Transcript Adding Access for the Delivery of Chronic Health Care

Alegent Health at Home
Brenda Bergman-Evans, PhD, APRN
Paula Egan, BSN, RN
Federal Interagency Forum on Aging-Related Statistics, “Older Americans 2000: Key Indicators of Well-Being,”
at www.agingstats.gov/chartbook2000
 Chronic
diseases
• A long latency period
• Multiple risk factors
• Prolonged course
 Do not resolve spontaneously
 Complete cure is rarely achieved
 A prolonged course of illness
• Uncertain etiology
Chronic disease epidemiology and control, 2nd Edition
 More
than 90 million people
affected (CDC).
 Leading
causes of death and
disability.
 Cause
for 7 out of every 10
deaths.
 Accounts
for 75% of annual
total health care cost.
AGS, 2011
% of US population
Percent of People With Inpatient
Hospital Stays (Average
Inpatient Days)
Chronic Disease and
Hospitalization
50%
40%
(3.1)
31%
30%
(2.5)
23%
(1.7)
20%
(0.8)
(0.4)
10%
(0.2)
17%
12%
7%
4%
0%
0
1
2
3
4
5+
Number of Chronic Conditions
Source: Medical Expenditure Panel Survey, 2001.
“Patients
Hospitalization affect
on ADLs
-Ability declines for ~15%
- Another 20% leave
without recovering prehospitalization abilities
can
undo a month’s
worth of
expensive and
intensive care just
going home
and going about
their normal
routines.”
John Charde, MD
VP Strategic Development, Enhanced Care
Initiatives, Inc (April 2006)
 Elderly
• 85.6% are age 65+

Chronic Diseases
• 80% with one chronic condition
• Almost 50% with more than one chronic condition
 Cognitive impairment
• 23.7 % assessed with mild impairment
• 12.5 % assessed with moderate to severe impairment
 Depression
• Ranges from 10% - 40% depending on chronic disease
Source: Murtaugh, et al. (2009) Complexity in Geriatric Home Healthcare. Journal for Healthcare Quality. Vol 31, No. 2, pp 34-43.
Source: Jorge R. Petit, MD. Associate Commissioner of Program Services Division of Mental Hygiene, New York City Department of
Health and Mental Hygiene
Source: Anderson, G.; Chronic Conditions: Making the Case for Ongoing Care; Johns Hopkins University; November 2007
 Adverse
drug reactions (ADR)
• # of drugs is single greatest risk for ADR
• Exponential increase as the number of drugs
•
•
•
•
•
rise
Decreased medication compliance
Poor quality of life
Unnecessary drug expense
Transition times
Drug-drug reactions
 Hospital
• Admissions: 5-28%
• Multiple medications cited as cause for many of
the readmissions
 Up
to 70% of individuals enter ALFs
secondary medication mismanagement
(Pytlarz, 2006)
 Estimated
cost: $200 billion annually
(Cameron, 1998)
Contributes to:
• Increased number and length of acute care visits
•
•
•
•
 25% of hospitalizations due to medication errors
Increase in ED visits
Unnecessary changes
Overuse of scarce and expensive medical
resources
Loss of productivity and decreased quality of life
“The degree to which individuals have
the capacity to obtain, process, and
understand basic health information
and services needed to make
appropriate health decisions.” (Healthy
People 2010)
Why is Low Health Literacy
Overlooked?
• If we don’t ask…they won’t tell
–
–
–
–
–
Lack of awareness
Not sure how to ask
Not sure of a good response
Adequate reading skills = health literacy
Fearful of opening a “can of worms”
15
 Silo
mentality
 Poor
communication and knowledge sharing
 Lack
of care coordination
 Rushed
 Lack
 Pts
 Pts
practitioners
of active follow-up
unsure what to do
seeking care via ER visits &
hospitalizations
 Transitions
 Wagner’s
 Patient
of Care
Chronic Care Model
Centered Medical Home
 Home-Based
 Project
Red
Chronic Care Model
Expert in disease specific
guidelines and care
Highly trained in
behavior change
techniques
Facilitates
effective
transitions
Expert in care
coordination
“Sought after” partner
that brings value
Communication
competencies
& ability to share
data
Willing to share
responsibility
for outcomes
High Touch Delivery
Specialist Oversight
Self-Management Support
Technology
 Establishing
trust
 Determining
barriers for changes
 Connecting
 Building
 Plan
the dots
self-confidence
for action
1%
Medical
Management
99%
Self-Management
The systematic provision of education and
supportive interventions to increase
patients’ skills and confidence in
managing their health problems, including
regular assessment of progress and
problems, goal setting and problem
solving support
 Patient-Centered
 Patient-Clinician
 Assessment
Focus
Relationship
and Tailoring
 Collaborative
Goal-Setting
 Problem-Solving
 Putting
the person being served and his
needs above all else – at the center of
everything
 Giving
patient choices and enabling
them to make decisions about their
health.
 An
emphasis of the patient’s goals
coupled with evidenced based care
 Lecturing
 Ignoring
readiness or lack
thereof for change
 Giving advise for action
 Solving pt. problems
 Setting goals for pts
• Lack meaningfulness
 Threatening
• Dire consequences
 Support
Case Managers
 Specialty Modules
• Congestive Heart Failure
• COPD
• Diabetes
• Depression
 Other
• Wound Care
• Infusion Therapy
 Using
health information exchanged via
electronic communications to improve
the health status of the consumer
• Store and forward telehealth information
• Phone visit – prescheduled with use of a protocol
• Interactive video – for “real time” visits
 Chronic
Care Course for all clinical
employees (8 hours, 158 employees over
9 months)
• Repeat twice yearly for new employees
• Certification of 25 direct-care and 12 non-direct
staff
 Initiation
of new model for case
conferences
 Schedulers
 Insure
visits that are made are effective,
and not just because of the order string
(2w9)
 Template
to guide phone assessment for
consistent practice (HHQI)
 Determine
patient need for f/u visit
 Decreased
number of different nurses
seeing patient
 Increased
• Patient satisfaction
• Staff satisfaction
• Staff involvement
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