Transcript Washington Association of Area Agencies on Aging

Washington Association
of Area Agencies on
Aging
Staff Development Conference
June 12, 2008
Intensive Chronic Case Management
Project Sites (09/06)
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Olympic Area Agency on Aging
Northwest Regional Council
Pierce County Aging and Long Term Care
SE Washington Aging and Long Term Care
Aging and Long Term Care of Eastern
Washington
A quick look at the data
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The number of Americans with chronic conditions is
expected to increase from 125 million in 2000 to 157
million by 2020.
The number of people with multiple chronic conditions
will rise from 60 million to 81 million.
Care for people with chronic conditions accounts for
77 percent of Medicaid spending for beneficiaries living
in the community.
(Mollica and Gillespie, 2003)
Per capita health expenditures
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The average per capita medical expenditure is
significantly higher for individuals with one or more
chronic conditions than for those with no chronic
conditions
Among the Medicaid population the costs are more
than double and for people over age 65 and older who
are dually eligible the costs are more than five times
higher.
(Mollica and Gillespie, 2003)
The Governor’s Memo (01/06)
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Five percent of Medicaid
clients account for 50 percent
of the costs.
They are consumers of LTC
Are diagnosed with
depression and chronic pain.
Current health care system is
focused on acute care and
misses working with clients
with chronic conditions from
developing complications.
Who are the most vulnerable?
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5 % have the most claim activity
60% female and 40% male
Most are 25 to 64 years old
Health services cross all agencies
Common health risks;
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Cardiovascular, muscular and cancers
60% are on narcotics and antidepressants
Their co-morbid conditions make all interventions
challenging.
High risk factors include mental illness and chemical
dependency.
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WA state data
Definition of a chronic condition
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A chronic condition is one that is expected to
last more than one year
Limits a persons activities
 May require ongoing medical care
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Arthritis, asthma, congestive heart failure, diabetes, eye
disease, hypertension, cancer and cardiovascular disease,
mental illness, and obesity.
(Partnerships for Solutions, 2004)
And so what about care
coordination…
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Care coordination for people with chronic conditions
who participate in Home and Community Based
Services has been narrowly focused on supportive
services.
At the same time, a medical model of care coordination
has begun to emerge in the Fee For Service health care
system.
Yet… a gap exists between supportive and medical
services and needs to be addressed.
(Mollica and Gillespie, 2003)
(Partnerships for Solutions, 2004)
Definition of “chronic care
management?”
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“Chronic care management" means programs that provide care
management and coordination activities for medical assistance
clients determined to be at risk for high medical costs.
"Chronic care management" provides evidence-based assessment
and interventions, coordination of health care and other
supportive services, education and training that assists program
participants in improving self-management skills to improve
health outcomes, reduces medical costs, improve functional and
self-care abilities, and slows progression of disease or disability.
Chronic care management recognizes and provides interventions
for the medical, social, economic, mental health and
environmental factors impacting health and health care choices.
Six Goals of Chronic Care
Management
Goal # 1
1.
Improve or enhance case management
interventions to allow the client to partner
with health and social service providers to
manage their care and services.
Goal # 2
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Implement evidence-based preventive care
measures that delay the decline or promote the
abilities of the client to be able to achieve the
highest level of health.
Goal # 3
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Develop or adopt protocols that enhance the
client’s options to manage their care and services
to achieve individual goals.
Goal # 4
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Identify individual health goals the client would
like to achieve. The goals are expected to include
principles of the IOM Chasm Report. These
goals are established cross DSHS agency when
possible.
Goal # 5
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Combine medical and personal care services to
improve cost and service utilization;
Create a medical home for the client.
 Apply predictive modeling results for long term care
planning with the client and their community.
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Goal # 6
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Improve cost effectiveness and utilization to
achieve individual client outcomes;
Nurse case managers to have access to medical
cost and provider utilization for each client in
their respective projects and work with the client
and their providers to address these health care
issues.
Program Description
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The focus of the ICCM projects is:
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Integration of acute and long term care services through
coordination;
Consideration of adoption of evidence-based practices that
promote health outcomes;
Targeted to populations with high-cost and high-risk chronic
conditions;
Recognition and interventions for the medical, social,
economic, mental health, chemical dependencies, and
environmental factors impacting health and health care
choices.
Risk Determinants
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High medical cost and risk client determinants
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Predictive modeling software
Past twelve months medical claims, gender and age
determine future medical costs and risk.
 Diabetes, cardiovascular disease, mental health and
substance abuse.
 Pharmacy, inpatient care, and emergency room utilization.
 Care opportunities
 Risk Score
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IMPACT PRO © Risk Profile
Impact Pro© Care Opportunities
High Risk Determinants
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CARE risk criteria
Client lives alone
 High risk moods/behaviors
 Self health rating is fair or poor
 Overall self-sufficiency declined in last 90 days
 Greater than six medications
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Evidence Based Practice
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An intervention that has been tested and
proven to be effective.
The intervention must be applied as tested
with fidelity to the intervention.
Why do we want to use Evidence
Based Practices?
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Studies have supported that outcomes are
substantially improved when health care is based
on evidence from well designed studies versus
tradition or clinical expertise alone.
Examples from ICCM include:
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Diabetes management
Pain management
Fall assessment and prevention planning
Medication management
Skin Observation Protocol
EBP Resources
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CDC Community Preventive Services
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CDC’s Healthy Aging Program
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www.effectivehealthcre.ahrq.gov
US Preventive Services Task Force
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www.cdc.gov.aging
AHRQ Evidence Based Practice Centers
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www.thecommunityguide.org
http://preventiveservices.ahrq.gov
National Guidelines Clearinghouse
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http://www.guideline.gov
Patient Activation Measure ©
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The process of working with the client to
determine their:
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Perceived level of confidence for change
Readiness for change
Priority of needs based on risk and individualized
service planning
Assessing for Activation
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A person’s level of activation can help the client,
caregivers, and nurse case manager to assess for:
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The client’s readiness and skills for change, emotional
support needs and beliefs
With activation, the client can:
Build knowledge and confidence,
 Take action, and
 Maintain behaviors
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Activation for Chronic Conditions
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Determine how they feel about their ability to manage
their health – For example how do these statements apply
to your client?
(Copyright 2003, Insignia Health)
When all is said and done, I am the
person who is responsible for taking
care of my health problems.
Disagree
Strongly
Disagree
Agree
Agree Strongly
N/A
Taking an active role in my own
health care is the most important
thing that affects my health.
Disagree
Strongly
Disagree
Agree
Agree Strongly
N/A
I am confident I can help prevent or
reduce the problems associated with
my health condition
Disagree
Strongly
Disagree
Agree
Agree Strongly
N/A
I know what each of my prescribed
medications do
Disagree
Strongly
Disagree
Agree
Agree Strongly
N/A
What Assessing For Activation Can
Tell You
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Whether a client:
Is or isn’t ready to make changes
 Is thinking about changing or is ready to change but
doesn't have a plan
 Is ready to change and has some steps in place
 Is currently making a change
 Has made some changes and is staying on track
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Examples of Discussion Points
When all is said and done, I am the person
who is responsible for managing my health.
Tell me what you were thinking about when you
answered that you disagree/strongly disagree that
you are the person who is responsible for managing
your health?
Taking an active role in my own health care
is the most important factor in determining
my health and ability to function.
Tell me what you were thinking when you answered
disagree/strongly disagree that taking an active role
in your own health care is the most important factor
in determining your health and ability to function.
(Copyright 2007 Insignia Health)
Coaching for Activation
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Encourage client confidence - that their actions
can make an impact on their health and
independence
Discuss and offer options that allow the client to
increase their ability to manage their own care to
improve quality of life and/or health outcomes
Ask the client what ideas they have to better
manage their health care.
Habit is habit.
It is not to be flung out of the
window by anyone, but
coaxed downstairs a step at a
time.
- Mark Twain
ICCM Summary
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The client is in charge of the care plan;
There is value in bridging systems of care;
Behavioral changes take time;
A client’s perception of need and readiness for
change will determine the speed of the change;
This approach includes; physical, mental,
emotional, psycho-social and environmental
needs.
Closing and Questions
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Contact Information
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Candace Goehring
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253-798-7236
[email protected]
Kathy Medford
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[email protected]
Kay Coulter
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360-725-2562
509-965-0105
[email protected]
Jessie Stopsen
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360-538-2456
[email protected]