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?