Community-based
Chronic Illness Management:
Strategies and Tools to Reduce
Costs and Improve Outcomes
April 5, 2010
Steve H. Landers MD, MPH
Brent T. Feorene, MBA
Director, Cleveland Clinic Center
for Home Care and Community
Rehabilitation
President, House Call Solutions
landers@ccf.org
bfeorene@housecallsolutions.com
Today’s Agenda
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Welcome and Introduction
Current trends
What is on the table?
Future tense
Programs that hold promise
CCF: Today and Tomorrow
Q&A
Powerful Trends Impact Medical
Practice
Aging Population
Technology
Chronic Illness
Consumer Expectations Economic Pressures
Demographic Imperative
Administration on Aging. A Profile of Older Americans: 2007. Accessed at www.aoa.gov
Activity Limitations
Administration on Aging. A Profile of Older Americans: 2007. Accessed at www.aoa.gov
Chronic Illness Epidemic
Johns Hopkins University, Partnership for Solutions. Chronic Conditions: Making the Case
for Ongoing Care, A Chartbook. September 2004 Update
Aging + Chronic Illness
Johns Hopkins University, Partnership for Solutions. Chronic Conditions: Making the Case for Ongoing
Care, A Chartbook. September 2004 Update
Costly
Congressional Budget Office
“High Risk”
2005 MCR FFS stats from MedPAC
DataBook June 2008
Johns Hopkins University, Partnership for Solutions.
Chronic Conditions: Making the Case for Ongoing
Care, A Chartbook. September 2004 Update
Readmissions
Half of Medicare Patients
Rehospitalized Without
Seeing Doctor After
Discharge
~60% of Rehospitalized
HF patients hospitalized
due to another problem
Jencks SF et al. N Engl J Med 2009;360:1418-1428
Physician Frustration
 “Train Wrecks” “Gomers”
 Frustration with the complexity, communication
barriers, and administrative burdens…
Adams WL, McIlvain HE, Lacy NL, et al. Primary Care for Elderly People: Why Do Doctors Find it So
Hard? The Gerontologist. 2002;42(6):835-42.
Adams WL, McIlvain HE, Geske JA, et al. Physicians’ Perspectives on Carring for Cognitively Impaired
Elders. The Gerontologist. 2005;45(2):231-9.
Quality Concerns
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“suffering in spite of spending”
“silo care” “no care zone”
avoidable readmissions
hospital acquired conditions
the “hidden patient”
frustration
What’s On the Table?
• Patient Centered Medical Home
• Bundled Payments
• Penalties for Re-hospitalizations
• “Accountable Care
Organizations”
Chronic Care is Different
• Engaging community
• Self-management support
• Advanced information systems/
tracking
Bodenheimer T, Wagner EH, Grumbach K. Improving primary
care for patients with chronic illness: the chronic care model,
Part 2. Jama 2002;288(15):1909-14.
‘New Model’ Primary Care
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Practice “Redesign”
Team Approach
Advanced Information Systems
“Patient-Centered”
“Healing Relationships”
14.
Martin JC, Avant RF, Bowman MA, et al. The Future of Family Medicine: a
collaborative project of the family medicine community. Ann Fam Med 2004;2 Suppl 1:S3-32.
Patient-Centered Medical Home
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Whole-Person
Team Based
Accessible
Advanced Information Systems
NCQA Certification Process
Kellerman R, Kirk L. Principles of the patient-centered medical home. Am Fam
Physician 2007;76(6):774-5.
The Case of Mrs. Jones
• 82 year old woman, h/o HF and
OOP
• “Tired and weak and swollen
ankles x 5 days”
• Walker, Oxygen, Son’s Assistance
Bringing Home Medical Home?
• Highest risk patients may not be able to
access offices
- Permanent
- During time of vulnerability
• Accessibility and whole person
approach enhanced when care is done
at home
• Scalability of team
Landers SH. The other Medical Home. Jama 2009;301(1):97-9.
“Secret Weapons”
Enhances view of patient and caregivers
Reduces barriers to care
Strengthens patient relationships
Avoids hazards of hospitalization
Costs less
Desired more
Enabling technology emerging
Workforce Estimates
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Annual FFS MCR HHA Visits > 110,000,000
Medicare Home Health FTEs >250,000
Annual FFS MCR Physician Visits < 2,000,000
Home Care Physician and Mid-Level FTE’s ?
Total Primary Care Physician FTEs ~270,000
Role for Home Health
Home health is likely the (only) truly scalable
infrastructure for improving quality and access for
the low-mobility, high risk Medicare beneficiaries
who drive the majority of program expenditures and
suffer the most---1st step in impacting quality for
this group may be conceptualizing home health as
THE central architecture/ platform to deliver
transitional, post-acute, and primary care/ chronic
care management for these individuals
Programs that hold promise
• Transitional Care
- Multi-level targeting patients with the
right provider at the right time
• House call programs
- Reserved for the frailest, most
complex patients
Technology in the form of EMR/EHR and telehealth among others is
not an absolute necessity, but has proven itself to be an excellent
enabler to improve productivity, reduce costs and enhance outcomes.
A Role for Chronic Care Management
Public
Health
Primary
Care
Acute
Care
Adapted from, “The Glide Path”
Kyle R. Allen, DO
Medical Director, Post-Acute and Senior Services
Summa Health System
Long-term
Care
High
Health
Capacity
Normal
Aging
Accelerated Loss of Health
Disability
Disease
Management
Chronic Care Management
Acute Event
Death
Time
Risk
Factors
• Obesity
• Hypertension
• Tobacco and • Rapid weight
alcohol
gain/loss
• Environmental • Hyperglycemia
• Hip fracture
• Stroke
• CHF
• COPD
• Incontinence
• Dementia
• Caregiver burnout
• IADL/ADL decline
Cumulative, inter-related risk factors require ongoing, coordinated care interventions.
Transitional Care
• Goal
- Ensuring a smooth transition for the
patient from one site or level of care
to another that meets goals of care
• Why?
- Limits of traditional disease and case
management in preventing adverse
events and unnecessary
utilization/costs
Rates of Rehospitalization within 30 Days after Hospital Discharge
Jencks SF et al. N Engl J Med 2009;360:1418-1428
Who to target?
• Community dwelling
• Admitted for ambulatory sensitive
conditions, such as COPD, CHF,
Diabetes, Pneumonia and Dementia
• Frequent flyers – two or more
admissions in the past six months to
one year
• Individuals currently enrolled in case
management
Patient Factors Contributing to Poor
Post-Discharge Outcomes
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Multiple conditions/therapies*
Functional deficits
Emotional problems
Poor general health behaviors
Poor subjective health rating*
Lack of support
Cognitive impairment**
Language, literacy and culture
Level I
• A health coaching model using RNs
- 25 – 30 patients per coach
- Not a “doing” model
• Lowest-intensity, lowest-cost model
• Target thirty day duration
• Enroll patients who are able to be
“coached” to effectively self-manage
through the transition
Level I
• Five Principals
- Medication self-management
- Nutrition management
- Patient health record
- Physician follow-up
- Red flag awareness
Level I
Process
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Health coach visits while I/P
- Introduce the program and gain acceptance
- Prepare patient and family for follow-up
Home visit
- One visit within 48 – 72 hours of discharge
- Structured
• Review the program in detail
• Environmental scan
• Medication reconciliation
• Review discharge instructions
• Introduce PHR
• Discuss physician follow-up
• Educate on red flags
Level I
Process
• Key follow-up phone calls
- 2 – 3 calls as needed
- Ensures compliance and continuity
- Modify plan
• Plan to call after major post-acute events
- Physician visit
- Home health/therapy
- Change in Rx regimen
- Graduation
Level II
• Use RNs in a more active model of care
• RN must balance “coach” and “do”
- Patient capabilities
- Support systems
• More extended time frames up to 6 months
• Criteria are the same as Level I, but add
- Significant ADLs/IADLs
- Psycho-social concerns
Level II
Process
• Builds on Level I activities
- RN visits while I/P
- Initial home visit within 48 – 72 hours
of discharge
- Key follow-up phone calls
• Coaches and provides care
• May need additional home visit(s)
• Graduation date can be extended based
on situation
Level III
• Highest level of intensity and care provision
using NPs and/or PAs
• A hybrid model, but weighted more toward
medical than nursing
• SNF-level patient able to remain community
dwelling
- Geriatric syndromes
- ADLs/IADLs
- Polypharmacy
• Risk loss of functionality and/or exacerbation
of chronic condition(s)
• Most likely to bridge “at-risk” period
successfully with effective, coordinated care
Level III
Process
• Builds on concept of Levels I & II
• Initial visit within 48-72 hours of
discharge from SNF or hospital
• Key follow-up phone call(s)
• Typical 30 days enrollment to
graduation
- Back to office-based practice
- Enrollment in house call program
House Call Program
• Provide a patient-centered medical home to frail,
low-mobility elderly
• Physician and NP serve as the patient’s inresidence PCP
- Primary care house calls
- Urgent care visits
• Collaborate with hospitalists on IP care
• Coordinate specialty care, ancillaries and other
health services, as needed
• Offer counseling and social service coordination
for patient and family/caregivers
House Call Programs
• Typical profile
- Difficulty getting to/from the PCP office
- Have not seen PCP in 12 -18 months
- ED most likely access point for healthcare
services
- 2+ deficiencies in ADLs
- Complicated, chronic medical conditions and
polypharmacy not likely responsive to other
programs
• Disruptive to PCP office flow
- Physical/facility issues
- Time and resource intensive
- Difficult to meet the full spectrum of patient’s
needs
What are the outcomes?
• Community-based chronic illness
management programs have
demonstrated positive outcomes
- Reduced utilization
- Lower costs
- Improved outcomes
• Health
• Quality of life/Goals of care
Transitional Care
• Eric Coleman, MD
• Randomized controlled trial of a Level I
program
• Outcomes
- Reduced readmissions
- Lower costs
• In use by over 135 health systems
nationally
House Calls
Montefiore Medical Center
Results for Medicare Advantage Enrollees
Initial Six
Mos.
Pre-HCP
CMO HCP Patients
Member Days
Total Hospital Days
Total Admits
Hospital Admit PPPY
Hospital Avg. LOS
Total SNF Days
Total SNF Admits
SNF Admit PPPY
SNF Avg. LOS
112
12,936
820.0
102.0
2.9
8.0
2,148.0
41.0
1.2
52.4
112
12,936
503.0
59.0
1.7
8.5
703.0
17.0
0.5
41.4
Absolute
Change % Change
(317.0)
(43.0)
(1.2)
0.5
(1,445.0)
(24.0)
(0.7)
(11.0)
-38.7%
-42.2%
-42.2%
6.0%
-67.3%
-58.5%
-58.5%
-21.1%
How are these programs paid?
Managed Care/Payer Perspective
• The economic incentives are aligned and
the programs produce positive ROI
- Montefiore
- Summa Health System
- Inspiris
- United
How are these programs paid?
Medicare FFS environment
• Programs’ downstream benefits
- Capacity management
• Avoided admission
• Reduced ALOS
• Less pressure on ED
- Fewer re- admissions
- Increased market share
• Provider professional billings
- Partial contribution
- MDs, NP & PAs
• Community agencies
Cleveland Clinic
Center for Home Care and Community Rehab
Today: Gaining a beach head
• System-wide recognition
- Oversight and Strategy Board
- Department of Home Care Physicians
• Services
- Mobile physician services
• Geriatric consults
• PCP
- Home care, hospice, home infusion, etc.
• Expansion of MPS
- First to a specific CCF member hospital in
development for 2010
Cleveland Clinic
Center for Home Care and Community Rehab
The future: Strategic tool for CCF
• Seamless delivery and coordination of care
- Regardless of location
- Regardless of age/time in life
• Care transitions
• New roles for home care staff
• Use of telehealth and remote technologies
Transitional Care Resources
• Eric Coleman, MD
- www.caretransitions.org
• National Transitions of Care Coalition
- www.NTOCC.org
• Better Outcomes for Older adults through Safer
Transitions (BOOST)
- www.hospitalmedicine.org/ResourceRoomR
edesign/RR_CareTransitions/CT_Home.cfm
House Call Resources
• American Academy of Home Care
Physicians
- www.aahcp.org
• American Geriatrics Society
- http://www.americangeriatrics.org/pro
ducts/positionpapers/housecall.shtml
Thank You
“The future belongs to those
who believe in the beauty of
their dreams”
- Eleanor Roosevelt