Presentation delivered by Steven Fuller, MD, Vice President and Corporate Medical Director, Presbyterian Senior Living at the marcus evans Long-Term Care & Senior Living CXO Summit 2019 held in Orlando, FL

1. Fundamentals of Chronic Disease
Management in Higher Acuity Patients
to Positively Impact Readmissions
Steven Fuller, PhD DO
Vice President and Corporate Medical Director
Presbyterian Senior Living

2. Part 1
GENERAL CONSIDERATIONS

3. The Social Management of Chronic Diseases
• This presentation: non-medical management.
• Emphasis: Fundamentals

4. Chronic Diseases are the leading cause of
death and disability in the U.S.
Some of these chronic diseases may be stable and require very little ongoing management,
while others are much more active and require almost daily intervention.
70% of deaths1
86% of overall healthcare costs2
1. https://www.lhsfna.org/index.cfm/health-promotion/chronic-disease/
2. https://www.healthitoutcomes.com/doc/chronic-disease-is-healthcare-s-rising-risk-0001

5. https://www.census.gov/library/visualizations/2018/comm/historic-first.html

6. How Many Chronic Diseases?
HIGHEST IMPACT FOR CHRONIC DISEASE MANAGEMENT:
• ELDERLY
• EFFECT OF RESIDENTIAL SETTING

7. Community dwelling seniors:
Most have up to 3 chronic diseases
Chronic Conditions Among Medicare Beneficiaries.
https://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/Chronic-Conditions/Downloads/2012Chartbook.pdf
These data do not separate institutional vs. non-institutional seniors.

8. Prevalence of Chronic Diseases
Assisted Living vs. Independent Living
Assisted Living Independent Living

9. Prevalence of Chronic Diseases
SNF vs. Homebound
Skilled Nursing Homebound w/House Calls

10. What are the Chronic Diseases?

11. Health Profile
Assisted Living vs. Independent Living
Assisted Living Independent Living

12. Skilled Nursing Homebound w/House Calls
Health Profile
SNF vs. Homebound

13. What are the most expensive chronic
diseases?
https://www.healthsystemtracker.org/chart-collection/health-expenditures-vary-across-population/#item-
diagnosis-serious-chronic-health-condition-associated-higher-spending_2015

14. Delicate Equilibrium
• The challenge in managing elderly residents with multiple chronic diseases is to keep all the diseases in equilibrium,
in balance with each other. And this includes all the medications that are used to treat these diseases.
• Any disruption in this delicate equilibrium by one disease “acting up” can affect all the other diseases, and the
“house of cards” of our residents’ health can come tumbling down into an ER visit, hospitalization, or readmission.

15. Actively managing chronic diseases stabilizes the
“House of Cards” and achieves results.
• Hip replacement:
• Shorter length of stay in SNFs.
• Patients with hypertension, hyperlipidemia, and diabetes:
• Fewer inpatient hospital stays.
• Fewer ER visits.
• Dementia care program:
• Reduces nursing home admissions 40% and trims Medicare costs.

16. Where is our Thinking?
Our thinking is here… …but it needs to be HERE!
5 Star
Readmissions
Vision
• Data and Analytics
• Fundamentals Chronic
Disease Mgmt
Only 3 percent of inpatient long-term care providers reported having
the capabilities of data-driven analytics to lower cost of care, reduce
unnecessary hospital readmissions and ensure facilities receive proper
reimbursement for the care provided to the patient.
https://blackbookmarketresearch.newswire.com/news/post-acute-care-the-next-frontier-for-health-systems-under-risk-black-
20056199hhjhhjjhjhjh

17. Importance of Residential Setting
Different Settings…Different Solutions
HOMES
Single family home, senior apartments, affordable housing.
CONGREGATE SETTINGS
Independent Living, Assisted Living, SNF (Long Term Care)

18. Chronic Disease Management
Location Dictates Management
Congregate Setting
• IL
• AL/MC
• SNF
Homes
• Single Family
• Senior Apartments
• Affordable Housing
Medical Determinants Social Determinants
• [Social determinants are managed]
• # and types of chronic diseases
• # and types of RxMeds
• Cost of specific chronic diseases
• [Medical determinants]
• Unsafe neighborhoods
• Low educational level
• Diet
• Transportation
• Health Literacy
• Financial status
• Family Environment
• Health literacy
• Cultural heritage

19. Part 2
STRATEGIES

20. Strategies for Managing
Chronic Diseases
IMPORTANCE OF CLOSE CONNECTIONS
“WHAT’S MEASURED IS MANAGED.”

21. Close Connections - Ideal

22. Close Connections - Reality
• Straight Line connection between resident and the
healthcare system.

23. Close Connections - Reality
Chronic disease management is NOT the problem!
The GAP is the problem!
The ’Secret’ for managing chronic diseases is to CLOSE THE GAP.

24. How to Close the GAP
First Step: Healthcare Coordinator
• Facilitate communication between patients and their
doctors.

25. How to Close the GAP
Second Step: Use Your Data.
• Develop the outcome metrics that are important to YOUR
setting, and make sure you can reliably measure them.
• “What outcomes are influenced by good chronic disease
management?”
• ER trips
• Hospitalizations
• Readmissions
• Length of stay in your community

26. Health Care in Residential Settings
AnalyticsData
Only 3 percent of inpatient long-term care
providers reported having the capabilities of
data-driven analytics to lower cost of care,
reduce unnecessary hospital readmissions and
ensure facilities receive proper
reimbursement for the care provided to the
patient.

27. How to Close the GAP
Third Step: Target your approaches.
• Resident - specific
• Community - specific

28. ***Resident - Specific Approaches
Community - Specific Approaches
FUNDAMENTALS are the key!
• Chronic Diseases predict acute diseases
• Know your residents’ Health Profile
• Close Connections

29. Knowing the underlying chronic disease allows us to
predict the acute illnesses for which patients are at risk.
Performance Improvement Plan (Suggestion):
• 3 month look-back: what are the diagnoses (acute illness) that most
frequently cause ER trips or hospitalizations?
• Trace that acute illness to the chronic illness that put them at risk.
• THOSE are the chronic illnesses to focus on in YOUR community.
• The more proactively we manage chronic diseases, the better
your outcomes.
ACUTE ILLNESS UNDERLYING CHRONIC DISEASE
Pneumonia COPD, Swallowing disorder that predisposes a resident to aspiration
(neurologic diseases: stroke, Parkinsons Disease, MS, ALS, dementia)
Falls Mobility problems (arthritis, Parkinsons) that may be coupled with vision,
hearing, and/or cognitive problems. Certain medications.
Foot Infections, poorly
healing ulcers
Underlying diabetes, vascular disease, morbid obesity, bedbound.
Behavioral Disturbances Dementia, anxiety

30. Know your residents’ Health Profile
Resident - Specific
• Focus on the top 3-5 chronic diseases and RxMeds
• Educate all caregivers about these diseases and
medications (effects, side-effects, interactions).
• Close the gaps!
• Add more chronic diseases and RxMeds when able.
Health Profile
Gap

31. Community - Specific Approaches
• Healthcare Coordinator
• Programmatic interventions
• Make it a ‘Community Affair’
• Recruit every resident and employee as a cohesive
healthcare team.
• Create a community “mindfulness” to proactively address
health concerns BEFORE they become a problem.
• Modelled after the way you would care for a parent in your own
home.

32. Proactive Monitoring
• Residents
• Kitchen
• Housekeeping
• Aides
• Nurse
• Receptionist
• Coordinator
• Administrator

33. Summary
Secret of Chronic Disease Management
CLOSE THE GAPS!
• Make chronic disease management and prevention a
top priority
• Implement a healthcare coordinator.
• Know your data and become comfortable working
with it.
• Target Interventions:
• Resident – specific
• Community - specific

34. The End
Steven Fuller, PhD, DO
Vice President and Corporate Medical Director
Presbyterian Senior Living
208-830-0476