Transcript Cover in Arial Bold

New Models of comprehensive
care for patients with chronic
conditions: Guided Care
Katherine Frey, MPH
March 20, 2009
Supported by the John A. Hartford Foundation,
the Agency for Healthcare Research and Quality,
the National Institute on Aging, and
the Jacob and Valeria Langeloth Foundation
Aging Trends in Spain
• Two Demographic Processes
 Declining Birth Rate
 Increasing Life Expectancy
• By 2015 the labor force will contract and the
population over 65 will grow.
Sandell, Documento del Real Instituto, 2003
The population is aging.
Funding Health Care in Spain
• Taxes main source of finance
• Health care expenditures 7.4% GDP (1997) and
growing
• Mix of public (89%) and private (21%) expenditures
• Among people with private insurance (12%
population)
 Private expenditures primarily for outpatient and specialist
expenses
 Public expenditures primarily hospitalizations
• 48% hospital expenditures attributable to over 65
Rodriguez et al, Health Policy, 2000
Complex care is:
Fragmented
Discontinuous
Difficult to access
Inefficient
Unsafe
Expensive
The ¼ of Beneficiaries Who Have
4+ Chronic Conditions Account
for 80% of Medicare
Spending
1
0
1%
3%
2
6%
3
10%
4
12%
5+
Conditions
68%
Source: Medicare 5% Sample, 2001
Failing System
Patient Perspective:
• Poor quality of care
• Low levels of patient satisfaction
• High cost of care
Physician Perspective:
• Low levels of satisfaction
• Low levels of reimbursement
Usual Care
• Mr. Jackson
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
Has 8 medical conditions
Takes 8 medications
1 primary care physician
4 specialists
• Effect on Life
 Confused by his care
 Out of pocket costs are
high
 Quality of life is poor
 Wife is stressed out
Is our system working?
How can we improve
chronic care?
What alternatives have been tested?
How effective are they?
How can they be useful in the real world?
GEM
(Geriatric Evaluation and Management)
• Home visit by social worker
• Two inpatient examinations; one by an NP, one by a
geriatrician/nurse pair
• Multidisciplinary Care Planning
• Monthly care received at the GEM clinic; average 6 months
treatment per study participant
• Randomized trial
 Decrease in loss of function, decreased rate of depression and
caregiver burnout
 Improved patient and physician satisfaction
 cost $1,350 per person treated
 Boult JAGS 2001
Transitional Care for CHF
• Education about CHF by a nurse, using book
specifically written for geriatric HF patients
• Dietary assessment and planning by dietician, with
nurse follow-up
• Referral to social services
• Medication adjudication by physician
• Follow-up by study nurse post-discharge
• Randomized clinical trial
 Increased quality of life
 Reduced hospital admissions for CHF reduced costs
- Rich N Engl J Med 1995
Transitional Care for Multiple
Chronic Conditions
• Advanced Practice Nurse (APN) visited patient with
48 hrs admission and then at least every 48 hours
during hospital course
• APN visits twice (at least) post-hospitalization, once
within 48 hours, once within 7-10 days.
• Telephonic support, including weekly calls
• Randomized trial
 Fewer re-admissions
 Lower hospital charges
- Naylor JAMA 1999
Self-Management
• Evaluation of 6-week Chronic Disease SelfManagement Course
 Subjects covered: cognitive symptom management;
nutrition, fatigue and sleep management; use of
community resources; medication management; exercise;
dealing with emotions; communicating with physicians;
problem-solving; decision making
• Randomized clinical trial
 Improved function, general health, energy
 Reduced hospital days and costs
 Lorig Med Care 1999
Health Enhancement Program
• Community-based exercise intervention, nutrition
counseling, and home evaluation
• Randomized trial
 Reduced disability
 Reduced hospital days
 Wallace JGMS 1998
Summary of Effects
GEM
T. Care
(CHF)
T. Care
(multi)
SM
HE
Health
↑
↑
↑
↑
↑
Hospital
admits
and
Cost
↑
↓
↓
↓
↓
Effect on:
Guided Care Strategy: To
Translate Knowledge to Practice
Combine successful innovations
Integrate them into primary care
Make the model diffusable
The Guided Care Model
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
Foundation of Guided Care
Motivational Interviewing
Self-Management
Guided Care Nurses’ Activities
Assess needs and preferences
Create an evidence-based “care guide”
Monitor patients proactively
Support chronic disease self management
Support caregivers
Communicate with providers in EDs, hospitals, specialty clinics, rehab
facilities, home care agencies, hospice programs, and social service
agencies in the community
Smooth transitions between sites of care
Facilitate access to community services
Boyd et al. Gerontologist 2007
Electronic Health Record
Creates:
Evidence-based “Care Guides”
Reminders
Provides:
Decision support: drug interactions
Documentation of GCN-pt/cg encounters
Guided Care Nurse & Mr. Jackson
• Using a computerized data collection tool, assesses Mr. Jackson’s
clinical needs and preferences
• With the physician and electronic decision support, creates an
evidence-based comprehensive care plan and patient friendly
Action Plan
• By telephone, monitors Mr. Jackson proactively
• Around the care plan, coordinates efforts of providers in primary
care, EDs, hospitals, specialty clinics, rehab facilities, home care
agencies, social services, and community agencies (with emphasis
on facilitating transitions between sites of care)
• Through a self-management course and access to educational
materials, informs and empowers Mr. Jackson (and his wife) to
participate in his care
• By telephone, supports Mrs. Jackson in her role as a caregiver to
Mr. Jackson.
Mr. Jackson is Hospitalized
• Exacerbation of CHF
 Cardiac catheterization reveals occlusion LAD coronary
artery
 CABG x 3 + mitral valve replacement
• New medications
 Change from hydrochlorothiazide to furosemide
 Oxycodone for pain management
 Warfarin
• New providers
 Cardiac rehabilitation
 Home care nurse
GCN Transitional Care Activities
• Visits him within 48 hours of admission and delivers
Care Guide
• Prepares Mr. and Mrs. Jackson for his discharge,
including explanation of new drugs
• Reviews the updated Action Plan within 48 hours of
discharge
• Coordinates services with new providers
• Updates primary care provider of all changes
Mr. Jackson’s Perspective
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Two-hour interview with the nurse at home
Seven-session self-management course
Educational materials (verbal, written, Internet)
Telephone inquiries and reminders from nurse
Assistance in accessing the services of health care providers and
community agencies
• Assistance in integrating all health-related services
• Direct access to a nurse during normal business hours
• Assistance making the transition from the hospital home
Physician’s Perspective
Assistance with most difficult patients
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Creating/implementing comprehensive plans
Proactive follow-up
Responding promptly to patients’/families’ calls
Communicating with other providers
Facilitating transitions from hospitals
Minimal time requirement
Randomized Trial
High-risk older patients (n=904) of 49 community-based
primary care physicians practicing in 14 teams
Physician/patient teams randomly assigned to receive Guided
Care or “usual” care
Outcomes measured at 8, 20 and 32 months
Supported by the John A. Hartford Foundation, the Agency for Healthcare
Research and Quality, the National Institute on Aging, and the Jacob and
Valeria Langeloth Foundation
Baseline Characteristics
Guided Care
Usual Care
Age
77.2
78.1
Race (% white)
51.1
48.9
Sex (% female)
54.2
55.4
Education (12+)
46.4
43.4
Living alone
32.0
30.6
Conditions
4.3
4.3
HCC score
2.1
2.0*
ADL difficulty
30.9
29.3
Cognition (SPMS)
9.1
9.0
Effects on Quality of Care
PACIC scales:
GC
UC
aOR*
95% CI
P
Goal setting
24.6
11.6
2.4
1.5-3.7
<0.001
Coordination
14.2
7.1
2.3
1.3-4.0
0.005
Decision support
42.7
33.1
1.5
1.1-2.1
0.014
Problem solving
33.4
24.7
1.4
1.0-1.9
0.096
Patient activation
26.6
23.0
1.1
0.7-1.5
0.763
Aggregate
17.4
8.5
2.0
1.2-3.4
0.006
Boult et al. J Gerontol Med Sci 2008
Effects on Physician Satisfaction
• Compared with Usual Care, Guided Care
physicians were significantly more satisfied with
their:




Communication with their patients
Caregiver education
Ability to motivate patients
Knowledge of patient medications
Annual Costs of Guided Care
Guided Care Nurse
Salary
Benefits (@ 30%)
Travel (to pts’ homes, hospitals)
$71,500
21,450
588
Communication services
Internet, cell phone
1,800
Equipment (amortized)
Computer
500
Cell phone
67
TOTAL
$95,905
Annualized Use of Services
per Caseload (55 Beneficiaries)
Guided Care
Usual Care
Hospital days
241
317
SNF days
170
270
Primary care visits
558
557
Specialist visits
473
434
Home health care
episodes
50
70
Leff et al. (in press)
Annualized Cost of Services
per Caseload (55 Beneficiaries)
GC – UC
Difference
Average
Expenditure
Difference in
Expenditures
Hospital days
-76
$1,519/day
-115,600
SNF days
-99
$305/day
-30,200
Primary care
visits
-1.3
$41/visit
-100
Specialist
visits
39
$41/visit
1,600
Home health
episodes
-20
$1331/episode
-26,800
Gross savings
-----
-----
-170,900
Net Savings
-----
-----
-75,000
Future of Guided Care
• Diffusion Activities
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Online course for nurses
Online course for physicians
Guided Care Implementation Textbook
Technical Assistance for practices seeking to adopt Guided
Care (www.medhomeinfo.org)
Conclusion
Guided Care is an innovative approach to efficiently managing
caseloads of older, complex patients living in the community.
Patient, physician and nurse satisfaction is high.
Compared to usual care, Guided Care appears to improve the quality
and the efficiency of health care for patients with chronic
conditions.
References
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Boult C et al. A randomized trial of outpatient geriatric evaluation and
management. JAGS, 2001;49:351-359.
Boult C et al. Early effects of "Guided Care" on the quality of health care for
multimorbid older persons: A cluster-randomized controlled trial. Journal of
Gerontology: Medical Sciences 2008;63A(3):321-327.
Boyd C et al. Guided Care for multimorbid older adults. The Gerontologist
2007;47(5):697-704.
Leff B et al. Guided Care and the cost of complex health care (in press)
Lorig K et al. Evidence suggesting that a chronic disease self-management
program can improve health status while reducing hospitalization: A
randomized trial. Medical Care 1999;37:5-14.
Naylor M et al. Comprehensive discharge planning and home follow-up of
hospitalized elders: A randomized clinical trial. NEJM 1999;281:613-620.
Rich M et al. A multidisiplinary intervention to prevent the readmission of
elderly patients with congestive heart failure. NEJM 1995;333:1190-1195.
Wallace J et al. Implementation and effectiveness of a community-based
health promotion program for older adults. Journal of Gerontology: Medical
Sciences 1998;53:M301-306.
Thanks to:
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Dr. Charles Boult
Lisa Reider, MHS
Tracy Novak, MHS
The Guided Care Nurses
The Guided Care research Team
The Guided Care Patients
Johns Hopkins HealthCare and Kaiser Permanente
The John A. Hartford Foundation, the Agency for
Healthcare Research and Quality, and the Joseph
and Valeria Langeloth Foundation
www.guidedcare.org
Katherine Frey, MPH
[email protected]