Transcript Here - Leyden Academy

Caring for Older Persons
with Multiple Chronic Conditions
Chad Boult, MD, MPH, MBA
Director, Improving Healthcare Systems,
Patient-Centered Outcomes Research Institute
Leyden Academy on Vitality and Ageing
9 April 2013
Hans Nijpels
79 year old widower
Retired teacher, lives
alone
Income: small pension
Daughter lives 10 km
away, has three
teenagers
Five chronic conditions
Three physicians
Eight medications
In the past year, he has had..
22
6
8
scripts
community
referrals
meds
19
2
home care
agencies
Mr.
Hamond
outpatient
visits
3
5
months
homecare
hospital
admissions
2
6
nursing
homes
weeks subacute care
Mr. Nijpels
Confused by care, meds
Gets discouraged
Self-care is poor
Mr. Nijpels’ daughter
“Stressed out “
Reduced work to half-time
Considering nursing
homes
Chronic care is:
Fragmented
Discontinuous
Difficult to access
Inefficient
Unsafe
Expensive
The ¼ of older persons who have
4+ chronic conditions account for
80% of health care spending
0
1%
1
3%
2
6%
3
10%
4
12%
5+
Conditions
68%
“Every system is designed perfectly
to produce the results it gets”
Donald Berwick, MD
What’s Wrong Here?
Chronically ill
population
Health care
system designed
to provide acute
care
“We simply cannot afford to postpone
health care reform any longer.
We must attack the root causes of
the inflation in health care.”
Barack Obama
June 2, 2009
What Can We Do?
Health System
Health Care Organization
Community
Resources and
Policies
SelfManagement
Support
Informed,
Activated
Patient
Delivery
System
Design
Productive
Interactions
Clinical
Information
Systems
Decision
Support
Prepared,
Proactive
Practice Team
Chronic Disease Self-Management,
Caregiver Support,
Action Plan
Improved Outcomes
Monitoring
Coaching
- T Bodenheimer et al
JAMA, 2002
A Search for Success
Literature review to identify recent
innovations in chronic care that have
shown promising results
Rank the promising models’ potential for
“diffusability”
Methods
Literature search: Medline,1987-2011
Tabulation of evidence for promising models
Classification of the strength of the evidence
Consensus ratings of models’ diffusability
2,714 titles identified
2,409 excluded
305 abstracts read
174 excluded
131 articles read
51 articles added
from bibliographies
59 excluded
123 articles met
inclusion criteria
10 Successful Diffusable Models
Model
APN-physician team
(for dementia pts)
Improves health care
quality or outcomes
Improves health Diffusability
care efficiency score (6-30)
1 cluster RCT
None
19
IDT (for CHF)
1 meta-analysis
2 reviews
1 meta-analysis
2 reviews
25
Guided Care (for multimorbid pts)
1 cluster RCT
1controlled trial
1 cluster RCT
1 controlled trial
23
Care mgmt (for CHF)
3 RCTs
3 RCTs
21
Pharmaceutical care
4 RCTs
2 RCTs
19
1 meta-analysis
9 RCTs
4 RCTs
24
4 RCTs
2 RCTs
19
1 meta-analyses
1 RCT
2 meta-analyses
2 RCTs
19
Self-management
training
Proactive rehabilitation
Caregiver
support/education
Successful Diffusable Models
Model
Transitional care
APN-physician dyads
(for NH residents)
Improves health
care quality or
outcomes
Improves health
care efficiency
Diffusability
score
(6-30)
1 meta-analysis
1 RCT
1 meta-analysis
2 RCTs
20
3 quasiexperimental
studies
3 quasiexperimental
studies
21
Summary
Four types of successful, diffusable models:
Primary care by interdisciplinary teams
Adjuncts to traditional primary care
Transitional care
Dyadic care of residents of nursing homes
“Successful Models of Comprehensive Care
for Older Adults with Chronic Conditions”
- IOM “Re-Tooling for an Aging
America” report, 2008
- Boult et al. J Am Geriatr Soc, 2009
Guided Care:
Comprehensive Care for Persons with
Chronic Conditions
Specially trained RNs based in primary
physicians’ offices
GCNs collaborate with physicians in caring
for 50-60 high-risk older patients with
chronic conditions and complex health
care needs
Nurse/physician team
Assesses needs and preferences
Creates an evidence-based “care guide”
and a patient-friendly “action plan”
Monitors the patient proactively
Supports chronic disease self-management
Smoothes transitions between care sites
Communicates with providers in EDs,
hospitals, specialty clinics, rehab
facilities, home care agencies, hospice
programs, and social service agencies in
the community
Educates and supports caregivers
Facilitates access to community services
Boyd C et al. Gerontologist, 2007
Who is Eligible?
25%
High-Risk
All
Patients
Age 65+
Review previous
year’s insurance
data with PM
software
75%
Low-Risk
Patient Selection
13,534 Patients of 14 teams/49 physicians
3,383 (25% highest-risk)
904 = Consenting Patients
(Baseline Evaluation)
485 in seven
Guided Care
teams
Random
Allocation
419 in seven
Control teams
Boult C et al. J Gerontology, 2008
Baseline Characteristics
Age
Race (% white)
Sex (% female)
Education (12+)
Living alone
Chronic conditions
Risk of utilizaton
ADL difficulty
Guided Care
77.2
51.1
54.2
46.4
32.0
4.3
2.1
30.9
Usual Care
78.1
48.9
55.4
43.4
30.6
4.3
2.0*
29.3
Effects on Quality of Care
PACIC
2.1
AGGREGATE
1.3
Activation
1.3
Problem Solving
1.5
Decision Support
1.8
Coordination
1.5
Goal Setting
0
1
2
3
4
aOR
Quality rated in the highest category on PACIC
Boyd et al. J Gen Intern Med, 2009
Effects on Caregiver Strain
Wolff et al. J Gerontology Med Sci, 2009
Effects on Physician Satisfaction
0.6
Guided Care Physicians (n=18)
Change in Satisfaction
0.4
P = 0.014
Usual Care Physicians (n=20)
P = 0.042
P = 0.079
0.2
P = 0.148
P = 0.182
0.0
-0.2
-0.4
-0.6
Patient/family
communication
Clinical
knowledge of
patients
Helps make Written info sent
appointment for to specialists
referral visit
Useful info
received from
specialists
Marsteller et al. Ann Fam Med, 2010
Very satisfied
6
Satisfied
5
Somewhat satisfied
4
Somewhat dissatisfied
3
Dissatisfied
2
Very dissatisfied
1
GCNs' Satisfaction with Clinical
Activities
1
2
3
4
5
6
Satisfaction Items
Satisfaction Items
1= Familiarity with patients
2= Stability of patient relationships
3= Comm. w/ patients; availability of clinical info; continuity of care for patients
4= Efficiency of office visits; access to evidence based guidelines
5= Monitoring patients; communicating w/ caregivers; efficiency of primary care team
6= Coordinating care; referring to community resources; educating caregivers
7= Motivating patients for self management
7
Comments by
Guided Care Nurses
“The best job I’ve ever had”
“I love this role.”
Annual Costs of Guided Care
Guided Care Nurse
Salary
Benefits (@ 30%)
Travel (to pts’ homes, hospitals)
Communication services
Internet, cell phone
Equipment (amortized over 3 years)
Computer
Cell phone
TOTAL
$71,500
21,450
588
1,800
500
67
$95,905
Effects on Costs of Care
(per caseload, 55 patients)
GC – UC
Difference
Average
Expenditure
Cost
Difference
Hospital days
-76.1
$1,519/day
-115.6
SNF days
-99.1
$305/day
-30.2
Home health
episodes
-20.1
$1331/episode
-26.8
Physician visits
40.0
$41/visit
Gross savings
-----
-----
Cost of GCN
NET SAVINGS
1.7
-170.9
95.9
-----
-----
-75.0
Leff et al. Am J Manag Care, 2009
Health Service Use, 1st 20 Mos
20
8%
10
Percent difference
*
*
0
-10
-20
9%
-7%
-15%
-17%
-21%
-30
-40
-50
-60
-49%
-47%
Hospital Hospital Hospital SNF
admits re-admits
admits
days
-52%
SNF
days
ED
visits
Primary Specialist Home
care visits visits health
episodes
Boult et al. Arch Intern Med, 2011
Technical Assistance for
Practices
• Guided Care: a New Nurse-Physician
Partnership in Chronic Care (Springer
Publishing Company)
• Online course for registered nurses
• Online course for physicians and practice
leaders
• Orientation booklet for patients
www.GuidedCare.org/adoption.asp
Take Home Points
For patients with several chronic conditions,
interdisciplinary primary care can improve
care and reduce costs, especially in wellmanaged systems of care.
Primary care physicians of the future may
practice in new team-based models of
care.
How could these lessons be
used to improve chronic care
in the Netherlands?