New York: A Housecall to Help With Doctor's Orders

Experts say the failure to comply with medical directives is a major reason sick patients do not get better and US health care costs are high. The problem is widespread -- about three-quarters of patients fail to keep appointments for follow-up care -- and seen across social strata. But it is particularly critical for patients confronting multiple challenges like HIV/AIDS, mental illness, and substance abuse.

With three sites in Manhattan, St. Luke's-Roosevelt Hospital Center's Center for Comprehensive Care functions as a "medical home" for persons affected by HIV/AIDS. In 2009, its multiple health services were supplemented with a program called Care Coordination. That effort uses nine patient-navigators to improve treatment adherence among the most difficult clients.

At present, 216 patients are enrolled. Patient-navigators may accompany clients to medical appointments and make sure their prescriptions are filled and organized. Much of their task, however, is simply to provide encouragement and support as patients struggle to comply with medical advice and inch their way back to health.

The Care Coordination program has since grown to 28 sites in different hospitals across New York City. The idea for the effort came from the Boston-based program Prevention, Access to Care and Treatment. PACT is part of the noted non-governmental organization Partners in Health, whose strategy includes paying community residents to visit patients, observe them taking their medications, and offer support. Some of the community workers trained by PACT have the same health conditions their clients face.

The effort appears to be working. A study of PACT's AIDS patients found their medical adherence rose, while spending on their hospitalization dropped by almost two-thirds. Even factoring in PACT's $6,000 per-patient cost, patient costs dropped by 16 percent. Among the sickest patients, 70 percent saw clinical improvement.