Then I started on wheelchairs, and the people using walkers and oxygen, and so on. Soon I had 75 charts… going around every afternoon making about five or six house calls.

Helen is a house calls patient. She’s 93 and lives alone in a retirement community. She’s in decent health but struggles with mobility – a tremendous challenge and a pain for most people her age. What happens when she comes down with pneumonia?

Boling describes the typical scenario when someone like Helen gets sick:

It’d take days to get organized to get somebody to help, arrange for transportation. Somebody would have to take time off from work to go with them. Then there was the matter of getting an appointment, [which is] usually brief, and the people seeing them knew nothing about their cases, and made silly recommendations for their home-based care. Because they really didn’t know their story, what they needed.

A person in Helen’s condition will often land in the hospital’s intensive care unit (ICU) – “She got really sick. I mean, she got really sick,” Boling says. Once in the hospital, geriatric patients are likely to stay for much longer, and they’re susceptible to complications like infections, delirium, and falling. It can be scary for the patient – especially one like Helen, who can’t hear or see well. It is also hard on the family and extremely costly for the hospital and health care system.

Instead, with help from the house calls team, Helen rode out pneumonia at home. The team administered IV antibiotics and collected specimens for lab work. Staying home was a calculated risk that she took, but it led ultimately to better care. She recovered completely, in her own environment, with her own food, and without all the jarring realities that come with a hospital stay. And then there’s the price tag. “She didn’t have the $20,000 hospital stay. She had about $1,500 worth of care in the home, and she’s all better.”

The Value Proposition

Medicare provides health insurance for the vast majority of elderly Americans, and it would have footed most, though not all, of Helen’s hospital bill. There are a couple of things to know about Medicare. First, it pays providers lower rates than private health insurance, and payments are often less than a provider’s costs. This means a hospital can lose money caring for Medicare patients. Second, traditional Medicare payments tend to reward volume of patients seen over quality of care delivered.

Medicare is the main insurer for patients of VCU House Calls, which was up and running by the end of 1984. Boling could see pretty quickly the value in caring for patients this way. “Once you go into a home, you know what the real story is right away,” he says. “We just need to find a way to pay for it. I would spend a lot of time on that.” One of the issues with house calls was that it was hard to make a living at it.

Boling found that Medicare was reimbursing physicians for house calls at a far lower rate than it paid for those same services provided in the hospital or a clinic. He knew that the services he provided in a patient’s home were at least as complex as those he would deliver in a hospital with more assistance – why was he paid less for them?

He did some digging and found others in the house call field coming up against the same barriers. Together, they discovered that Medicare didn’t really understand house calls. The payment system didn’t reflect how sick these patients were. They couldn’t account for a patient being anything more than mildly sick. There was just no billing code for it.

You might imagine that if an ailment can be treated with a house call, it isn’t “serious.” But the house calls team cares for patients with needs as serious and urgent as those seen by specialists in the ICU. This was the case Boling made as he went to bat for more of the Medicare pie.

We were arguing with radiologists and dermatologists and heart surgeons and ophthalmologists and other people and saying, “We’re taking care of very complicated, sick patients.” It's really almost just like the ICU sometimes except you don't have a nurse for every two patients and you don't have an arterial line and a monitor beeping and an oximetry device and X-ray at your shoulder and labs in the morning every day when you come to make rounds. You're just going there by yourself with your brain and your backpack. Whatever happens, happens.

They got the message across to the Medicare coding organization and “We ended up more than doubling the values associated with those codes, which was almost enough to get you to a viable model,” Boling says. What he means by “almost” is that you’d have to practice what Boling calls “rip and run”: working without a team and keeping appointments as brief and patients as numerous as possible, since payments are made per service – the volume-based system.

But this went against Boling’s core beliefs and his understanding that caring for the whole person, especially a very sick, complex person, takes time. Doing anything less, he says, “you leave the value proposition behind.”

Quality Improvement

Boling’s problem with the system wasn’t new. In fact, less than 10 years into Medicare’s existence, policymakers could see it needed flexibility and adaptability. As the main provider of health insurance for America’s elderly – a population that would eventually explode with aging baby boomers – Medicare had to be responsive to change.

“There are certain parts of patient care that don’t make any money,” Boling says. “But when targeted and done well, these things ultimately improve the care [patients] get and make them healthier – and ultimately, it does save everyone money. But it only works if the payment system and the clinical system have the same values.”

In 1972, Congress gave the agency that runs Medicare, the Centers for Medicare & Medicaid Services (CMS), the authority to conduct demonstration programs and experiment with alternative forms of payment and service delivery. This became an avenue for quality-based change.

In 1999, the Institute of Medicine issued To Err Is Human, which estimated that preventable medical errors claim 44,000 to 98,000 lives each year. This news generated a flood of responses, including creation of the National Quality Forum to help develop nationwide patient safety standards. CMS also began to conduct pilot programs to help hospitals evaluate and improve patient safety practices.

So, theoretically, the system can evolve. But the Medicare payment system is based in law, so to change it, you have to change the law. It can be done, but it often requires painstaking, incremental progress. It requires timing. It requires knowing how to open doors in Washington and finding a lawmaker willing to listen to your ideas while also thinking about every other issue in America.

Boling and his peers knew they had a good clinical model. “There was no doubt in any of our minds that this was a better way to deliver health care for this group of patients. It was so unequivocally clear,” he says. Since the move toward quality improvement, “patient-centered care” has become a buzzword in the health care industry. But as Boling says, “It’s not patient-centered to take a sick, frail, miserable, painful older person, drag him out of bed, put him in an ambulance, haul him down to the doctor’s office for 20 minutes, and haul him back home. Sometimes, it takes two or three days to get over [that]. It’s an upside down world for these patients.”

Plus, when patients with multiple chronic conditions have to go to the hospital, it costs a lot of money. They generally have to stay longer and use more of the hospital’s resources. The hospital never will recoup the full cost of their care from Medicare. By demonstrating that regular house calls could help keep these complicated, costly patients out of the hospital – or, at least, shorten their stays once there – Boling and his group knew they could save money for everyone and take better care of these people. Better care, lower costs – the ultimate goal.

The Moving Vehicle

So, with a model in hand and lobbying help in Washington to build congressional support, they wrote a draft amendment. Now they needed a legislative vehicle: a bill actively moving through Congress that could carry their amendment. But this can be a challenge, as bills often stall and remain untouched for long periods.

In 2008, 14 years after VCU House Calls began, Boling and his group found their vehicle: the Affordable Care Act (ACA). Most active bills attract amendments. Lawmakers can use amendments as bargaining chips to move a bill through Congress, and the ACA is notable for the considerable number of amendments attached to it.

The amendments Boling helped write – one for the House, one for the Senate – moved fairly smoothly through with bipartisan support. The Senate amendment was actually voted in unanimously. The amendments were also supported by a broad coalition of stakeholders, including America’s Essential Hospitals, which may have helped push them along. “We made our way through to the ACA, Section 3024. That’s how Independence at Home came to be,” Boling says.

Independence at Home

The Independence at Home demonstration project was passed in the ACA as part of a larger effort to propel the idea of pay-for-performance in health care forward. The ACA mandated that CMS create an innovation center to foster demonstration programs and other initiatives as a part of health reform. Independence at Home was included as part of the CMS Innovation Center’s work.

The three-year pilot, which began June 2012, includes 17 physician practices that can serve up to 10,000 people enrolled in Medicare. The practices provide personalized, home-based care to people who have complex, chronic conditions and limited function or mobility. Practices that succeed in meeting quality measures while generating Medicare savings will have an opportunity to share in those savings.

VCU House Calls is part of the project. It’s in a group of practices called the Mid-Atlantic Consortium.

In June 2015, CMS released the results from the first year of Independence at Home. The practices saved more than $25 million while delivering quality care. The Mid-Atlantic Consortium reduced the cost of health care for their patients by 20 to 30 percent. “We met all the quality measures, we had very high patient satisfaction, and we substantially reduced total health care costs in a group of people with very serious health problems,” Boling said in response. “These results are externally validated evidence that delivering the right care – in the right place, at the right time, and with the right team – makes a difference.”

As of now, it seems that Independence at Home is on the right track. In July of 2015, Congress voted to extend the demonstration from three to five years. And maybe one day it will be more than a demonstration. But that’s not where the story ends. House calls is destined for more, as it is just part of a whole.

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In the eyes of some, change begins with a perfect storm. “We had more patients requiring our services than we had capacity for,” says Arline Bohannon, MD, medical director of Virginia Coordinated Care. It’s a pervasive theme in American health care: too many patients, too few resources. But how do you change it? Where do you start?

You have to dig deeper, stratify. Find patterns. Some patterns show that a very small percentage of people can be the costliest to a health care system. People who fit this pattern are sometimes called superutilizers. They are sick, with multiple chronic physical conditions, mental health conditions, and social challenges. They are often poor and uninsured, or on Medicaid or Medicare. All of these issues compound to create huge barriers to accessing routine preventive and primary care. So they end up in the emergency department (ED) instead – one of the most expensive places to get care.

It is a perfect storm. And it happened at Virginia Commonwealth University (VCU) Medical Center.

Virginia Coordinated Care

A recent study noted that the average charge for a visit to the ED is 40 percent more than the average American rent each month. That’s costly for patients, costly for insurers, and costly for hospitals – especially those caring for the uninsured. Way back in 2000, VCU Health System began to address costly ED misuse by targeting uninsured patients who were eligible for Virginia’s indigent care program. Through this program, the commonwealth of Virginia provides supplemental funding to the two state-affiliated teaching hospitals (VCU being one of those) which, in turn, render free or low-cost care to people living in poverty (specifically, below 200 percent of the federal poverty level).

VCU Medical Center found some local providers with independent practices, free clinics, etc., who were already caring for the same patient population. The providers agreed to build a medical home for these patients - a place where every provider who cares for a patient has a clear and complete understanding of the patient’s health and health history. A relationship is built over time so patient and doctor aren’t starting over at every visit.

In return for committing to this goal, the local practices would receive some support – and hopefully improve patient care. They called it Virginia Coordinated Care for the Uninsured (VCC).

The idea was to help create access, to give people a place to go for care in their community for care so they wouldn't have to rely on the ED. And it worked. By 2015, the program had reached more than 80,000 people. “We realized this was a great program,” says Sheryl Garland, MHA, VCU’s vice president for health policy and community relations. “We consistently showed reductions in ED visits, inpatient visits, and cost.”

In fact, when America’s Essential Hospitals reported on the VCC program in 2014, the association noted a 38 percent reduction in ED use and a 45 percent reduction in hospitalizations for patients who were continuously enrolled in VCC for a three-year period. Also in that report, community providers discussed the benefits of the program to them. One provider commented that the program was “freeing” in terms of the ability to care for patients without having to “balance every single treatment decision on the patient’s ability to pay for every single piece of it.”

VCC Overcrowded

But in 2011, a second storm was brewing. “We were approaching the point where we didn’t have capacity for primary care coverage for all of the patients that required [these] services in our area,” Bohannon says. Essentially, ED overcrowding had become VCC overcrowding. Somewhere, someone still wasn’t being served in the best way.

It sounds familiar, right? That was the problem Peter Boling saw when he started targeting patients for house calls. His patients were generally immobile, so his solution was to go to them. What Bohannon, Garland, and their team found was a group who needed the same kind of personalized attention, but going to them wasn’t quite so easy.

These were VCC’s superutilizers – roughly 6 percent of the program population responsible for a large majority of the cost. They weren’t consistently using their medical home, instead still opting for the higher-cost ED and hospital services. Simply put, VCC wasn’t working for them. As Bohannon explains, “Many of these people have alienated themselves from their community, and so we have them in isolation.” That means that they have little, if any, support. No one is checking on them to see if they are going to the doctor, if they are taking their meds. They needed more support – in health care terms it’s called intensive case management. So the VCC team brought them back in from the community, back into the health system.

Complex Care Clinic

In 2011, Bohannon and VCC Director Barbara Harding, RN, began to build VCU’s Complex Care Clinic, which would become the new medical home for this group of people. Both Bohannon and Harding have a partial background in home care, and they conceptualized the clinic from that viewpoint. Their thinking followed closely along the lines of Boling’s. “Being in people’s homes, you know the challenges that patients are experiencing and you can relate to those particular challenges,” Harding says. “Now you have them in front of you, so what do you offer them? What would be the perfect world?”

It would be a world that destroys all of those barriers to health. There is a hierarchy to these patients’ needs – and medicine doesn’t come first. “You suddenly understand that if I don’t deal with food, shelter, and transportation, I’m not going to be able to get to those health needs,” explains Harding.

So the world must include a multidisciplinary team. In this case, a social worker, a pharmacist, a clinical psychologist, a clinical nurse, and a nurse case manager all working together with a physician to help address the hierarchy of needs.

Many of these patients are homeless. A large percentage are unemployed or have very little employment. A disproportionate number also have mental health conditions such as anxiety or depression or more serious mental illness, such as schizophrenia or bipolar disorder.

These factors complicate the already complex physical issues. Bohannon tells us of one patient who had 19 different medications but very little money to pay for them. “Even at $4 a copay, that’s a lot,” she says. On her own, the patient was picking and choosing which medications she could afford each month. But there wasn’t any sound medical reasoning to her choices. And that was bad for her health.

In the clinic, the pharmacist was able to sit her down and help her prioritize. “No matter what happens during your month, these are the medicines that you have to buy. These are the medicines that you probably could do without,” Bohannon explains. “We were able to actually keep her out of the hospital because she was able to make better decisions about which medications she was going to buy, [even with her] limited income.”

“Skin in the Game”

It’s a model of care that patients – especially vulnerable patients such as these – were not used to. And, like anything new, it took some adjustment. Harding notes that some patients initially resisted the concept – having a group of people sit down and focus on you as a patient, to want to know all of the issues you’re dealing with. For the average person, that would likely be a unique experience. For someone who typically lives an isolated life, even more so.

So how do you build trust so they will tell you what they need? “By sitting and listening and hearing what this person has to say,” Harding says.

Once trust is established, the team begins the process of stabilizing physical health. “When a patient first comes in to the clinic there are a lot of things that are out of control,” Harding says. During this time, they also begin to uncover each patient’s particular challenges. Some are better hidden than others. Many of the patients have very low health literacy, for example. That means they don’t understand the terms doctors and nurses use and, afraid to ask, they miss key pieces of information. Like what it says on their prescription labels.

Once physical stability is achieved, the clinic staff can begin to mitigate those underlying challenges. “Our ideal goal is for this person to become engaged, empowered,” Harding says. “And to be able to take some ownership of their health and well-being.” She admits that it’s hard work to change ingrained behaviors, and that both sides must commit to change. Harding believes that having a team like the one at the clinic that supports you and provides the tools you need to make those changes makes a huge difference, but that alone is not enough. As Bohannon says, “You need to have skin in the game.” So the clinical teams works diligently to move patients toward self-help, bit by bit, accepting the responsibility for caring for themselves.

Taking odd jobs to cover your copays, getting into housing and off of couches or the street, attending diabetes education classes at the Y and engaging with others; these are all steps toward this goal. The clinic relies on connections within the community to foster these steps, open up the doors so that bit by bit, they can gain control of their health. Bit by bit, they can come out of isolation. “The patients graduate and transition back to a community practice closer to their home, knowing they could come back if they need to,” Harding says. “This is a huge accomplishment … they’ve become better and empowered.”

For Harding, it’s been an exciting process to watch. “To be a part of that journey, you don't often have that experience. I feel privileged to have had that opportunity.”

The Pathway

In its first year, the Complex Care Clinic achieved a 44 percent decline in inpatient admissions, a 38 percent decrease in ED use, and a 49 percent reduction in total hospital costs. This resulted in a total cost savings of $4 million and an average annual cost savings of $10,769 per patient. Patients with costly chronic diseases, such as diabetes and hypertension, are in better health. And they are gaining a better quality of life.

So what does this mean for VCC’s perfect storm? Well, in addition to decreasing the cost of caring for these patients, the clinic is also a pathway to coverage programs such as Medicaid or Medicare. “Once they get into the clinic and they're working with us, we're able to build their social security disability portfolio … which is an entrance point to Medicaid,” Harding explains. Once a person has Medicaid, they no longer need the indigent care program, making room for others in need.

By itself, the clinic is a proven model for better health and lower costs for some of health care’s most costly patients. But as part of a whole, the clinic is more. It is a key ingredient in a new approach – a new demonstration that began enrolling patients in 2014. Javaun Harris was one of them.

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Javaun Harris is a sun-seeker. On the day we met him, the weather turned from driving snow to sunshine within minutes. As the sun came through the window of Javaun’s apartment, he immediately turned his body toward it – as much as he could. Javaun is quadriplegic. He can’t move his legs or his upper body very well. He leans forward from his waist as he talks to us, and then relaxes back against his chair. He can move his arms some, fold them across his body, but his hands stay mostly locked in fists.

His head sought out the sun and he took it in with his eyes, and a slow smile spread across his face. The sun is his first love.

“Being shot alters your body. Your circulation gets poor. You're cold all the time. I think back to when I was in Children's Hospital and all the staff would leave, and I would go outside. It was quiet and I would just sit and close my eyes and think, imagine, and wonder ... I've been doing it ever since. I'll go outside and sit in the one spot, and I'll close my eyes, and I'll get the energy that I need. It soothes me in a lot of ways.”

The Physical Part

Javaun was shot in the back on the streets of Richmond, Virginia. He was a 15-year-old drug dealer. “I was subjected to peer pressure at an early age, and it led me into doing some things that I had no business doing,” he says. “As a kid, I was living an adult life, and the consequences were dire.”

Javaun lived with his mother and four siblings in Hillside Court, an area of Richmond known for violent crime. “[It] was just me and my brother trying to fend off all the wolves,” he says.

Javaun was shot multiple times in the back and neck with different caliber weapons. “I was just a kid – to take that type of impact to my body, it was tremendous,” he says. In the early days of his two-year hospital stay, “All I thought about was getting up ... I didn't realize that I wasn't even really moving ... I got shot in October. It took me [until] December to realize that it was real and things wouldn't change.”

But by the age of 18, Javaun had been discharged. He had his own apartment and multiple physical issues to contend with. Ordinary functions like urination take considerable effort. He has muscle spasms and swelling in his feet and legs. He relies on a steady supply of medical equipment. For a long time, he depended on a nursing company for home care, which he describes as hit or miss. Sometimes he ended up sleeping in a chair because no one would show up to help him into bed. Other times he would lay in bed for hours waiting for someone to come and help him get up and get dressed.

The Mental Part

While the physical challenges are extreme, for Javaun, the mental struggle is perhaps a heavier burden. He had gone from popular, flush with cash, and – for better or worse – of a certain status, to ashamed to leave his house. All while still a teenager.

“It is extremely, extremely hard. You have to battle depression … just to maintain your mindset and function like a human being. It's a constant battle. But I won't give up. It's not in me to give up. I didn't give up when I was gunned down. I didn't give up when I wanted to die.

[I remember thinking,] ‘All right, Javaun, what are you going to do? Are you going to always cry on the inside or are you going to just try to make the best of it?’”

And he began to live again. He eventually grew more comfortable with his physical condition. He went out. He met women and began to date. Then one night, in a club, he met Shamyka. “I saw her and I was struck. I thought, ‘Man, if I leave here and I don't say anything to her, I’m going to regret this.’”

Shamyka smiles shyly as Javaun talks about her. As of May 2015, Shamyka and Javaun had been married for 7 years and together for nearly 10. Dressed simply in jeans and a black T-shirt with the word “faith” on it, she is a quiet, comforting presence in the room. For most of our conversation, she’s been sitting off to the side, watching and listening. Tears glisten in her eyes as he talks about his past and his pain.

Javaun says her presence in his life is the first and foremost motivation he has to carry on. Shamyka is the main reason he endures his pain.

It’s difficult, he says. And there are more negative than positive days – still, 21 years after the shooting. “I have to pull myself out of that because it can get to the point where I can get into a real, real dark depression. There’s no comfort for it.” And it is then that he resists Shamyka’s nurturing. “I don’t want anyone to make me feel good.”

It comes from the layers of issues that make Javaun’s life pretty complicated. There are the physical issues affecting his bladder and bowels that complicate the most human of functions. There is hope and the issue of accepting what can and can’t be – and figuring out where that line should be drawn.

“I’m not going to say it’s impossible, because if I believed that, I’d be dead – but I still have thoughts of walking, of the day I have children,” he says. “That’s a big issue with me. One day I really want to be able to have children.” And he wants Shamyka to have them too. And it may not be impossible, but it is complicated.

Paths Cross

In the health care coverage world, Javaun is a dual-eligible. That means he’s eligible for both Medicaid and Medicare coverage. Medicaid because of his income level and Medicare because he has a long-term disability. By definition, a person with this dual eligibility is likely going to have complex problems. These programs were designed to help the vulnerable.

Adding to this complexity is the fact that people with dual-eligible status must deal with three siloed sets of benefits – one for Medicare, one for Medicaid, and one for prescription drugs. This means three different ID cards, three different statements.

Dual-eligible beneficiaries are noted as being routinely frustrated with the administrative side of their health care – erroneous billing, confusion over which plan pays for which services. Even lapses in coverage because of the need to continuously resubmit forms.

In 2011, the Centers for Medicare & Medicaid Services (CMS) announced a demonstration project to pilot a new model for providing a better health care experience for those patients dually eligible for Medicaid and Medicare.

Patients with this caliber of medical and social issues benefit from individualized, coordinated care. That means the physician, the mental health professional, the social worker, the pharmacist – they all need to work together to figure out how each person is best served. One size doesn’t fit all.

This project would attempt to do that. And it would simplify the process. The demonstration model is designed to be the single entity accountable for all of a person’s health care needs.

In 2013, the commonwealth of Virginia signed on to this pilot, calling the program Commonwealth Coordinated Care. And VCU Health System’s Medicaid health plan, operated by Virginia Premier, decided to participate. Then they needed someone to develop the program. They called Peter Boling, MD.

Boling and his VCU House Calls team were already, bringing personalized primary care to elderly Medicare patients in their homes. So he had part of the foundation built. To make that foundation complete, Boling reached out to the folks from the Complex Care Clinic.

For years, VCU House Calls and the Complex Care Clinic had been building parallel structures for similar patients. The clinic delivers personalized, clinic-based, multidisciplinary care to very complex, low-income patients. This pilot was an opportunity to combine those efforts and demonstrate that patients receive better care when everything – payment, information, and resources – can be shared.

With this in mind, Boling led a team in developing The Center for Advanced Health Management (CAHM). It’s a standalone clinic that combines the complex care structure with nursing home care, house calls, and transitional care as needed, all integrated in one health plan.

For Javaun, this is how it worked.

Stair-Stepping

In 2015, Javaun got a call from Robin Taylor. Taylor is a triage nurse at CAHM. “Initially, I was skeptical,” Javaun says. Taylor agrees, remembering their phone introduction.

The first call was like, “Oh, no. Everything is fine. I got what I need. I don't need Virginia Premier. I don't need VCU House Calls. Everything is good,” she says with a laugh. As I ended the initial call I said, “Well, if you have a problem with anything, just feel free to call me.”

Lo and behold, she says, a few days later he did call. He was having trouble getting some of his supplies. He asked Taylor for help, and she did sort it out, but still he was hesitant to sign up for the program.

“I didn’t think change was going to be positive,” he says. Given his experience dealing with the complicated dual-eligible process, he was concerned this “experiment” would be more of the same.

But Taylor says that every day was progress. “We stair-stepped it every day.” Lots of phone conversations – many more before they actually met in person. And when Javaun finally allowed a house call, it was a new experience. “If I don't feel good, they're on top of things,” he says. The care team comes out immediately. Even for the little things that he tries to shrug off.

I'm pretty sure my wife loves that. When it's cold outside, I don't have to go out in 10 degrees and try to get to the hospital. They'll just come here and make sure everything is okay. We're moving forward. We're definitely moving forward.

The Social Worker Calls

Physically, Javaun was in decent health – all things considered. But he was struggling to find a purpose for enduring life trapped in his body – a body he’d lived in longer than he had in the previous one.

Nurse Practitioner Susanna Payne, NP, had spent months getting to know Javaun during her house calls, and he finally allowed her to discuss this challenge with Eris Tursley, a clinical social worker at CAHM.

The social worker’s role in caring for complex patients cannot be overstated. Helping people find connections and networks within the community is a crucial part of the job. Social workers give people resources to overcome the social barriers that often make good health impossible. In Javaun’s case, finding a purpose, something tangible to believe in, was essential for his ongoing health.

Javaun mentioned wanting to talk to kids, to volunteer somewhere. “I'm racking my brain,” Tursley says. “I have no idea, so I just Google. I found a community in schools volunteer program, and then I thought, ‘You know, I actually know someone who works in the school system.’”

Before he knew it, he had a call from a local high school asking him to make a presentation to a group of at-risk kids. For him, an opportunity like this was a long time coming. He’d had the desire for years, but CAHM made it possible.

Once they said, “Hey, we're going to help you,” and the actual calls started coming in, it was like, “Okay, this is real now. It's time to do what you're supposed to be doing.” It's like, man, I can see the road … The struggle can't last forever, and this life is not my own. If I can help somebody else, it's actually going to help me because I can feel like, “Hey, I did something. I helped somebody.”

The Kid

If the story ended there, it would be okay. This holistic approach to care. This approach that was made possible through a Medicare-Medicaid demonstration program. It was working. It found one of the root problems in Javaun’s life. That is a success. But what if there is more to it?

I called Javaun a few months later to see how his presentation went. He told me a story of a kid he met. One who seemed particularly uncomfortable during Javaun’s school presentation. He asked a lot of questions afterward. And they kept in touch.

In fact, Javaun had recently heard from the kid after several days of silence. The kid had been in a fight, but left early – before the gun was pulled. But there was a gun pulled.

It doesn’t sound like anyone was hurt. But afterward, he had to face the friends who felt he’d left them. Javaun says they talked for more than an hour that night about choices and the consequences of those choices.

Javaun knows it’s an ongoing battle on the streets. But one night, this kid made a good choice. And one good choice can lead to another. One good conversation can lead to others, and two lives can be changed.

After all these years of pain and suffering and being challenged in how to go forward. My life has some kind of purpose. It may not have the purpose that I wanted for it – my own selfish thoughts – but if I can help somebody else, at the end of the day it won’t all be in vain. You know, I have other purposes in life, but sometimes I wonder what is all this for? To have someone actually depend on me and call me and even check on me…”

Javaun hopes that this is just the beginning of his work. He hopes to develop an outreach program that goes into communities and rewards students for making good decisions. He is working on a book. And this is his song. There is a plan for moving forward. There is a purpose.

Like Me

And then the sun came out, so we hung up the phone.