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Community-based Chronic Care Management


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A PowerPoint used in a webinar that (1) describes the importance of community-based chronic care management today and in the future; and (2) details programs that have worked. A video of the webinar is available at our web site

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Community-based Chronic Care Management

  1. 1. Community-based Chronic Illness Management: Strategies and Tools to Reduce Costs and Improve Outcomes Steve H. Landers MD, MPH Director, Cleveland Clinic Center for Home Care and Community Rehabilitation [email_address] April 5, 2010 Brent T. Feorene, MBA President, House Call Solutions [email_address]
  2. 2. Today’s Agenda <ul><li>Welcome and Introduction </li></ul><ul><li>Current trends </li></ul><ul><li>What is on the table? </li></ul><ul><li>Future tense </li></ul><ul><li>Programs that hold promise </li></ul><ul><li>CCF: Today and Tomorrow </li></ul><ul><li>Q&A </li></ul>
  3. 3. Powerful Trends Impact Medical Practice Aging Population Chronic Illness Economic Pressures Consumer Expectations Technology
  4. 4. Demographic Imperative Administration on Aging. A Profile of Older Americans: 2007. Accessed at
  5. 5. Activity Limitations Administration on Aging. A Profile of Older Americans: 2007. Accessed at
  6. 6. Chronic Illness Epidemic Johns Hopkins University, Partnership for Solutions. Chronic Conditions: Making the Case for Ongoing Care, A Chartbook. September 2004 Update
  7. 7. Aging + Chronic Illness Johns Hopkins University, Partnership for Solutions. Chronic Conditions: Making the Case for Ongoing Care, A Chartbook. September 2004 Update
  8. 8. Costly Congressional Budget Office
  9. 9. “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
  10. 10. Jencks SF et al. N Engl J Med 2009;360:1418-1428 Readmissions Half of Medicare Patients Rehospitalized Without Seeing Doctor After Discharge ~60% of Rehospitalized HF patients hospitalized due to another problem
  11. 11. <ul><li>“ Train Wrecks” “Gomers” </li></ul><ul><li>Frustration with the complexity, communication barriers, and administrative burdens… </li></ul><ul><li>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. </li></ul><ul><li>Adams WL, McIlvain HE, Geske JA, et al. Physicians’ Perspectives on Carring for Cognitively Impaired Elders. The Gerontologist. 2005;45(2):231-9. </li></ul>Physician Frustration
  12. 12. Quality Concerns <ul><li>“ suffering in spite of spending” </li></ul><ul><li>“ silo care” “no care zone” </li></ul><ul><li>avoidable readmissions </li></ul><ul><li>hospital acquired conditions </li></ul><ul><li>the “hidden patient” </li></ul><ul><li>frustration </li></ul>
  13. 13. <ul><li>Patient Centered Medical Home </li></ul><ul><li>Bundled Payments </li></ul><ul><li>Penalties for Re-hospitalizations </li></ul><ul><li>“ Accountable Care Organizations” </li></ul>What’s On the Table?
  14. 14. Chronic Care is Different <ul><li>Engaging community </li></ul><ul><li>Self-management support </li></ul><ul><li>Advanced information systems/ tracking </li></ul>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.
  15. 15. ‘New Model’ Primary Care <ul><li>Practice “Redesign” </li></ul><ul><li>Team Approach </li></ul><ul><li>Advanced Information Systems </li></ul><ul><li>“Patient-Centered” </li></ul><ul><li>“Healing Relationships” </li></ul>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.
  16. 16. Patient-Centered Medical Home <ul><li>Whole-Person </li></ul><ul><li>Team Based </li></ul><ul><li>Accessible </li></ul><ul><li>Advanced Information Systems </li></ul><ul><li>NCQA Certification Process </li></ul>Kellerman R, Kirk L. Principles of the patient-centered medical home. Am Fam Physician 2007;76(6):774-5.
  17. 17. The Case of Mrs. Jones <ul><li>82 year old woman, h/o HF and OOP </li></ul><ul><li>“ Tired and weak and swollen ankles x 5 days” </li></ul><ul><li>Walker, Oxygen, Son’s Assistance </li></ul>
  18. 18. Bringing Home Medical Home? <ul><li>Highest risk patients may not be able to access offices </li></ul><ul><ul><li>Permanent </li></ul></ul><ul><ul><li>During time of vulnerability </li></ul></ul><ul><li>Accessibility and whole person approach enhanced when care is done at home </li></ul><ul><li>Scalability of team </li></ul>Landers SH. The other Medical Home. Jama 2009;301(1):97-9.
  19. 19. “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
  20. 20. Workforce Estimates <ul><li>Annual FFS MCR HHA Visits > 110,000,000 </li></ul><ul><li>Medicare Home Health FTEs >250,000 </li></ul><ul><li>Annual FFS MCR Physician Visits < 2,000,000 </li></ul><ul><li>Home Care Physician and Mid-Level FTE’s ? </li></ul><ul><li>Total Primary Care Physician FTEs ~270,000 </li></ul>
  21. 21. Role for Home Health <ul><li>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---1 st 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 </li></ul>
  22. 22. Programs that hold promise <ul><li>Transitional Care </li></ul><ul><ul><li>Multi-level targeting patients with the right provider at the right time </li></ul></ul><ul><li>House call programs </li></ul><ul><ul><li>Reserved for the frailest, most complex patients </li></ul></ul>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.
  23. 23. Health Capacity A Role for Chronic Care Management Time Disability Normal Aging Chronic Care Management <ul><li>Hip fracture </li></ul><ul><li>Stroke </li></ul><ul><li>CHF </li></ul><ul><li>COPD </li></ul><ul><li>Hypertension </li></ul><ul><li>Rapid weight gain/loss </li></ul><ul><li>Hyperglycemia </li></ul><ul><li>Incontinence </li></ul><ul><li>Dementia </li></ul><ul><li>Caregiver burnout </li></ul><ul><li>IADL/ADL decline </li></ul><ul><li>Obesity </li></ul><ul><li>Tobacco and alcohol </li></ul><ul><li>Environmental </li></ul>Cumulative, inter-related risk factors require ongoing, coordinated care interventions. Public Health Primary Care Acute Care Long-term Care Accelerated Loss of Health Acute Event Disease Management Adapted from, “ The Glide Path ” Kyle R. Allen, DO Medical Director, Post-Acute and Senior Services Summa Health System Risk Factors Death High
  24. 24. Transitional Care <ul><li>Goal </li></ul><ul><ul><li>Ensuring a smooth transition for the patient from one site or level of care to another that meets goals of care </li></ul></ul><ul><li>Why? </li></ul><ul><ul><li>Limits of traditional disease and case management in preventing adverse events and unnecessary utilization/costs </li></ul></ul>
  25. 25. Rates of Rehospitalization within 30 Days after Hospital Discharge Jencks SF et al. N Engl J Med 2009;360:1418-1428
  26. 26. Who to target? <ul><li>Community dwelling </li></ul><ul><li>Admitted for ambulatory sensitive conditions, such as COPD, CHF, Diabetes, Pneumonia and Dementia </li></ul><ul><li>Frequent flyers – two or more admissions in the past six months to one year </li></ul><ul><li>Individuals currently enrolled in case management </li></ul>
  27. 27. Patient Factors Contributing to Poor Post-Discharge Outcomes <ul><li>Multiple conditions/therapies* </li></ul><ul><li>Functional deficits </li></ul><ul><li>Emotional problems </li></ul><ul><li>Poor general health behaviors </li></ul><ul><li>Poor subjective health rating* </li></ul><ul><li>Lack of support </li></ul><ul><li>Cognitive impairment** </li></ul><ul><li>Language, literacy and culture </li></ul>
  28. 28. Level I <ul><li>A health coaching model using RNs </li></ul><ul><ul><li>25 – 30 patients per coach </li></ul></ul><ul><ul><li>Not a “doing” model </li></ul></ul><ul><li>Lowest-intensity, lowest-cost model </li></ul><ul><li>Target thirty day duration </li></ul><ul><li>Enroll patients who are able to be “coached” to effectively self-manage through the transition </li></ul>
  29. 29. Level I <ul><li>Five Principals </li></ul><ul><ul><li>Medication self-management </li></ul></ul><ul><ul><li>Nutrition management </li></ul></ul><ul><ul><li>Patient health record </li></ul></ul><ul><ul><li>Physician follow-up </li></ul></ul><ul><ul><li>Red flag awareness </li></ul></ul>
  30. 30. Level I Process <ul><li>Health coach visits while I/P </li></ul><ul><ul><li>Introduce the program and gain acceptance </li></ul></ul><ul><ul><li>Prepare patient and family for follow-up </li></ul></ul><ul><li>Home visit </li></ul><ul><ul><li>One visit within 48 – 72 hours of discharge </li></ul></ul><ul><ul><li>Structured </li></ul></ul><ul><ul><ul><li>Review the program in detail </li></ul></ul></ul><ul><ul><ul><li>Environmental scan </li></ul></ul></ul><ul><ul><ul><li>Medication reconciliation </li></ul></ul></ul><ul><ul><ul><li>Review discharge instructions </li></ul></ul></ul><ul><ul><ul><li>Introduce PHR </li></ul></ul></ul><ul><ul><ul><li>Discuss physician follow-up </li></ul></ul></ul><ul><ul><ul><li>Educate on red flags </li></ul></ul></ul>
  31. 31. Level I Process <ul><li>Key follow-up phone calls </li></ul><ul><ul><li>2 – 3 calls as needed </li></ul></ul><ul><ul><li>Ensures compliance and continuity </li></ul></ul><ul><ul><li>Modify plan </li></ul></ul><ul><li>Plan to call after major post-acute events </li></ul><ul><ul><li>Physician visit </li></ul></ul><ul><ul><li>Home health/therapy </li></ul></ul><ul><ul><li>Change in Rx regimen </li></ul></ul><ul><ul><li>Graduation </li></ul></ul>
  32. 32. Level II <ul><li>Use RNs in a more active model of care </li></ul><ul><li>RN must balance “coach” and “do” </li></ul><ul><ul><li>Patient capabilities </li></ul></ul><ul><ul><li>Support systems </li></ul></ul><ul><li>More extended time frames up to 6 months </li></ul><ul><li>Criteria are the same as Level I, but add </li></ul><ul><ul><li>Significant ADLs/IADLs </li></ul></ul><ul><ul><li>Psycho-social concerns </li></ul></ul>
  33. 33. Level II Process <ul><li>Builds on Level I activities </li></ul><ul><ul><li>RN visits while I/P </li></ul></ul><ul><ul><li>Initial home visit within 48 – 72 hours of discharge </li></ul></ul><ul><ul><li>Key follow-up phone calls </li></ul></ul><ul><li>Coaches and provides care </li></ul><ul><li>May need additional home visit(s) </li></ul><ul><li>Graduation date can be extended based on situation </li></ul>
  34. 34. Level III <ul><li>Highest level of intensity and care provision using NPs and/or PAs </li></ul><ul><li>A hybrid model, but weighted more toward medical than nursing </li></ul><ul><li>SNF-level patient able to remain community dwelling </li></ul><ul><ul><li>Geriatric syndromes </li></ul></ul><ul><ul><li>ADLs/IADLs </li></ul></ul><ul><ul><li>Polypharmacy </li></ul></ul><ul><li>Risk loss of functionality and/or exacerbation of chronic condition(s) </li></ul><ul><li>Most likely to bridge “at-risk” period successfully with effective, coordinated care </li></ul>
  35. 35. Level III Process <ul><li>Builds on concept of Levels I & II </li></ul><ul><li>Initial visit within 48-72 hours of discharge from SNF or hospital </li></ul><ul><li>Key follow-up phone call(s) </li></ul><ul><li>Typical 30 days enrollment to graduation </li></ul><ul><ul><li>Back to office-based practice </li></ul></ul><ul><ul><li>Enrollment in house call program </li></ul></ul>
  36. 36. House Call Program <ul><li>Provide a patient-centered medical home to frail, low-mobility elderly </li></ul><ul><li>Physician and NP serve as the patient’s in-residence PCP </li></ul><ul><ul><li>Primary care house calls </li></ul></ul><ul><ul><li>Urgent care visits </li></ul></ul><ul><li>Collaborate with hospitalists on IP care </li></ul><ul><li>Coordinate specialty care, ancillaries and other health services, as needed </li></ul><ul><li>Offer counseling and social service coordination for patient and family/caregivers </li></ul>
  37. 37. House Call Programs <ul><li>Typical profile </li></ul><ul><ul><li>Difficulty getting to/from the PCP office </li></ul></ul><ul><ul><li>Have not seen PCP in 12 -18 months </li></ul></ul><ul><ul><li>ED most likely access point for healthcare services </li></ul></ul><ul><ul><li>2+ deficiencies in ADLs </li></ul></ul><ul><ul><li>Complicated, chronic medical conditions and polypharmacy not likely responsive to other programs </li></ul></ul><ul><li>Disruptive to PCP office flow </li></ul><ul><ul><li>Physical/facility issues </li></ul></ul><ul><ul><li>Time and resource intensive </li></ul></ul><ul><ul><li>Difficult to meet the full spectrum of patient’s needs </li></ul></ul>
  38. 38. What are the outcomes? <ul><li>Community-based chronic illness management programs have demonstrated positive outcomes </li></ul><ul><ul><li>Reduced utilization </li></ul></ul><ul><ul><li>Lower costs </li></ul></ul><ul><ul><li>Improved outcomes </li></ul></ul><ul><ul><ul><li>Health </li></ul></ul></ul><ul><ul><ul><li>Quality of life/Goals of care </li></ul></ul></ul>
  39. 39. Transitional Care <ul><li>Eric Coleman, MD </li></ul><ul><li>Randomized controlled trial of a Level I program </li></ul><ul><li>Outcomes </li></ul><ul><ul><li>Reduced readmissions </li></ul></ul><ul><ul><li>Lower costs </li></ul></ul><ul><li>In use by over 135 health systems nationally </li></ul>
  40. 40. House Calls Montefiore Medical Center Results for Medicare Advantage Enrollees
  41. 41. How are these programs paid? Managed Care/Payer Perspective <ul><li>The economic incentives are aligned and the programs produce positive ROI </li></ul><ul><ul><li>Montefiore </li></ul></ul><ul><ul><li>Summa Health System </li></ul></ul><ul><ul><li>Inspiris </li></ul></ul><ul><ul><li>United </li></ul></ul>
  42. 42. How are these programs paid? Medicare FFS environment <ul><li>Programs’ downstream benefits </li></ul><ul><ul><li>Capacity management </li></ul></ul><ul><ul><ul><li>Avoided admission </li></ul></ul></ul><ul><ul><ul><li>Reduced ALOS </li></ul></ul></ul><ul><ul><ul><li>Less pressure on ED </li></ul></ul></ul><ul><ul><li>Fewer re- admissions </li></ul></ul><ul><ul><li>Increased market share </li></ul></ul><ul><li>Provider professional billings </li></ul><ul><ul><li>Partial contribution </li></ul></ul><ul><ul><li>MDs, NP & PAs </li></ul></ul><ul><li>Community agencies </li></ul>
  43. 43. Cleveland Clinic Center for Home Care and Community Rehab Today: Gaining a beach head <ul><li>System-wide recognition </li></ul><ul><ul><li>Oversight and Strategy Board </li></ul></ul><ul><ul><li>Department of Home Care Physicians </li></ul></ul><ul><li>Services </li></ul><ul><ul><li>Mobile physician services </li></ul></ul><ul><ul><ul><li>Geriatric consults </li></ul></ul></ul><ul><ul><ul><li>PCP </li></ul></ul></ul><ul><ul><li>Home care, hospice, home infusion, etc. </li></ul></ul><ul><li>Expansion of MPS </li></ul><ul><ul><li>First to a specific CCF member hospital in development for 2010 </li></ul></ul>
  44. 44. Cleveland Clinic Center for Home Care and Community Rehab The future: Strategic tool for CCF <ul><li>Seamless delivery and coordination of care </li></ul><ul><ul><li>Regardless of location </li></ul></ul><ul><ul><li>Regardless of age/time in life </li></ul></ul><ul><li>Care transitions </li></ul><ul><li>New roles for home care staff </li></ul><ul><li>Use of telehealth and remote technologies </li></ul>
  45. 45. Transitional Care Resources <ul><li>Eric Coleman, MD </li></ul><ul><ul><li> </li></ul></ul><ul><li>National Transitions of Care Coalition </li></ul><ul><ul><li> </li></ul></ul><ul><li>Better Outcomes for Older adults through Safer Transitions (BOOST) </li></ul><ul><ul><li> </li></ul></ul>
  46. 46. House Call Resources <ul><li>American Academy of Home Care Physicians </li></ul><ul><ul><li> </li></ul></ul><ul><li>American Geriatrics Society </li></ul><ul><ul><li> </li></ul></ul>
  47. 47. Thank You <ul><li>“ The future belongs to those who believe in the beauty of their dreams” </li></ul><ul><li>- Eleanor Roosevelt </li></ul>