Caring for Older Persons with Multiple Chronic Conditions

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Caring for Older Personswith Multiple Chronic
Conditions

• Chad Boult, MD, MPH, MBA
• Director, Improving Healthcare Systems,
• Patient-Centered Outcomes Research Institute
• Leyden Academy on Vitality and Ageing
• 9 April 2013

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Hans Nijpels

• 79 year old widower
• Retired teacher, lives alone
• Income small pension
• Daughter lives 10 km away, has three teenagers
• Five chronic conditions
• Three physicians
• Eight medications

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In the past year, he has had..
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• Mr. Nijpels
• Confused by care, meds
• Gets discouraged
• Self-care is poor

Mr. Nijpels daughter Stressed out
Reduced work to half-time Considering
nursing homes
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Chronic care is

• Fragmented
• Discontinuous
• Difficult to access
• Inefficient
• Unsafe
• Expensive

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The ¼ of older persons who have 4 chronic
conditions account for 80 of health care spending
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• Every system is designed perfectly
• to produce the results it gets
• Donald Berwick, MD

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Whats Wrong Here?
Health care system designed to provide acute care
Chronically ill population
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We simply cannot afford to postponehealth care
reform any longer.We must attack the root
causes of the inflation in health care.

• Barack Obama
• June 2, 2009

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What Can We Do?
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Health System
Health Care Organization
Community Resources and Policies
ClinicalInformationSystems
Self-Management Support
DeliverySystem Design
Decision Support
Prepared, Proactive Practice Team Monitoring Coac
hing
Informed, Activated Patient Chronic Disease
Self-Management, Caregiver Support, Action Plan
Productive Interactions
- T Bodenheimer et al JAMA, 2002
Improved Outcomes
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A Search for Success

• Literature review to identify recent innovations
  in chronic care that have shown promising results
• Rank the promising models potential for
  diffusability

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Methods

• Literature search Medline,1987-2011
• Tabulation of evidence for promising models
• Classification of the strength of the evidence
• Consensus ratings of models diffusability

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(No Transcript)
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10 Successful Diffusable Models
Model Improves health care quality or outcomes Improves health care efficiency Diffusability score (6-30)
APN-physician team (for dementia pts) 1 cluster RCT None 19
IDT (for CHF) 1 meta-analysis 2 reviews 1 meta-analysis 2 reviews 25
Guided Care (for multi- morbid pts) 1 cluster RCT 1controlled trial 1 cluster RCT 1 controlled trial 23
Care mgmt (for CHF) 3 RCTs 3 RCTs 21
Pharmaceutical care 4 RCTs 2 RCTs 19
Self-management training 1 meta-analysis 9 RCTs 4 RCTs 24
Proactive rehabilitation 4 RCTs 2 RCTs 19
Caregiver support/education 1 meta-analyses 1 RCT 2 meta-analyses 2 RCTs 19
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Successful Diffusable Models
Model Improves health care quality or outcomes Improves health care efficiency Diffusability score (6-30)
Transitional care 1 meta-analysis 1 RCT 1 meta-analysis 2 RCTs 20
APN-physician dyads (for NH residents) 3 quasi-experimental studies 3 quasi-experimental studies 21
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Summary

• Four types of successful, diffusable models
• Primary care by interdisciplinary teams
• Adjuncts to traditional primary care
• Transitional care
• Dyadic care of residents of nursing homes
• Successful Models of Comprehensive Care
• for Older Adults with Chronic Conditions
• - IOM Re-Tooling for an Aging
• America report, 2008
• - Boult et al. J Am Geriatr
  Soc, 2009

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Guided CareComprehensive Care for Persons with
Chronic Conditions
Specially trained RNs based in primary
physicians offices GCNs collaborate with
physicians in caring for 50-60 high-risk older
patients with chronic conditions and complex
health care needs
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Nurse/physician team

• Assesses needs and preferences
• Creates an evidence-based care guide and a
  patient-friendly action plan
• Monitors the patient proactively
• Supports chronic disease self-management
• Smoothes transitions between care sites
• Communicates with providers in EDs, hospitals,
  specialty clinics, rehab facilities, home care
  agencies, hospice programs, and social service
  agencies in the community
• Educates and supports caregivers
• Facilitates access to community services

Boyd C et al. Gerontologist, 2007
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Who is Eligible?
All Patients Age 65
25 High-Risk
75 Low-Risk
Review previous years insurance data with PM
software
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Patient Selection
13,534 Patients of 14 teams/49 physicians
3,383 (25 highest-risk)
904 Consenting Patients
(Baseline Evaluation)
485 in seven Guided Care teams
Random Allocation
419 in seven Control teams
Boult C et al. J Gerontology, 2008
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Baseline Characteristics
Guided Care Usual Care
Age 77.2 78.1
Race ( white) 51.1 48.9
Sex ( female) 54.2 55.4
Education (12) 46.4 43.4
Living alone 32.0 30.6
Chronic conditions 4.3 4.3
Risk of utilizaton 2.1 2.0
ADL difficulty 30.9 29.3
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Effects on Quality of Care
PACIC
2.1
AGGREGATE
1.3
Activation
1.3
Problem Solving
1.5
Decision Support
1.8
Coordination
1.5
Goal Setting
Quality rated in the highest category on PACIC
Boyd et al. J Gen Intern Med, 2009
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Effects on Caregiver Strain
Wolff et al. J Gerontology Med Sci, 2009
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Effects on Physician Satisfaction
Change in Satisfaction
Marsteller et al. Ann Fam Med, 2010
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Very satisfied
Satisfied
Somewhat satisfied
Somewhat dissatisfied
Dissatisfied
Very dissatisfied
Satisfaction Items 1 Familiarity with
patients 2 Stability of patient relationships 3
Comm. w/ patients availability of clinical info
continuity of care for patients 4 Efficiency of
office visits access to evidence based
guidelines 5 Monitoring patients communicating
w/ caregivers efficiency of primary care team 6
Coordinating care referring to community
resources educating caregivers 7 Motivating
patients for self management
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Comments by Guided Care Nurses

• The best job Ive ever had
• I love this role.

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Annual Costs of Guided Care
Guided Care Nurse
Salary 71,500
Benefits (_at_ 30) 21,450
Travel (to pts homes, hospitals) 588
Communication services
Internet, cell phone 1,800
Equipment (amortized over 3 years)
Computer 500
Cell phone 67
TOTAL 95,905
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Effects on Costs of Care(per caseload, 55
patients)
GC UC Difference Average Expenditure Cost Difference
Hospital days -76.1 1,519/day -115.6
SNF days -99.1 305/day -30.2
Home health episodes -20.1 1331/episode -26.8
Physician visits 40.0 41/visit 1.7
Gross savings ----- ----- -170.9
Cost of GCN 95.9
NET SAVINGS ----- ----- -75.0
Leff et al. Am J Manag Care, 2009
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Health Service Use, 1st 20 Mos
8
9
-7
-15
-17
-21
-47
-49
-52
Boult et al. Arch Intern Med, 2011
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Technical Assistance for Practices

• Guided Care a New Nurse-Physician Partnership
  in Chronic Care (Springer Publishing Company)
• Online course for registered nurses
• Online course for physicians and practice
  leaders
• Orientation booklet for patients
• www.GuidedCare.org/adoption.asp

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Take Home Points

• For patients with several chronic conditions,
  interdisciplinary primary care can improve care
  and reduce costs, especially in well-managed
  systems of care.
• Primary care physicians of the future may
  practice in new team-based models of care.

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How could these lessons be used to improve
chronic care in the Netherlands?