Whatever It Takes

Before she leaves, Sullivan presents Lam with a magnifying glass and a card of prethreaded needles for sewing. "You bring up a lot of good deeds," Lam tells her through the translator. "What you are doing does more good than if you go to the temple."

Sullivan is one of 44 nurse care managers at Senior Whole Health. Another 22 employees are community resource coordinators, or CRCs, who help members over the bumps of daily life. Only nine of the company's 181 employees process claims.

When a new member joins Senior Whole Health, a nurse visits his or her home, often with a translator in tow. After an assessment of health and living conditions, the nurse works with the member's physician, a CRC, and community-based elder organizations to create a care plan and arrange the necessary treatment and support. About 1,250 members in Massachusetts who are not in nursing homes have health problems that affect their ability to live independently; nurses will visit them every few months to make sure they are seeing the right doctors, taking the right prescriptions, eating, sleeping, not succumbing to depression. Between visits, follow-up and monitoring are performed by the community care organizations. Senior Whole Health tracks its healthier members chiefly through their physicians and devotes more attention to those whose conditions deteriorate. The CRC, meanwhile, answers questions, makes appointments, and translates the member's correspondence or simply reads it to him or her out loud. (Forty-three percent of enrollees don't speak English, and 20 percent are illiterate. Collectively, the CRCs are fluent in 11 languages.) The CRC also arranges for housing, electric scooters, Meals on Wheels -- whatever good sense and the member's physician recommend.

The company pays for Dung Lam's time in adult day care and sponsors her seniors' tai chi class, which promotes balance. It has bought enrollees air conditioners, tacked down their carpets so they don't trip, and hired nurse's aides to spell family members exhausted by a long deathbed vigil. When a member was recently forced onto a liquid diet by a stroke that rendered her unable to chew, the company ordered two weeks of treatment from a speech therapist who taught her new techniques for swallowing solid food.

"Remember, these aren't people who spent down their assets to qualify for Medicaid. These are poor people who got old," says Baackes. "Their needs aren't just physical but also social and psychological. Our innovation is looking at the whole context in which they live."

Senior Whole Health is headquartered in a converted twine factory a few miles from the Massachusetts Institute of Technology. During a meeting in Baackes's office there, the executive team tries to demystify for a visitor the bewildering regulatory environment in which the company operates. Repeatedly the conversation devolves into abbreviations: ASAP, CRC, PCP, HCC, DME -- it's as though the team hopes to increase efficiency by reducing the amount of time people spend saying entire words.

Despite their expertise at navigating government bureaucracy, the leaders often find the system frustrating. Medicare and Medicaid won't release information on people with dual eligibility, so the company cannot reach them through direct mail or other mass marketing techniques. "If they would share the names and addresses under some kind of control, we could get to people faster," says Baackes, who has spent many hours at the state capitol lobbying to get the rules changed. "The amount of money we are spending on this is ridiculous."

Senior Whole Health can approach only individuals who raise their hands, so it relies on doctors' referrals and the occasional presentation at senior centers. Most sales take place around the senior's kitchen table. Sales staff -- outreach representatives in company parlance -- are drawn from members' communities and speak their native languages. "I speak Creole-French and English, and I do quite well in Spanish also," says representative Ingrid Pamphile. "Most of my clients are Creole-Haitian. Even when I go to a home where the caregiver or adult children speak English, they want me to do it in Creole, so the mother or father can understand what I am saying."

Pamphile says her neighborhood roots build trust, which is critical when dealing with people who cling for dear life to their Medicare and Medicaid cards. "I know what it's like to come from a country where you don't have health care," she says. "When you finally get it, you don't want to part with it. I have to make them understand we are not taking their Medicare away. We are going to add to it, give them more benefits."

Identifying prospective members may be hard, but converting them is relatively easy. About 75 percent of pitches result in sales. Enrollee retention is 99 percent. Senior Whole Health's internal research shows it has reduced the number of avoidable hospital admissions -- that is, admissions treatable in an outpatient setting -- by 25 percent even as the number of high-risk enrollees has grown. Jen Associates, a health care policy consultancy, found that SCO enrollees are more than 25 percent less likely to turn up in nursing homes than the general Medicare-Medicaid population in Massachusetts. (Senior Whole Health represents nearly 50 percent of the Massachusetts SCO market.) Jen Associates also found that SCO members are generally older when they do enter nursing homes and remain there for shorter periods.

Senior Whole Health is now looking outside Massachusetts. The company raised an additional $16 million in December 2006 and used it to expand into parts of New York and Connecticut. And there's room to grow in Massachusetts, where SCOs represent just 10,000 of roughly 100,000 dual eligibles. In Connecticut and New York, Senior Whole Health also plans to roll out coverage for those who are on Medicare because they are disabled rather than old.

But though this model's advantages for seniors are demonstrable, the advantages for taxpayers remain unclear. No one has yet quantified the cost reduction from delaying or avoiding nursing-home care. Richard Moore, the Massachusetts senator, believes savings exist but are not as great as was once expected. "Providing these professional services is not inexpensive if you do it right," says Moore. "So there's a savings, but it's more that the quality of care is better and people are able to maintain their independence.

"I've talked to my constituents about Senior Whole Health and gotten a lot of positive feedback," says Moore. "They understand that every time a person goes into a nursing home prematurely, they've lost a battle. And they don't want to lose."

Leigh Buchanan is an editor-at-large for Inc.

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Leigh Buchanan

Leigh Buchanan is an editor at large for Inc. Magazine. A former editor at Harvard Business Review and founding editor of WebMaster magazine, she writes regular columns on leadership and workplace culture, and she contributes Inc.'s capsule book reviews, "A Skimmer's Guide to the Latest Business Books."