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  • The video is powerful and so are the growing trends. Chronic disease is pervasive throughout our population Enormous toll on individuals, families and the health care system While chronic disease is a growing problem for all Americans, in our Beyond 50 Report, we’ve focused on the 50+
  • The number of chronic conditions grows are we age As our population ages, this will continue to put an significant strain on the system and our resources
  • In just 5 years, the number of beneficiaries with 5+chronic conditions increased by 20% (Thorpe and Howard) Diabetes, heart disease and cancer continue to threaten lives and well-being The next slide shows how dramatically it increases with # of conditions.
  • More Medicare money is spent on increasingly sicker patients We have minimal returns on our investment in the health care system today
  • Chronic disease—and the increasingly complexity of dealing with many diseases at once—drives up expenditures. While only 50% of the people are 3% of expenditures, 22% of costs are spent on 22% of the people While chronic disease makes the situation even graver Implementing models that improve its management provides us with an opportunity to make changes that will benefit everyone living with chronic disease—of all ages.
  • TRANSITION—In our studies, we looked at the toll placed on both the individual and the caregiver We conducted national quantitative and qualitative studies—reviewed secondary research to gain clear understanding Complete findings in Beyond 50 Report Transitions and communication are key issues
  • Quality suffers from the lack of coordination in the transitions, lack of communication between the doctors and providers
  • The two national surveys were independent samples – the respondents in first survey were not linked to the respondents in the second.
  • The Patient Activation Measure was developed by Professor Judith Hibbard and colleagues. PAM has been used in other recent studies. Based on expert review, scores from the PAM for caregivers appeared consistent with previous research findings, which have validated the PAM for people with chronic conditions.
  • This will hit highlights of some of the highlights in the papers in the report itself -- for stimulate interest and discussion.

"Through the Looking Glass" "Through the Looking Glass" Presentation Transcript

  • Looking Through the Looking Glass: Opportunities for Nurses with Geriatric Competencies Susan Reinhard, RN, PhD, FAAN Connecting the Dots: Geriatric Nursing, Education, and Clinical Simulation April 2, 2009
  • Focus
    • Preparing the New Nursing Workforce
    • Health Care Reform in the US: Opportunities for Nurses with Geriatric Competence
    • Chronic Diseases: Nurses in the Lead
    • Competencies
      • Institute of Medicine
      • Working with Family Caregivers
      • Working with unlicensed assistive personnel
    • Centers to Champion Nurses in America
  • Preparing the New Nursing Workforce
    • Chronic Conditions, all ages
    • Acute Care is a “slice of life”
    • Person and family-centered care is what we need to really change the frame for HC costs and delivery
    • … the Nursing Model: Humans (Person), Environment, Health, Nursing
  • So….
    • Hospital-based care is a critical slice..a sentinal event
    • Can use as a starting point to “change the trajectory” of a chronic illness (Strauss, 1970s; Naylor 2009)
    • Nurses must focus on Humans , across settings
      • We will pay for care across settings
      • Bundled payments, episodes of care
  • Current Health Care System
    • Could not be designed worse for current needs of humans/society
    • Educational system for preparing nurses parallels this acute care, non-functional system
    • We (the national and the world) must change how we deliver care
      • US behind many countries
    • Changing education of nurses is a true challenge for faculty, universities, funders, regulators
    • Need manufacturers, innovators, educators
  • Challenges
    • Need to place human simulations into real world context
      • Homes, as well as institutions
      • Cultural contexts
    • It is possible for simulations to do this—to go beyond high-tech, pharmaceutical solutions?
    • How will we program life-long coping, attention to trajectories, personal responsibility, cultural exchanges?
    • Limits of short-term education of nurses…need for life-long learning
  • Health Care Reform in the US
  • Looking Back: Gauging the Future What’s different from 1993-94 to produce a more compelling platform for change?
    • Costs are much higher
    • Employer-sponsored coverage eroding and unemployment up
    • Business and providers now more open
    • Many more uninsured
    • Primary care in crisis; Massachusetts reinforced
    • Quality measures: major performance issues
    • Geographic variation; 30% costs questioned
    • Agreement on common elements this time :
        • Delivery reform
          • Focus on chronic care; Nurse-led, evidenced based reforms elevated
          • Team-based/Episode of illness care, where possible—geriatric competence key
          • “ Medical Home”/Health Care Home
          • Emphasize prevention
          • Primary care/workforce—Nursing!
    State of Play
    • Agreement on common elements :
        • Reimbursement reforms in Medicare
          • Replace SGR—Physician Payment Reform? Consequences for advanced practice nurses?
          • Move from fee-for-service to “blended” reimbursement
          • Pay for performance; pay for value (cost in relation to quality)
          • Start to address geographic variations (What does nursing have to say?)
    State of Play
    • President Obama and key Committee Chairs all agree on health care policy direction –in general
      • e.g. Baucus’ 85-page “vision”
      • We’re all on “Massachusetts Avenue”
    • White House Forum on HC Reform
    State of Play
    • Agreement on common elements :
        • Governance structure
          • Federal standard as minimums
          • National oversight through a “Federal Reserve Board” model
          • Limited congressional intervention or review
          • State-based “Connectors”
    State of Play
    • Important HC players in Congress are generally on the same page, but many key issues remain :
      • Overarching policy issues
      • Delivery reforms: How to improve Value
      • Insurance coverage: How to include all?
      • Health promotion: How to change behavior?
      • Financing: How to pay?
    State of Play
        • Financing
          • Several sources under consideration
          • will need $1.5 trillion over 10 years
        • Public Plan option
        • LTC
    Remaining Challenges
  • What are the Chances?
    • Health Reform is KEY to our long-term economic health
    • The nation cannot afford another failure
    • “ Perfect is the enemy of the good”
    • Working together: We can.
  • Chronic Disease: Opportunities for Nurses
    • Chronic illnesses affect people of all ages in our country
      • 125 million had 1+ chronic conditions in 2000—will grow to 157 million by 2020
      • 30 states have obesity prevalence of 25%+ across population
      • Greatest number of people with chronic conditions are working age with insurance
    • Strains the system—acute care system not designed for chronic care
  • Many Older Americans Have Multiple Chronic Conditions Source: AARP. “Beyond 50.09: Chronic Care: A Call to Action for Health Reform.” Washington, DC. 2009
  • The Burden on Medicare
    • Number of beneficiaries with 5+ conditions increased from
    • 30% in 1997
    • to more than 50% in 2002
    Source: Thorpe and Howard, “The Rise in Spending Among Medicare Beneficiaries”, Health Affairs, August 22, 2006
  • Health Spending Increases with the Number of Chronic Illnesses Source: AARP. “Beyond 50.09: Chronic Care: A Call to Action for Health Reform.” Washington, DC. 2009
  • Good Chronic Care Management Key to a Large Segment of Cost Percent of Population 100% 20 40 60 80 20% 40% 60% 80% 100% 0% 3% of costs for 50% of people 22% of costs for 1% of people % Health Care Dollars Spent SOURCE: Conwell & Cohen, Agency for Healthcare Research and Quality, Statistical Brief #73, March 2005
  • AARP Public Policy Institute Report on Chronic Care
    • Transitions are risky
      • Nearly 20% care recipients and 25% caregivers said transitions not well coordinated
      • 15% care recipients and 32% caregivers reported readmissions within 30 days of discharge
    • Communication is problematic
      • 21% of patients said providers did not communicate with each other and 20% said their health suffered as a result
      • 24% received conflicting information from 2+ providers
    Source: AARP. “Beyond 50.09: Chronic Care: A Call to Action for Health Reform.” “Washington, DC. 2009 publication forthcoming.
  • Top Findings
    • Quality suffers
      • 23% reported medical errors; 61% of which were major
      • 16% endured unnecessary tests and 13% unnecessary hospitalizations
      • 27% did not do something recommended—32% said because they disagreed with the provider
    • Patient and caregiver engagement is critical
      • People not engaged were more likely to report health worsened because they did not get help they needed
      • Quality problems were more likely among caregivers who felt less capable
    Source: AARP. “Beyond 50.09: Chronic Care: A Call to Action for Health Reform.” “Washington, DC. 2009 publication forthcoming.
  • Patients Report Problems with Transitions
    • The most frequently reported issues around transitions between hospitals (and other health care facilities) and home were:
      • Loss of mobility and/or independence
      • Uncertain expectations for recovery and/or prognosis
      • Pain
      • Anxiety
      • Not remembering their clinician’s instructions
      • Feeling abandoned
    Source: AARP. “Beyond 50.09: Chronic Care: A Call to Action for Health Reform.” “Washington, DC. 2009 publication forthcoming.
  • Caregivers Report Problems with Transitions
    • The most frequently reported issues around transitions between hospitals (and other health care facilities) and home were:
      • Finding resources, such as medical equipment and services
      • Arranging for assistance in and around the home, both paid and unpaid
      • Communication with doctors and other health professionals
      • Finances/affordability
  • Caregivers Report Problems with Transitions (continued)
    • The most frequently reported issues around transitions between hospitals (and other health care facilities)
      • Uncertain expectations for their relative’s or friend’s recovery and/or prognosis
      • Managing their relative’s or friend’s expectation
      • Not enough time for competing demands (e.g., care coordination, job, children, self)
      • Stress/emotional strain/guilt
  • “David”
    • an 82-year-old Richmond caregiver caring for his wife, 64, who has terminal cancer and dementia…
    • “ They don’t assist on the transition home. You have to be tough, be an advocate… I’d like somebody to tell me what’s available. I don’t know.”
    Source: AARP. “Beyond 50.09: Chronic Care: A Call to Action for Health Reform.” “Washington, DC. 2009 publication forthcoming.
  • “ Joanne”
    • is a 79-year-old Philadelphia caregiver…
    • “ We don’t know what we don’t know.”
    Source: AARP. “Beyond 50.09: Chronic Care: A Call to Action for Health Reform.” “Washington, DC. 2009 publication forthcoming.
  • Focus Group Findings…
    • Many individuals and caregivers felt that the “ball
    • was dropped” after discharge.
    Source: AARP. “Beyond 50.09: Chronic Care: A Call to Action for Health Reform.” “Washington, DC. 2009 publication forthcoming.
  • Focus Group Findings…
    • Many patients, especially those newly diagnosed or discharged from a health care facility for the first time, and caregivers did not know what to expect, where to find resources, or what services they would need, either in terms of health care or support services
    Source: AARP. “Beyond 50.09: Chronic Care: A Call to Action for Health Reform.” “Washington, DC. 2009 publication forthcoming.
  • Overview: Beyond 50.09 Survey
    • AARP Public Policy Institute conducted two national opinion surveys to learn more about chronic illness from the consumer perspective.
    • Surveys targeted:
    • (1) people (ages 50+) with selected (more serious) chronic conditions who had at least one serious health episode, and received care from a health care facility in the past three years, and
    • (2) caregivers (ages 45+) of people who needed assistance, had a serious health episode, and received care from a health care facility within the past three years.
    Source: AARP. “Beyond 50.09: Chronic Care: A Call to Action for Health Reform.” “Washington, DC. 2009 publication forthcoming.
  • Patient Engagement
    • Studies suggest that people who are more knowledgeable, skilled, and confident about handling their chronic conditions, whom we refer to as “engaged”, are better able to manage their own care, promote their own health, and make better decisions affecting their condition.
    Source: AARP. “Beyond 50.09: Chronic Care: A Call to Action for Health Reform.” “Washington, DC. 2009 publication forthcoming.
  • Patient Activation Measure (PAM)
    • Patient Activation Measure (PAM) captures the extent to which patients feel engaged and confident in taking care of their condition.
    • The PAM for people with chronic conditions has been tested and validated repeatedly (Hibbard et al. 2004)
    • The PAM for caregivers was adapted for first-time use in our caregiver survey.
    • The caregiver PAM asks about the caregiver’s knowledge, skill, and confidence for managing the health of the care recipient – the level of ability or competence as a caregiver
    Source: AARP. “Beyond 50.09: Chronic Care: A Call to Action for Health Reform.” “Washington, DC. 2009 publication forthcoming.
  • Beyond 50.09 Survey Results…
    • People who were not engaged were more likely to report that their health got worse because they did not get the health care they needed
    • Caregivers support people with greater use of health services
    • Quality problems were more likely among caregivers who feel less capable
  • Chronic Care Delivery Needs to Change
  • IOM Report…
    • The Institute of Medicine’s 2001 report Crossing the Quality Chasm: A New Health System for the 21st Century presented four areas where health care should be redesigned to organize care around patients’ needs:
      • Care should be based on continuous health relationships;
      • Care should be customized based on patients needs and preferences;
      • Patients should be the source of control; and
      • Knowledge should be shared and information should flow freely.
    Source: Institute of Medicine (IOM). Crossing the Quality Chasm: A New Health System for the 21 st Century. Washington DC: National Academy Press, 2001.
  • Ideal Elements of Quality Chronic Care
    • Important components of what is generally agreed to be good chronic care management are found in Wagner’s the Chronic Care Model (CCM)
    • Six components of CCM:
        • Self-management support
        • Community resources
        • Organization of health care
        • Interdisciplinary teams
        • Decision support
        • Clinical information systems
    Source: AARP. “Beyond 50.09: Chronic Care: A Call to Action for Health Reform.” “Washington, DC. 2009 publication forthcoming.
  • Examples of Successful Chronic Care Models
    • The Care Transitions Intervention – funded by the Hartford Foundation and based at the University of Colorado
      • This program provides individuals and their caregivers with tools and support to encourage them to participate more actively in their care transitions
    Source: AARP. “Beyond 50.09: Chronic Care: A Call to Action for Health Reform.” “Washington, DC. 2009 publication forthcoming.
  • Examples of Successful Chronic Care Models
    • Transitional Care Model (TCM)
      • The model targets older adults with no cognitive impairment who have two or more risk factors, such as poor self-health ratings, multiple chronic conditions, or a history of recent hospitalizations. The heart of the model is the master’s-prepared advanced practice transitional care nurse who is well versed in national standards of care delivery and experienced in providing comprehensive care and acute and community-based services. (Naylor, 2006)
    Source: AARP. “Beyond 50.09: Chronic Care: A Call to Action for Health Reform.” “Washington, DC. 2009 publication forthcoming.
  • Policy Recommendations
    • Better Knowledge
      • Expand testing of care delivery models to find out what works
      • Include best practices from chronic disease care in clinical preparation and training
      • Engage patients by giving them information they will understand and act on
      • Support family caregivers and engage them as partners with professionals
      • Encourage wise use of pharmaceuticals in managing chronic conditions
      • Improve research on disparities and dissemination of information in this area
    Source: AARP. “Beyond 50.09: Chronic Care: A Call to Action for Health Reform.” “Washington, DC. 2009 publication forthcoming.
  • Policy Recommendations
    • Better Tools
      • Increase use of health information technology
      • Develop better tools for patients to manage their conditions
    • Better Incentives
      • Make innovative changes to payment policy
      • Maximize use of the health care workforce
      • Make medications and preventive care affordable
    Source: AARP. “Beyond 50.09: Chronic Care: A Call to Action for Health Reform.” “Washington, DC. 2009 publication forthcoming.
  • Competencies to Support Caregivers
    • Caregiver as Client and Provider
    • Competencies needed to support family caregivers, and methods to develop them
  • Importance of Informal Caregiving
    • Family caregivers bulwark of LTSS
      • help with essential daily activities
      • perform many medically-oriented tasks
      • serve as translators, navigators, care coordinators, advocates, and more
    • Economic value of caregiving estimated at $375 billion
  • Importance of Informal Caregiving
    • Delays or prevents the use of nursing home care
    • Is associated with shorter hospital stays and fewer readmissions
  • Impact on Family Caregivers
    • Adverse health effects
      • chronic illness – neglected health habits
      • increased mortality
      • stress and depression
    • Threats to economic security
      • changes in work patterns
      • “ opportunity” costs
      • direct out-of-pocket expenses
  • Caregivers Need More Recognition & Support from Providers
    • Better communication
      • HIPAA interpretation as barrier
    • More preparation for transitions from hospitals and post-acute settings
    • Assessment of their own needs
    • Recognition as “team member”
      • Knowledge of care recipient
      • Care skills
      • Desire to be partners
  • Invitational State of the Science Symposium, January 29-30, 2008
    • Interdisciplinary symposium of 50 RNs, SWs, family caregiver researchers, and others
    • Presentations of peer reviewed papers summarizing the “State of the Science”
    • Recommendations from the symposium circulated to all participants for feedback
    • Report published as supplement to Sept. 2008 AJN and as special issue of JSWE
  • Competencies: Communication
    • Active listening, empathy, and respect
    • Translation of information across systems and providers
    • Transfer of information from family caregivers to providers and vice versa
  • Competencies: Assessment and Practice
    • Understand each caregiver’s circumstances, needs, strengths, goals
    • And cognitive abilities, cultural and spiritual situation (including ability to perform direct care)
    • Develop, evaluate, and modify care plans in collaboration with family caregivers
    • Assist family caregivers in identifying and accessing services
  • Competencies: Collaboration
    • Develop & participate in an interdisciplinary team approach
    • Work with multiple health care and social service systems
  • Competencies: Leadership
    • Know best practices in changing organizational cultures, e.g., to include paraprofessionals, patients, and family caregivers
    • Lead an interdisciplinary team in providing care
    • Advocate on behalf of family caregivers
  • Examples of Methods of Developing Competencies
    • Inclusion in core curriculum
    • Mentoring & “train the trainer” programs
    • Interdisciplinary training
    • Teaching strategies that include role-playing, video-taping, experiential approaches
    • Include family caregivers, as mentors, presenters
  • Strategies to Increase the Ability of RNs and Social Workers to Support Caregivers
    • Change organizational mind-set
    • Develop and integrate quality measures related to family caregiving into performance measurement
    • Require caregiving-related content in professional education
    • Promote public awareness and influence public policies
    • The Center to Champion Nursing in America - a joint initiative of AARP, the AARP Foundation and the Robert Wood Johnson Foundation - is committed to addressing the growing nursing and nursing faculty shortage that threatens access to health care and quality of care across the nation.   The Center is made possible by a $10million grant to the AARP Foundation from RWJF and dedicated funding from AARP.
  • Nurse Faculty Shortages a Significant Barrier
    • Key Factors
    • Aging nurse faculty
    • Short working life of faculty
    • Inadequate faculty pipeline
    • Faculty workload
    • Significant income gaps between practice and academia
    • Lack of diversity
    Source: National League of Nursing-Carnegie National Survey of Nurse Educators
  • Additional Hurdles to Capacity Expansion
    • Need to focus on demand side of the faculty issue as well as supply
    • Insufficient clinical rotation space and placements
    • Insufficient clinical instructors
    • Turnover rates of first year nurses
  • Work for Change
    • Build Coalitions
    • Engage Federal and State Policy-Makers
    • Develop a Clearinghouse for Data
    • Support State and Grassroots Efforts
    • Encourage Innovation
  • For more information
    • [email_address]
    • www.aarp.org/family/caregiving
    • www.nursingcenter.com/ajnfamilycaregiving
    • www.gero-edcenter.org
    • www.caregiver.org