Hongdao Meng, PhD, University of South Florida
Dianne V. Liebel, RN, PhD, University of Rochester
Brenda R
R. Wamsley,
Wamsley PhD,
PhD West Virginia State University
Acknowledgements
g
 Funding Agencies:
 Centers for Medicare and Medicaid Services (CMS)
 Office of Rural Health Policy/HRSA
 Research Team:
 Gerald M.
M Eggert,
Eggert PhD,
PhD Director,
Director Monroe County Long Term Care





Program, Inc.
Brenda R. Wamsley, PhD, Director, Center for Aging and Healthcare
in West Virginia,
Virginia Inc.
Inc & West Virginia State University
Bruce Friedman, PhD, University of Rochester
David Oakes, PhD, University of Rochester
T. Franklin Williams, MD, Monroe County Hospital
Staff members at the two study sites: Dianne Liebel, RN, PhD,
Ethan Corona,, PhD candidate,, Deanna Lewis,, MS,, Rowena
Sizemore, MSW, and many others…
Outline
 Background
 Rationale and Study Design
 Results:




 Total health care expenditures
 Discussion
Di
i
Background
 Trend in aging and demographic change
 Aging of the baby boom generation and beyond.
 Trend in disability
 NHANES data
d t suggested
t d th
thatt b
both
th ADL and
d IADL
disability increased between 1994‐2004 (Seeman 2010).
 The absolute number of individuals with
d bl
disabilities
is expected
d to increase.
Background
%p
 The 12%
patients with 33+ chronic conditions
accounted for one‐third of all Medicare spending.
 Evidence is mixed regarding the effectiveness and
costs of disease management/health
g
/
p
promotion
interventions
 Policymakers have been interested in:
 Ways
y to improve
p
patient
p
outcomes
 Ways to rein health care expenditures
The Medicare Demonstration
 Primary and Consumer‐Directed Demonstration (PCDC)
 A community‐based experiment: "A Randomized
Controlled Trial of Primary and Consumer‐Directed Care for
People with Chronic Illness.
Illness ”
 $16 million over 4 y
years (1998‐2002)
99
 Two study sites: upstate New York and West Virginia/Ohio
border
 Two interventions:
 Health promotion nurse (HPN)

CLINTON
FRANKLIN
ST. LAWRENCE
JEFFERSON
ESSEX
LEWIS
HAMILTON
WARREN
WASHINGTON
OSWEGO
NIAGARA
ORLEANS
MONROE
WAYNE
ONEIDA HERKIMER
FULTONSARATOGA
GENESEE
ONONDAGA
ONTARIO
MONTGOMERY
CAYUGA
SCHENECTADY
MADISON
RENSSELAER
SENECA
LIVINGSTON
CORTLAND
YATES
SCHOHARIE
ERIEWYOMING
OTSEGO
TOMPKINS
ALBANY
CHENANGO
SCHUYLER
ALLEGANY STEUBEN
CATTARAUGUS
CHAUTAUQUA
COLUMBIA
TIOGA
CHEMUNG
GREENE
BROOME DELAWARE
ULSTER DUTCHESS
SULLIVAN
PUTNAM
WES
CHESTER
ROCKLAND
ORANGE
BRONX
NEW NASSAU SUFFOLK
YORK
QUEENS
KINGS
RICHMOND
Rationale for the HPN intervention
 Health promotion and disease management:
 The transtheoretical model (TTM)



Stages of change (Prochaska & DiClemente 1992)
Patient empowerment
Self‐efficacyy enhancement (Bandura
(
1977)
977)
 Goals:
 Improve health and physical function
 Reduce demand for medical care
Study Design
 2 x 2 Factorial Design:
 Two factors (HPN
)
 Two
T levels
l l (Present
(P
t or Ab
Absent)
t)
 Sampling:
 Convenience sample from the communities
 Stages:
 Screening
 Randomization and enrollment
 Intervention
 Follow‐up
p (at 22 months)
Sample
c us o C
te a:
 Inclusion
Criteria:
 Enrollment in Medicare Parts A and B
 Needing or receiving help for


2+ ADLs
ADL (A
(Activities
ti iti off D
Daily
il Li
Living)
i ) or
3+ IADLs (Instrumental ADL)
 Recent health care utilization (ER, hospital, nursing home, or
M di l h
Medical
home health)
h lth)
 Exclusion Criteria:
 Living in a nursing home
 Enrollment in an HMO
 Enrollment
E ll
t in
i M
Medicaid
di id h
home and
d community‐based
it b d waiver
i
programs
 Receiving Medicare Hospice or End Stage Renal Disease
(ESRD) benefits
b
fit
The Intervention
p
 Components
of the HPN intervention:
 Patient education
 Monthly home visits
 Consumer Self‐Care Strategies and Health‐wise for Life handbooks
 Telephone consultation
 Individualized health promotion and disease self‐management
self management coaching
 PRECEDE health education planning model (Green & Kreuter, 1991)
 Personalized goal‐setting
 Medication management
 Physician care management
 Physician‐Patient‐Caregiver‐Nurse Planning Conferences
 Snapshot Reports
 Community resources
Data
 Baseline interview data
 Demographics: age, gender, ethnicity, education,
income, marital status, informal caregiver status
 Health and functional status:
status ADL
ADL, IADL
IADL, cogniti
cognitivee
status, SF‐36, number of chronic conditions
 Prior health care utilization
 Health care utilization data from a weekly diary
 Acute and post‐acute care:
 physician office visits
 hospital and ER visits (verified with providers)
 post‐acute nursing home visits (verified with providers)

data on prescription drug use were not collected
 Long‐term care
Outcome Measures:







 Total
T l h
health
l h care expenditures
di
Statistical Analyses







 Cost outcome: Generalized Linear Model (GLM)
Generalized Linear Model
(GLM)
p
p
 The dependent
variable is a member of the exponential
family of distributions.
E (Y )    g 1 ( X  )
 The variance of the dependent variable is a function of its
mean.
V (Y )  V (  )  V ( g 1 ( X  ))
Var
 Classical ordinary least squares model can be treated as a
special case of GLM with identity link function.
g ( )  
 GLM with log‐link.
g (  )  ln((  )
Descriptive Statistics
Table 1. Summary of Attrition Rate by Treatment
Control
HPN
Initial Sample
384
382
Mortality
18%
18%
Drop-out**
14%
20%
** P<0.01
Figure 1. Intervention (HPN) Effect on Monthly Total Expenditures†
1200
10411051
1000
Expenditures ($)
800
766
737
698
603 573
600
597
360
400
228
200
140
68
10
0
-30
-200
Prior Medicare
Medicare
-132
Non-Medicare
-400
Control
Intervention
Medicare +
Intervention
Total
Difference
Note: Expenditure estimates were obtained from the predictions of the GLM model.
The model adjusted for the following variables: intervention condition, age, gender, ethnicity, living arrangement, caregiver status,
baseline ADL/IADL, cognitive status, angina, congestive heart failure, myocardial infarction, stroke, COPD, arthritis, diabetes,
prior ER, hospital, nursing home and skilled home health care use, prior Medicare expenditures, BMI level, study site, and rural status.
†: exclude expenditures on prescription medications
Figure 22. Intervention (HPN) Effect on Monthly Expenditures,
Expenditures by BMI Level
750
654
Expendittures ($)
550
350
261
105 87
150
00 111
100
71
-50
-250
-93
Underw eight
-165
-252
Normal
-72 -58 -62
Overw eight/obese
-224
-341
-450
Prior Medicare
Non-Medicare
Total
Medicare
Medicare + Intervention
Summary of Key Findings (HPN)

 The HPN intervention
was cost
neutral.
 The HPN intervention was associated with lower total
expenditures among underweight beneficiaries.
Limitations
 Attrition rate was high
h h
 Regional sample, very few minorities
 Mixed results across different outcome
measures
Policy
o cy Implications:
p cat o s
based experiments are time
 Large scale community
community‐based
time‐
consuming and resource‐intensive.
 Lack of ability to track patient across providers and care
settings for fee‐for‐service beneficiaries
 The HPN intervention appeared to be effective in
improving functional outcomes without increase
totall health
h l h care expenditures.
di
 More
M
research
h is
i needed
d d tto improve
i
the
th design
d i off
health promotion & disease management
interventions for Medicare beneficiaries with multi
multi‐
morbidities.