Monique Reese, ARNP, MSN, FNP-C, ACHPN, Vice President, Clinical Services and Chief Clinical Officer, Iowa Health Home Care Vicki Wildman, RN, MSN, Edu, Statewide Education, Integrated Chronic Care Disease Management Specialist Trainer IHS Spring Symposium 2011 Objectives Review the incidence and prevalence of chronic diseases Discover the importance of patient-centered care concepts List the components of Integrated Chronic Care Disease Management model List the positive outcomes to enhance clinical practice, increase quality and improve patient outcomes Describe the impact of decreasing re-hospitalization rates Purpose A Broken Healthcare System Envision a New Care Delivery System Embrace, Embark, and Succeed! A Year in the Life of a Patient 5 6 13 Social Workers Meds Hospital Admissions Physical Therapists Nurses Weeks SNF Care 2 22 5 37 6 Nursing Homes 19 5 Clinic Visits Months of Home Care 6 Community Referrals Source Johns Hopkins, RWJ 2010 (G Anderson) 2 Home Care Agencies 4 Occupational Therapists 16 Physicians “Patients 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) Incidence of Chronic Disease Total U.S. population 133 million Americans (45%) have one or more chronic diseases Source: Wu S, Green A. Projection of Chronic Illness Prevalence and Cost Inflation. RAND Corporation, October 2000. The Number of People With Chronic Conditions Is Rapidly Increasing Source: Anderson, G.; Chronic Conditions: Making the Case for Ongoing Care; Johns Hopkins University; November 2007 Epidemic of Chronic Diseases Increasing incidence of chronic disease Complexity of care Poor transitions Telehealth data: poorly controlled disease Lack of evidenced based care “Non compliant” patients Think of Your New Year’s Resolutions Are you non compliant? Cost of Chronic Disease People with chronic conditions are the heaviest users of healthcare services. The more co-morbid conditions the heavier the use. Potentially preventable 30-day readmission rates Initial condition Heart failure COPD Pneumonia AMI CABG PTCA Other vascular Total for seven conditions Total for all DRGs Percent of total Type of hospital admission Medical Medical Medical Medical Surgical Surgical Surgical Number of potentially preventable 30-day readmissions(in thousands) 139.2 85.1 86.4 30.5 26.6 68.2 30.0 Percent readmitted within 30 days* 19.1% 16.5 13.3 18.7 18.1 14.7 18.6 Average Medicare payment for readmissions $6,490 6,491 6,681 6,540 8,085 8,342 10,061 Total spending on potentially preventable readmissions(in millions) $903 552 577 199 215 569 302 465.9 $3,318 1,715.5 27.2% $12,008 27.6% *30-day readmission rates are calculated based on the set of cases that are potentially eligible for an initial readmission, thus they exclude readmissions and people that died in the hospital from the denominator. Source: 3M analysis of 2005 Medicare discharge claims data. COMMONWEATLH STUDY New England Journal of Medicine April 2009 FINDINGS: • 1 in 5 discharged patients are readmitted within 30 days • 50% of discharged patients are readmitted within 1 yr • In 2004, $17.4 billion was spent by Medicare in unplanned rehospitalizations So what about coordination? Chronic Disease Management is Becoming More Complex • Increased incidence of patients with multiple comorbidities • Elderly patients with age-related complexities • Fewer resources to care for an ever increasing number of patients all seeking care in an acute environment Is that how you feel? Non-adherence: Significant for those with chronic disease • Increase in number and length of acute care visits (25% of hospitalizations due to medication errors) • Increase in ED visits • Unnecessary changes in treatment • Overuse of scarce and expensive medical resources • Loss of productivity and decreased quality of life Additional Focus Area : Medication Non-Adherence •Lower for patients with chronic diseases •Lower medication persistence with chronic disease Low adherence = twice the healthcare expenditures Do Non-Adherent People Care Less About Their Health? NIH Grant - Meta analysis of studies related to health behaviors Included interviews with adherent and non-adherent patients Major difference: non-adherent patients had lower selfefficacy but cared just as much about their health Butterworth, Prochaska, Redding –NIH CDC Grant -1-ROI DP000103/DP CDC HHS/United States The State of Chronic Care Management • • • • • • • • Health care systems act as silos No uniform way to share knowledge Lack of care coordination Rushed practitioners Lack of active follow-up Pts inadequately trained to manage their illnesses Pts seeking care via ER visits & hospitalizations Integrating “The Best of the Best” Redesigned Care Delivery Models Evidenced Based Care Lessons Learned CMS Demo Projects 60 Years Experience New Healthcare Delivery Paradigm Disease Management Components Behavioral Management Redesigning Care Delivery • Current healthcare systems cannot do the job • Trying harder will not work • Changing care systems will work Wagner’s Chronic Care Model Informed, Activated Patient Prepared Prepared Practice Practice Team Team •Motivation •Information •Skills •Confidence •Patient information •Decision support •Resources Key Derivatives: Wagner’s Model Informed, Activated Patient Prepared Practice Team Vision of a Provider with Value Expert in care coordination Highly trained in behavior change techniques Competent communication & ability to share data Expert in disease specific guidelines and care “sought after” partner that brings value Facilitates effective transitions Shares responsibility for outcomes Home-Based Chronic Care Model High Touch Delivery Specialist Oversight Self-Management Support Technology Healthcare Providers Role: Explore Barriers to Change •Understanding •Financial constraints •Energy level (depression) •Support system •Problem solving ability •Relationship with healthcare provider •Importance and confidence •Ambivalence: Many patients simply lack confidence in their abilities and that contributes to ambivalence Technology to Support High Quality Chronic Care Comprehensive Assessments Examples: Re-hospitalization risk to identify high risk/ high cost patients PHQ-9 Assessments by disease Medication Risk Assessment Multi-faceted Fall Risk Assessment Evidence-based care plans High quality educational materials Example of Telehealth Unit Defining Care Transitions “ ‘Care transitions’ refers to the movement patients make between healthcare practitioners and settings as their condition and care needs change during the course of a chronic or acute illness.” Eric A. Coleman, MD, MPH Care Transitions ProgramSM Implications for Healthcare Delivery Coordination of care in the first 30 days critical Coordination of care is traditional role of homecare Developing a standard approach to care coordination should be a key strategic objective Homecare’s Unique Role in Transitions Comprehensive assessments Evidenced-based screening tools Interdisciplinary team assessments Interdisciplinary approach to care intervention Medication reconciliation Process & outcome measures ICCDM : Skills for effective health coaching in self mgt support & evidenced based guideline care “Patient is a puzzle” Community-Based Transitions Model™ (CBTM) Medication Management Early Follow-up Is patient familiar& competent AND have access Appt Scheduled within a wk AND able to get there Adherence & Persistence Change in RX or TX Symptom Management Comprehend S&S that require attention AND whom to contact Change in RX or TX Sustaining ICCM Job description expectations Performance Appraisals Training of all staff on ICCM Computer Based-Learning training Demonstration of skills Competency of skills Case conference meetings Certification Certification Course Content Self-Management Support Concepts Working collaboratively with patients Behavior change theories and tools Adult Learning Evidence-based guidelines as they relate to disease self-management Use of telehealth and technology to support care Transitions of care Health literacy Showing an Improvement Data collection of outcomes Data collection of process measures Tracking certification Tracking use of tools Bringing All Concepts Together Multidisciplinary Case Conference Physician ST PT OT ICCM Team Leader Model Champion RN NCM SW CPSPC Telehealth Pharmacist Training Curriculum Making the Case for Integrated Chronic Care Principles of Adult Education and Health Literacy Problem Solving 101 Evidenced-Based facilitation of Behavior Change Theory –Based Telehealth Integrated Care Transitions Model Implementation into Practice Computer-Based Modules Evidenced-based training: Heart Failure Chronic Obstructive Lung Disease Diabetes Depression Each module contains: Pathophysiology/ incidence Treatment Modalities Self Management Support Behaviors Each module contains: Pathophysiology/ incidence Treatment Modalities Self Management Support Behaviors Vision : Develop Strategies to Achieve Proactive follow-up Leadership support Guidelines Planned visit Provider participation Provider education Visit system changes Expert support Delivery System Design Health System Organization Self-Management Support Links to Community Resources Patient activation Self-management assessment Self-management resources Guidelines to patients Decision Support Clinical Information Systems Telemonitoring Guidelines embedded Dashboard Source: Pearson, M. et. al. Chronic Care Model Implementation Emphases, Rand Health Presentation to Academy Health Meeting, 2004 Best Outcome for Every Patient Every Time Home Health will be a recognized leader in providing patient-centered, expert, quality care in the comfort of home. QUESTIONS?