4 18-2013 chicago-chronic disease management
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4 18-2013 chicago-chronic disease management

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examines the most prevalent chronic diseases, treatment technologies, and other cutting edge concepts.

examines the most prevalent chronic diseases, treatment technologies, and other cutting edge concepts.

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  • Sam: open with PROLOGUE: SAM: We are so happy to be here in Chicago with you all today. Truly this is one of the premier symposia in all the US regarding the industry segment that is near and dear to us all: the delivery of healthcare services in the Home. Today we are going to examine several dynamic issues regarding the management of chronically ill patients in the home healthcare setting. Again, my name is Sam Smith, and I am the VP of Business Development for Axxess Technology Solutions and Axxess Healthcare Consult. My bio is included in your packet.I am happy to reintroduce Debbie Cunningham, who is also employed by Axxess as a Senior Consultant and Implementation Specialist for us. Debbie has 20+ years’ experience in healthcare delivery to home bound patients and is an expert in tele-health services, private duty services, and the billing component of Medicare and private insurance related reimbursement of home care services. We are very proud of Debbie and her accomplishments.So, let’s get right to the topic at hand.
  • Sam: People with chronic conditions are more likely to have preventable hospitalizations and other poor outcomes. Most people with chronic conditions have private insurance (54%). Others have Medicare or Medicare with supplemental insurance (20%), Medicaid (11%), or other insurance 6%). Some are uninsured (8%).Debbie, what has been your experience as to the most relevant chronic diseases on which we as Home Health agency managers must seek to direct our focus? Sam: Ok Debbie, thank you, Another questions: What are the most relevant issues we must consider as we develop the necessary care pathways for our skilled nursing staff to follow as they address these chronic diseases?
  • Sam: People with chronic conditions are more likely to have preventable hospitalizations and other poor outcomes. Most people with chronic conditions have private insurance (54%). Others have Medicare or Medicare with supplemental insurance (20%), Medicaid (11%), or other insurance 6%). Some are uninsured (8%).Debbie, what has been your experience as to the most relevant chronic diseases on which we as Home Health agency managers must seek to direct our focus? Sam: Ok Debbie, thank you, Another questions: What are the most relevant issues we must consider as we develop the necessary care pathways for our skilled nursing staff to follow as they address these chronic diseases?
  • Sam: People with chronic conditions are more likely to have preventable hospitalizations and other poor outcomes. Most people with chronic conditions have private insurance (54%). Others have Medicare or Medicare with supplemental insurance (20%), Medicaid (11%), or other insurance 6%). Some are uninsured (8%).Debbie, what has been your experience as to the most relevant chronic diseases on which we as Home Health agency managers must seek to direct our focus? Sam: Ok Debbie, thank you, Another questions: What are the most relevant issues we must consider as we develop the necessary care pathways for our skilled nursing staff to follow as they address these chronic diseases?
  • Sam: Debbie, what has been your experience as to the most relevant chronic diseases on which we as Home Health agency managers must seek to direct our focus? Sam: Ok Debbie, thank you, Another questions: What are the most relevant issues we must consider as we develop the necessary care pathways for our skilled nursing staff to follow as they address these chronic diseases?
  • Sam: People with chronic conditions are more likely to have preventable hospitalizations and other poor outcomes. Most people with chronic conditions have private insurance (54%). Others have Medicare or Medicare with supplemental insurance (20%), Medicaid (11%), or other insurance 6%). Some are uninsured (8%).Debbie, what has been your experience as to the most relevant chronic diseases on which we as Home Health agency managers must seek to direct our focus? Sam: Ok Debbie, thank you, Another questions: What are the most relevant issues we must consider as we develop the necessary care pathways for our skilled nursing staff to follow as they address these chronic diseases?
  • Sam: People with chronic conditions are more likely to have preventable hospitalizations and other poor outcomes. Most people with chronic conditions have private insurance (54%). Others have Medicare or Medicare with supplemental insurance (20%), Medicaid (11%), or other insurance 6%). Some are uninsured (8%).Debbie, what has been your experience as to the most relevant chronic diseases on which we as Home Health agency managers must seek to direct our focus? Sam: Ok Debbie, thank you, Another questions: What are the most relevant issues we must consider as we develop the necessary care pathways for our skilled nursing staff to follow as they address these chronic diseases?
  • Sam: People with chronic conditions are more likely to have preventable hospitalizations and other poor outcomes. Most people with chronic conditions have private insurance (54%). Others have Medicare or Medicare with supplemental insurance (20%), Medicaid (11%), or other insurance 6%). Some are uninsured (8%).Debbie, what has been your experience as to the most relevant chronic diseases on which we as Home Health agency managers must seek to direct our focus? Sam: Ok Debbie, thank you, Another questions: What are the most relevant issues we must consider as we develop the necessary care pathways for our skilled nursing staff to follow as they address these chronic diseases?
  • Figure 1.1a.Data highlights: The most common chronic conditions among Medicare beneficiaries were: High blood pressure (58%), High cholesterol (45%), Heart disease (31%), Arthritis (29%) and Diabetes (28%).
  • Sam: People with chronic conditions are more likely to have preventable hospitalizations and other poor outcomes. Most people with chronic conditions have private insurance (54%). Others have Medicare or Medicare with supplemental insurance (20%), Medicaid (11%), or other insurance 6%). Some are uninsured (8%).Debbie, what has been your experience as to the most relevant chronic diseases on which we as Home Health agency managers must seek to direct our focus? Sam: Ok Debbie, thank you, Another questions: What are the most relevant issues we must consider as we develop the necessary care pathways for our skilled nursing staff to follow as they address these chronic diseases?
  • Our spending tends to be more for the demographics which tend to have the most chronic health issues. With 85 percent of the nation’s health care dollars spent on people with chronic conditions, “the challenge is to use these resources efficiently to provide people with access to high-quality care and appropriate services that maintain health and functioning in the face of disease progression and ensure that this care is coordinated across multiple providers and payers,” writes Gerard Anderson, PhD of the RWJ Foundation.
  • The 80-20 rule applies across the nation. Approximately 20% of the population generate 80% of the reimbursement costs. This is due to patients with chronic disease across the board.
  • Hypertension is one of the outlined diseases promulgated by CMS.
  • For example…
  • Sam: Debbie, what has been your experience as to the most relevant chronic diseases on which we as Home Health agency managers must seek to direct our focus? Sam: Ok Debbie, thank you, Another questions: What are the most relevant issues we must consider as we develop the necessary care pathways for our skilled nursing staff to follow as they address these chronic diseases?
  • Debbie:Sam, you have lots of experience with Home Health Technologies, What are the technological advances that you consider to be important as we consider the chronically ill patient and the care we provide for them in their homes?
  • a. Tele-health- Philips, Bosch, Cardiocomb. Core operations system- Axxess at the “Agencycore”c. Physician’s Portals -Standing Order Management from the Physician to the Home Care Agency to the Patientd. Disruptive Technology: Zirmed’s ClinicalLink system. A method for interchange of CCD (Continuum of Care Documentation) between hospitals, physicians, SNF’s and HHA’s- not using an HIEe. Outcome-Based Technology Management- Metrics of outcomes for Chronic patientsi. Reporting to the Hospital/ACO regarding the care applied to Reduce Readmissions. ii. Reports to be managed1. Discharges from hospital, with Admissions To Home Care; vs. # Hospitalizations, per month establishing the metrics
  • SAM: Debbie, can you elaborate on the various elements of the teaching that we as home health professionals must provide in order to enable the chronically ill patient to receive their care in the home setting?
  • SAM: In summary, Debbie, what are some ideas that we as home health managers enable our chronically ill patients to better cope with their illness and manage their unfortunate situation better?
  • SAM: In summary, Debbie, what are some ideas that we as home health managers enable our chronically ill patients to better cope with their illness and manage their unfortunate situation better?

4 18-2013 chicago-chronic disease management Presentation Transcript

  • 1. C. SAM SMITH DEBBIE CUNNINGHAMVice President – Business Implementation, Software SupportDevelopment Leader & TrainerAxxess Technology Solutions Axxess Technology SolutionsDallas, TX USA Dallas, TX USA Axxess | 2013 1
  • 2. TODAY’S LEARNING OBJECTIVESThe relevant chronic diseases Statistics for the Nation, Illinois: impact on systems Tools and Research – Strategic Information Care Transitions Technologies Teaching Methods Axxess | 2013 2
  • 3. WHAT ARE THE MOST PREVALENT DISEASES?High blood pressure High cholesterol Ischemic Heart Disease Arthritis Diabetes Heart FailureCKD Axxess | 2013 3
  • 4. WHAT ARE SOME OTHER PREVALENT DISEASES?Depression COPD Alzheimers Atrial fibrillation Cancer OsteoporosisAsthma Axxess | 2013 4
  • 5. THE STATISTICS ARE ALARMING• The number of people with chronic conditions is rapidly rising. For example, between 2000 and 2030, the number of Americans with one or more chronic conditions will increase 37 percent, an increase of 46 million people. • Some 28 percent of Americans have two or more chronic conditions and they are responsible for two-thirds (67%)of health care spending. • In the Medicare program over two-thirds of the expenditures are for beneficiaries with five or more chronic conditions. Axxess | 2013 5
  • 6. The impact of Chronic Diseases on theCHRONIC DISEASE HAS A and delivery system health care finance SIGNIFICANT IMPACT ON THE SYSTEM• People with chronic conditions are use over 75 percent of hospital days, office visits, home health care and prescription drugs. • Because the health care system is not designed to meet the needs of people with chronic conditions, their care is not coordinated, which leads to unnecessary service use. • Individuals often receive conflicting advice from different providers, report difficulty accessing services and have difficulty paying out-of-pocket for health care. • As a result, people with chronic conditions rely on others for financial support and personal assistance. --------------From the Robert Wood Johnson Foundation Axxess | 2013 6
  • 7. CMS HAS LAUNCHED AN INFORMATIONAL PORTAL TO ADDRESS THE SEVERITY OF THE ISSUECMS has launched a new web portal for the researchinvolvedin Chronic Disease Management—for you to utilizeCMS’s Medicare Chronic Conditions Dashboard may beaccessed at http://www.ccwdata.org/business-intelligence/chronic-conditions/index.htm Axxess | 2013 7
  • 8. IMPACT OF CHRONIC DISEASE IN ILLINOIS The 80-20 rule applies! Roughly 80% of the money is spent on 20% of the population Axxess | 2013 8
  • 9. PERCENTAGE MEDICARE FFS BENEFICIARIES PER CHRONIC DISEASESource: Centers for Medicare and Medicaid Services. Chronic Conditions among Medicare Beneficiaries, Chart book: 2012 Edition Baltimore, MD. 2012.
  • 10. CHICAGO IS A LEADER IN HOSPITAL READMISSIONS!ChicagoBlue IslandMunsterRegions:over 20% higherthan nationalaverage Axxess | 2013 10
  • 11. PER CAPITA SPENDING BY DEMOGRAPHIC GROUP FOR ILLINOISDollars Spent per Chronic Conditions Dollars Spent per Gender
  • 12. BENEFICIARIES WITH SELECTED CHRONIC CONDITIONS IN ILLINOIS
  • 13. BENEFICIARIES WITH CHRONIC CONDITION HYPERTENSIONAge Group all >65 in Illinois Total Population for Illinois Category Illinois Female 61% Male 55% <65 41% 65-74 53% 75-84 72% 85+ 72% Dual 60% Non-dual 58%
  • 14. BENEFICIARIES WITH CHRONIC CONDITION HYPERLIPIDEMIAIllinois - Age group all >65 yrs. Total Population for Chronic condition Category Illinois Female 46% Male 46% <65 31% 65-74 47% 75-84 53% 85+ 43% Dual 40% Non-dual 47%
  • 15. SYSTEMIC SOLUTIONS TO CHRONIC CARE PROBLEMS• Solutions to the chronic care problem will come from broad- based reforms that involve: o Incorporating people with multiple chronic conditions in medical research; o Rethinking how the health care financing system values and pays for the care received by people with chronic conditions; o Re-examining how we train health care providers; o Developing better connections between supportive and clinical care delivery systems; o Incorporating quality metrics for people with multiple chronic conditions; and o Encouraging and supporting patient self-management and family caregiving. --------------From the Robert Wood Johnson Foundation Axxess | 2013 15
  • 16. Click to add text
  • 17. CARE PATHWAYS FOR CHRONIC DISEASES• First -> what is the patient/caregiver’s understanding of the disease?• What do the patient/caregiver want to accomplish, how much do they want to know?• Breakdown teaching goals to meet patient/caregiver’s expectations.• Make sure teaching is easy to understand, remember and in simple terms for the patient to repeat back and information to retain.
  • 18. CARE PATHWAYS FOR CHRONIC DISEASES• Make sure teaching is easy to understand, remember and in simple terms for the patient to repeat back and information to retain.• Using templates to offer pathways for care, such as the templates modules contained in the Agencycore platform.• Utilize paper format that is simple, easy to read and is information that is specific to the patients needs.
  • 19. KEY TECHNOLOGIES THAT IMPACT HOME CARE• Tele–Health/Tele-Monitoring > Phillips, Bosch, Cardiocom• Core operations system - Axxess at the ‘Agencycore’• Physician’s portal – Standing Order Management• Disruptive Technology: Zirmed’s ‘Clinical Link system’ > A method for interchange of Continuum of Care documentations(CCD)• Outcome-Based Technology Management • Maintaining the Metrics of outcomes for Chronic Patients: Aim: To Reduce readmissions and reports to manage results
  • 20. PRIORITY TEACHING FOR CHRONICALLY ILL PATIENTS• Background for the disease• Diet• Medications• Activities• Equipment/supplies (have on hand or need)• Recognition of early signs & symptoms to handle/report• Request/include a MD treatment regimen if applicable• Standard orders
  • 21. REFLECTIONS• Allow patient/caregiver to absorb the diagnosis• Allow patient/caregiver to vent their feelings: anger; frustration; denial; acceptance; depression; helplessness or even loneliness.• Involve as much family/friends the patient will allow• The end –Death & Dying- planning funeral with or without family involvement, last wishes and deposing of assets and so on….
  • 22. CONCLUSIONS• Managing the Chronic Disease will be a challenge.• Home Health will be the key• Reducing costs and keeping the patient at home• More family involvement thus more teaching/training• Other community resources to assist with patient care• Web based teaching guides will assist the clinicians• Web based software will be the key to documentation
  • 23. Q&A Thank you! Sam Smith ssmith@axxessconsult.com Debbie Cunninghamdcunningham@axxessconsult.com