Transcript Document - National Council on Aging

Programs for Improving Health & Wellbeing
A Case for Chronic Disease Self-Management Education
Sue Vaeth
Health and Aging Liaison, DHMH
Purpose
 Learn what the Chronic Disease Self-Management
Program (CDSMP) is and how it is being implemented
in Maryland
 Learn how CDSMP interfaces with Patient Centered
Medical Homes
 Learn how “Living Well” can help meet the Triple Aim
of improving care management, clinical outcomes,
and lower health care costs
 Learn how CDSMP has evolved on the Eastern Shore,
and how it has benefitted health care partners and
the community
What is Self-Management and
Why is it Important?
 Self-management programs empower people to take
an active role in managing their chronic illnesses.
 These programs help participants make lifestyle
choices and changes, adhere to prescribed medical
treatments, and become educated, responsible and
informed patients.
 Based on its wide availability, proven results, and
fulfillment of several of the NCQA’s Physician Practice
 Connections® – Patient Centered Medical Home (PCCPCMH-CMS™) guidelines, the CDSMP is a key resource
for providers in meeting the requirements to become
a medical home.
http://medhomeinfo.org/pdf/CDSMP%20PCMH%202-pager%20Final.pdf
Why Self-Management
Workshops?
The CDSMP program is built on three underlying
assumptions:
 1. Regardless of the chronic condition, people have
similar challenges with self management.
 2. People can learn the skills needed to better manage
their diseases day to day.
 3. People who understand and take control of their
condition will be healthier and happier.
http://medhomeinfo.org/pdf/CDSMP%20PCMH%202-pager%20Final.pdf
Role of Self-Management Programs
in PCMH Recognition
 NCQA Recognition Standards reinforce the critical
role of patient self-management and practice selfmanagement support
 Referring patients to CDSMP workshops offered in
your community will help qualify medical practices
 to meet the following activities:
• Provides or connects patients/families to selfmanagement support programs
• Provides or connects patients/families to classes taught
by qualified instructors
• Provides or connects patients/families to other selfmanagement resources where needed
http://medhomeinfo.org/pdf/CDSMP%20PCMH%202-pager%20Final.pdf
Benefits of Self-Management
Programs in Health Care
 Connects external resource to medical practices to enhance
medical treatment, e.g., improve clinical outcomes and decrease
utilization
 Empowers patients to increase control of their health
 Promotes collaboration and continuity of care among providers,
community/organizations, individuals, caregivers
 Ensures quality by maintaining fidelity to the program
 Reinforces communication “feedback loop”
 Documents disease education/self-management in PCMH terms
DHMH and Department of Aging
Support
 Historically an Aging Network program
 Prevention and Health Promotion Admin (PHPA):
 Prison Project - Allegany AAA
 CDC grant - 5 year grant providing funding for Living Well,
with focus on diabetes
 Quit Line Referrals
 IRB Approval
 Branching out to include many types of health care and
community partnerships
Aging Network – An Infrastructure that Supports 11 Million Older
Adults and Caregivers
AoA
56 State Units on Aging
629 Area Agencies
246 Tribal organization
20,000 Service Providers & 500,000
Volunteers
Provides Services & Supports to 1 in 5 Seniors
242 million
meals
28
million rides
69,000
81,759
29 million
4 million hours 0ver 22,000
caregivers
individuals
hours of
of case
individuals
trained 855,000
completing
personal care
management transitioned
assisted
CDSMP
Area Agency on Aging (AAA Services)
 MARYLAND ACCESS POINT
(Information, Assistance, and
Options Counseling)
 Advocacy and Assistance
Programs (LTC Ombudsman,
Public Guardianship, Elder
Abuse Prevention)
 Caregiver Support
 In-Home Services
 Insurance Assistance (SHIP)
 Health Promotion and Disease
Prevention
 Nutrition (Meals on Wheels
and Congregate Meals)
 Medicaid Home and Community
Based Services
 Senior Centers
 Volunteer Services
 Assisted Living Program Subsidies
 MAC, Inc.
 Day Care Center for the memory
impaired
 Wellness Center
 Evidence-based program training,
implementation and quality assurance
 50+ Network for Creative Engagement
 Assisted Transportation
 Community Outreach
Maryland’s Living Well




Most Maryland counties and Baltimore City
Western Maryland
Southern Maryland
Eastern Shore
CDSMP workshop types include…
Living Well - All chronic conditions (CDSMP)
 Chronic Pain Self Management Program – (CPSMP)
 Living Well with Diabetes (DSMP)
 New Cancer CDSMP just beginning on the Eastern Shore
Others developed but not currently being provided in Maryland:
Arthritis and HIV
On-line CDSMP
Other languages (52 countries in 20+ languages)
 Maryland - Korean, Chinese
Living Well Reach
Living Well Statistics
9/1/12 through 8/31/14
3,500
100%
3,500
98%
3,000
2,500
80%
2,762
71%
63%
1,500
70%
60%
56%
2,000
90%
1,750
50%
2,194
40%
1,000
871
29%
1,558
30%
20%
500
10%
617
-
0%
Total Participants
Total Completers
Target
Completion rate
Actual
African American
% of Goal
Surveys SA/A
What People Are Saying…
 “The…class has been a remarkable resource for
anyone dealing with chronic health problem. Living
healthy life.”
 “During the many years I've had diabetes, I never
really knew what to eat and that is one of the most
important elements in managing diabetes. Thank you
to our instructors!”
 “I have a better understanding of how to manage my
chronic pain. Very helpful class!”
So just what goes on in Living Well?
 6-week workshop, 2.5 hours per session
 Interactive peer-led groups of 10-16 people
 Facilitated by 2 trained peer leaders, most of whom are nonhealth professionals with chronic diseases or are caregivers
 Standardized participant materials and standardized training for
leaders
 Highly scripted to maintain fidelity to original program
 Free or low cost to participants
 Learn skills that complement clinical care
 Participants become active in managing their care
 DOES NOT replace existing programs or treatments
Living well workshop topics





Action Planning and Goal Setting
Problem Solving
Decision Making
Nutrition
Appropriate exercise for strength, flexibility, and
endurance
 Communicating effectively with family, friends and
health care providers
 Appropriate use of medications
 Techniques to deal with pain, fatigue, frustration
15
CDSME includes
Living Well with Diabetes (DSMP)
 Glucose monitoring, Complications specific to diabetes,
Information about medication specific to diabetes, Prevention of
low blood sugar, Skin and foot care, Exercise and maintaining a
balance of blood sugar
Chronic Pain Self-Management (CPSMP)
 Includes a movement component where people actively exercise
in the workshops
Thriving and Surviving (Cancer)
 Geared to cancer survivors and caregivers
 Activities are specific to cancer and include dealing with the
unknown, integrative cancer care, telling your family
16
Class Materials
17
Where are programs held?
Disease
Specific
Groups
Senior
Centers
Libraries
55+
Communities
Hospitals &
Other
Health Care
A
Faith-Based
Private
Industry
Housing
Facilities
Assisted
Living
Facilities
Action Planning
1. Something YOU want or decide to do (not what someone else thinks you should do, or that
you think you should do)
2. Achievable (something you can expect to be able to do this week)
3. Action-specific (for example, losing weight is not an action or behavior, but replacing snacks
with fruit between meals is; losing weight is the RESULT of actions)
4. Answer the questions:
 What? (specific action) (for example, walking or replacing junk food snacks with fruit)
 How much? (time, distance, amount) (for example, 30 minutes, or 4 blocks, or 1portion.)
 When? (time of day or which days of the week) (for example, after dinner or Monday,
Wednesday, Friday)
 How often? (number of days in the week) (for example, 3 times; avoid “every day”, if
something comes up, it’s better to have succeeded when you say you’ll do something 3
times rather than to feel you’ve failed if you’ve done it 6 times; you feel even better if you
do it 7 times when you’ve said you’ll do it 3 or 5 times!)
5. Confidence level of 7 or more (Ask yourself, “On a scale of 0=not at all sure to 10=totally sure,
how sure am I that I will complete the ENTIRE action plan?” If you rate your confidence below a 7,
you might want to look at the barriers and consider reworking your action plan so that it’s
something you are confident that you can accomplish. It’s important that you succeed!
Action Plan
1. Something YOU want or decide to do
2. Achievable
3. Action-specific
4. Answer the questions:
 What? (specific action)
 How much? (time, distance, amount)
 When? (time of day or which days of the week)
 How often? (number of days in the week)
5. Confidence level of 7 or more
Leader Training
 Peer Leaders receive 4 days of training; are trained by Master
Trainers
 Master Trainers receive 4.5 days of training from T-trainers
trained at Stanford
 Maryland has a cadre of Peer Leaders and Master Trainers
 Master Trainers also ensure fidelity to the program
21
CDSMP Facilitates the Triple Aim Goals
 Better Care: Improving the experience of care
 Better Health: improving population health
 Lower Cost: reducing per capita health care costs
Triple Aim
Triple Aim
Goal
Better Care
Better
Outcomes
Lower
Health Care
Costs
Baseline
Mean
12Month
Mean
%
Change
Communication with MD IMPROVED
2.6
2.9
9%
Medication Compliance IMPROVED
.25
.21
12%
Health Literacy IMPROVED
3.0
3.1
4%
Self-assessed Health IMPROVED
3.2
3.0
5%
PHQ Depression REDUCED
6.6
5.1
21%
Quality of Life IMPROVED
6.5
7.0
6%
Unhealthy Physical Days REDUCED
8.7
7.2
15%
Unhealthy Mental Days REDUCED
6.7
5.6
12%
% w/ ED Visits in the Past 6 Months
REDUCED
18%
13%
ratio
.68
Outcome Measure
Whitelaw, N., Lorig, K., Smith, M. L., & Ory, M. G. (March 19, 2013)
Financial Effects
HOSPITALIZATIONS
EMERGENCY ROOM VISITS
NET COST SAVINGS PER
PERSON (after program cost
of $350)
REDUCTION AT 6 MONTHS
ODDS REDUCED BY 32%
$390 PER PERSON
Calculating Potential Cost Savings
 Examined the pattern of health care utilization use
 Identified mean costs from national data (ageadjusted)
 Estimated costs saved from reduced utilization
 Estimated program costs in CDSMP Study
 Deducted program costs for net savings
 Extrapolated to national savings
 Considered study limitations (e.g., self-reported data,
generalizing from aggregated national data instead of
exact expenses, only included people with chronic
conditions)
Estimated Cost Savings Related to
Reduced ER Visits & Hospitalization
 Preliminary Results:
 ~$740 per person savings in ER and hospital utilization
 ~$390 per person net savings after considering
program costs at $350 per participant
 Reaching even 10% of Americans with one or more
chronic conditions would save ~$4.2 billion!
Future of Living Well
 Increase New Partnerships
 Provide space, purchase workshop materials, recruit participants
 Have your staff or volunteers trained as Peer Leaders to provide Living Well
workshops for your patients
 Have your staff or volunteers trained as Master Trainers, to train Peer
Leaders and monitor fidelity
 Designate a CDSMP Manager with several hours per week dedicated to
coordinating CDSMP activities
 Refer patients to CDSMP and DSMP workshops
 CDC Claims Study for Evidence Based Programs
 Medicare Reimbursement
 Center of Excellence
Living Well Center of Excellence
at MAC, Inc.
Center of Excellence
 Coordinating body for all CDSMP activity beginning
January 2015
 Grant pending to further develop the concept and
create hubs in Western, and Central/Southern
Maryland
 Center will hold the statewide license and work with
regional partners as sublicensees
 Will become the training hub for all of Maryland, i.e.,
coordinating trainings for Peer Leaders and Master
Trainers
 Community Health Workers are an integral part of the
Center of Excellence plan to address MCC
Center of Excellence Vision
 The goal of the Maryland Living Well Center of Excellence
(MLWCE) "Project Living Well" is to develop a coordinated,
cost saving, replicable model to empower people to
manage multiple chronic conditions (MCC) using Community
Health Workers (CHWs) to conduct evidence-based selfmanagement and falls prevention programs. The CHWs will
also serve as a formal interface between medical providers
and community resources, to reduce risk factors and reduce
needs for ER care and re-hospitalizations
Learn more
Visit the Living Well website at
dhmh.maryland.gov/livingwell/
(or search dhmh maryland living well)
Questions
Contact
Sue Vaeth
DHMH
[email protected]
410-767-8992
Shirley Guinn
Maryland Department of Aging
[email protected]
301-463-6215
Pam Toomey
Maryland Department of Aging
[email protected]
410-767-2157
Leigh Ann Eagle
MAC, Inc.
[email protected]
410-742-0505
www.dhmh.maryland.gov/livingwell/
References
 Whitelaw, N., Lorig, K., Smith, M. L., & Ory, M. G. (March 19, 2013).
National Study of Chronic Disease Self-Management Programs (CDSMP).
Retrieved April 8, 2013, from www.ncoa.org/cha
 National Council on Aging, Chronic Disease Self Management & PCMH
Fact Sheet, http://medhomeinfo.org/pdf/CDSMP%20PCMH%202pager%20Final.pdf