Caring for Older Persons with Multiple Chronic Conditions
Chad Boult, MD, MPH, MBA
Director, Improving Healthcare Systems,
Patient-Centered Outcomes Research Institute
Leyden Academy on Vitality and Ageing
9 April 2013

Hans Nijpels
79 year old widower
Retired teacher, lives alone
Income: small pension
Daughter lives 10 km away, has three teenagers
Five chronic conditions
Three physicians
Eight medications

6 community referrals
22 scripts 8 meds
2 home care agencies
5 months homecare
2 nursing homes
Mr.
Hamond
19 outpatient visits
3
6 weeks subacute care hospital admissions

Mr. Nijpels
Confused by care, meds
Gets discouraged
Self-care is poor
Mr. Nijpels’ daughter
“Stressed out “
Reduced work to half-time
Considering nursing homes

Fragmented
Discontinuous
Difficult to access
Inefficient
Unsafe
Expensive

The ¼ of older persons who have
4+ chronic conditions account for
80% of health care spending
0
1%
1
3%
2
6%
3
10%
4
12%
5+
Conditions
68%

“Every system is designed perfectly to produce the results it gets”
Donald Berwick, MD

Chronically ill population
Health care system designed to provide acute care

“We simply cannot afford to postpone health care reform any longer.
We must attack the root causes of the inflation in health care.”
Barack Obama
June 2, 2009

Health System
Health Care Organization
Community
Resources and
Policies
Self-
Management
Support
Delivery
System
Design
Decision
Support
Clinical
Information
Systems
Informed,
Activated
Patient
Productive
Interactions
Prepared,
Proactive
Practice Team
Chronic Disease Self-Management,
Caregiver Support,
Action Plan
Improved Outcomes
Monitoring
Coaching
- T Bodenheimer et al
JAMA , 2002

Literature review to identify recent innovations in chronic care that have shown promising results
Rank the promising models’ potential for
“diffusability”

Literature search: Medline,1987-2011
Tabulation of evidence for promising models
Classification of the strength of the evidence
Consensus ratings of models’ diffusability

2,714 titles identified
305 abstracts read
131 articles read
51 articles added from bibliographies
123 articles met inclusion criteria
2,409 excluded
174 excluded
59 excluded

10 Successful Diffusable Models
Model
APN-physician team
(for dementia pts)
IDT (for CHF)
Guided Care (for multimorbid pts)
Care mgmt (for CHF)
Pharmaceutical care
Self-management training
Proactive rehabilitation
Caregiver support/education
Improves health care quality or outcomes
Improves health care efficiency
Diffusability score (6-30)
1 cluster RCT None 19
1 meta-analysis
2 reviews
1 cluster RCT
1controlled trial
3 RCTs
4 RCTs
1 meta-analysis
9 RCTs
4 RCTs
1 meta-analyses
1 RCT
1 meta-analysis
2 reviews
1 cluster RCT
1 controlled trial
3 RCTs
2 RCTs
4 RCTs
2 RCTs
2 meta
analyses
2 RCTs
25
23
21
19
24
19
19

Successful Diffusable Models
Model
Transitional care
APN-physician dyads
(for NH residents)
Improves health care quality or outcomes
1 meta-analysis
1 RCT
3 quasiexperimental studies
Improves health care efficiency
Diffusability score
(6-30)
1 meta-analysis
2 RCTs
3 quasiexperimental studies
20
21

Four types of successful, diffusable models:
Primary care by interdisciplinary teams
Adjuncts to traditional primary care
Transitional care
Dyadic care of residents of nursing homes
“Successful Models of Comprehensive Care for Older Adults with Chronic Conditions”
IOM “Re-Tooling for an Aging
America” report, 2008
- Boult et al. J Am Geriatr Soc, 2009

Comprehensive Care for Persons with
Chronic Conditions
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

Assesses needs and preferences
Creates an evidence-based “care guide” and a patient-friendly “action plan”
Monitors the patient proactively
Supports chronic disease self-management
Smoothes transitions between care sites
Communicates with providers in EDs, hospitals, specialty clinics, rehab facilities, home care agencies, hospice programs, and social service agencies in the community
Educates and supports caregivers
Facilitates access to community services
Boyd C et al. Gerontologist, 2007

All
Patients
Age 65+
25%
High-Risk
Review previous year’s insurance data with PM software 75%
Low-Risk

13,534 Patients of 14 teams/49 physicians
3,383 (25% highest-risk)
485 in seven
Guided Care teams
904 = Consenting Patients
(Baseline Evaluation)
Random
Allocation
419 in seven
Control teams
Boult C et al. J Gerontology, 2008

Age
Race (% white)
Sex (% female)
Education (12+)
Living alone
Chronic conditions
Risk of utilizaton
ADL difficulty
Guided Care Usual Care
77.2
78.1
51.1
54.2
48.9
55.4
46.4
32.0
4.3
2.1
30.9
43.4
30.6
4.3
2.0
*
29.3

PACIC
2.1
AGGREGATE
1.3
Activation
1.3
Problem Solving
1.5
Decision Support
1.8
Coordination
1.5
Goal Setting
0 1 2 aOR
3
Quality rated in the highest category on PACIC
Boyd et al. J Gen Intern Med, 2009
4

Wolff et al. J Gerontology Med Sci, 2009

0,6
Guided Care Physicians (n=18)
Usual Care Physicians (n=20)
0,4 P = 0.014
P = 0.042
P = 0.148
0,2
P = 0.079
P = 0.182
0,0
-0,2
-0,4
-0,6
Patient/family communication
Clinical knowledge of patients
Helps make appointment for referral visit
Written info sent to specialists
Useful info received from specialists
Marsteller et al. Ann Fam Med, 2010

GCNs' Satisfaction with Clinical
Activities
Very satisfied
Satisfied
Somewhat satisfied
Somewhat dissatisfied
Dissatisfied
Very dissatisfied
6
5
4
3
2
1
1 2 3 4
Satisfaction Items
5 6
Satisfaction Items
1= Familiarity with patients
2= Stability of patient relationships
3= Comm. w/ patients; availability of clinical info; continuity of care for patients
4= Efficiency of office visits; access to evidence based guidelines
5= Monitoring patients; communicating w/ caregivers; efficiency of primary care team
6= Coordinating care; referring to community resources; educating caregivers
7= Motivating patients for self management
7

“The best job I’ve ever had”
“I love this role.”

Guided Care Nurse
Salary
Benefits (@ 30%)
Travel (to pts’ homes, hospitals)
Communication services
Internet, cell phone
Equipment (amortized over 3 years)
Computer
Cell phone
TOTAL
$71,500
21,450
588
1,800
500
67
$95,905

(per caseload, 55 patients)
GC – UC
Difference
Average
Expenditure
Cost
Difference
Hospital days -76.1
$1,519/day -115.6
SNF days
Home health episodes
Physician visits
-99.1
-20.1
40.0
$305/day
$1331/episode
$41/visit
-30.2
-26.8
1.7
--------Gross savings
Cost of GCN
NET SAVINGS ---------
-170.9
95.9
-75.0
Leff et al. Am J Manag Care, 2009

st
20
10
0
-10
-20
-30
-40
-15%
-21%
* *
-17%
8%
-7%
9%
-50
-49%
-47%
-52%
-60
Hospital admits
Hospital re-admits
Hospital days
SNF admits
SNF days
ED visits
Primary care visits
Specialist visits
Home health episodes
Boult et al. Arch Intern Med, 2011

• Guided Care: a New Nurse-Physician
Partnership in Chronic Care (Springer
Publishing Company)
• Online course for registered nurses
• Online course for physicians and practice leaders
• Orientation booklet for patients www.GuidedCare.org/adoption.asp

For patients with several chronic conditions, interdisciplinary primary care can improve care and reduce costs, especially in wellmanaged systems of care.
Primary care physicians of the future may practice in new team-based models of care.