Bill Bechill Memorial Lecture: Caring for Tomorrow

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Bill BechillMemorial LectureCaring for
Tomorrows Elders

• George Taler, MD
• Director, Long Term Care
• Washington Hospital Center
• Professor, Clinical Medicine, Geriatrics
• Georgetown University

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Disclosures

• Speakers Bureau, Merck Co., Inc Transitions
  of Care
• Amer Academy of Home Care Physicians, Chair,
  Public Policy Committee

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Premises

• We are not who we once were.
• So, who are we? Will be?
• Organizations and institutions designed for who
  we were need to change to meet the needs of who
  we are.
• So, what is the foundation
  for that change?
• The best way to Predict the future is to Create
  it. Alan Kay

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Survival Curves 1840-1980
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Percent Gains in Life Expectancy Related at gt65
Years of Age During Overlapping Periods
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Population (106) by Age and Sex
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Survival Curves 1840-2050
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So, Who Are We?
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Demographics of Health Care Spending in the
United States
67 Healthy
5
500
1
of
Annual per capita
of Pop
- Catastrophic Illness
Legend -Healthy
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Catastrophic Illness

• Truly catastrophic
• New onset cancer
• Major trauma
• Organ transplant
• Need for recombinant gene-based Rx
• Accidentally catastrophic
• Saw it coming a mile away!

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Demographics of Health Care Spending in the
United States
gt100,000
Log
67 Healthy
25
15
5
500
1
of
Annual per capita
of Pop
- Catastrophic Illness
Legend -Healthy
- Chronic Condition(s)
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Chronic Condition(s)

• Irreversible organ system dysfunction
• Progressive v Stable
• Amenable to medical intervention
• Physiological
• Palliative
• Activities of Daily Living
• Disabling and/or Terminal

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Demographics of Health Care Spending in the
United States
gt100,000
Log
67 Healthy
25
30
5000
15
5
500
1
of
Annual per capita
of Pop
- Catastrophic Illness
Legend -Healthy
- Chronic Condition(s)
- Frailty
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Chronic Condition(s)

• gt ? gt
• gt ? persistently gt
• gt ADL impairment ?
• Hospitalization ?

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Frailty

• gt 2 chronic conditions (usually 3-5)
• gt 2 impaired ADLs
• At risk of hospitalization, followed by
• Acute rehabilitation
• Sub-acute rehabilitation
• Home health episode of care
• Social and financial insecurity

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Demographics of Health Care Spending in the
United States
gt100,000
7
Log
50
67 Healthy
50,000
25
30
5000
15
5
500
1
of
Annual per capita
of Pop
- Catastrophic Illness
Legend -Healthy
- Chronic Condition(s)
- Frailty
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Organizations and institutions designed for who
we were need to change to meet the needs of who
we are.

• You cannot find the answers to the
• present problems by looking for solutions
• from those who created them.
• ? Albert Einstein

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Per Capita Health Care Spending in Various
Countries in 2006, According to the Country's
Relative Wealth
Iglehart J. N Engl J Med 200910.1056/NEJMp0901927
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The Cost of a Long Life
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Longitudinal Trends in the Costs per Year of Life
Gained in Four Age Groups
Cutler D et al. N Engl J Med 2006355920-927
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If we do nothing to slow these skyrocketing
costs, we will eventually be spending more on
Medicare and Medicaid than every other
government program combined. Put simply, our
health care problem is our deficit problem.
Nothing else even comes close.
President Obamas Health Care Speech to Congress
September 9, 2009
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ObamaCare

• Health Insurance reform
• Exempt pre-existing conditions
• No caps on coverage for illness care
• Universal access to coverage
• Insurance underwriting competition
• Mandatory play-or-pay rules
• Bend the cost curve

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Re-Engineering Health Care DeliveryandRight-Si
zing Payments
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Re-Engineering Health Care Delivery

• Bolster the Primary Care workforce
• Commission to align health care workforce and
  national needs
• GME innovation
• Stipends, low-interest loans loan forgiveness
• Increase access to home-based care
• Increasing integration across settings
• Transitional Care
• ACO (Medicare Shared Savings Program)
• Independence at Home

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Right-Sizing Payments

• 10 premium for primary care (2011)
• Value-based purchasing (2012) (2015)
• Evidence-based payments Tx Devices
• Elimination of overpayments

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Accountable Care Organization

• Chief proponent Elliot Fisher, MD, MPH, The
  Dartmouth Project
• Creates a population based system of care
• Improve adherence to CPGs
• Accountable for all care across the continuum
• Goal reduce variability in the costs of care
• Accountable for all costs
• No penalties
• Potential for shared savings

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Annual Growth Rates of per Capita Medicare
Spending in Five U.S. Hospital-Referral Regions,
1992-2006
Fisher E et al. N Engl J Med 2009360849-852
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The Patient-CenteredMedical Home

• Proponents AAP, ACP and AAFP
• Care coordination for chronic conditions
• Improve adherence to evidence-based clinical
  practice guidelines
• Information repository (EMR health registries)
• Integration of the medical care plan over time
• Goal Advance the Primary Care enterprise
• CPT codes for monthly care coordination.

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Transitional Care Programs

• Proponents ANA, AANP, ACNP
• Manages the transition from Acute Care to
  Community Care
• NP driven care coordination episode
• Links to PCP, Pharmacy and Social Services
• Goal Reduce hospital recidivism
• Payments through demonstrations
• Possible bundling into hospital fees

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Independence at Home

• Proponents AAHCP, AANP, ASCP, AARP, Alzheimers
  Assoc., Continua Alliance
• Comprehensive management of the most frail in the
  community
• Supports Aging in Place
• Encourages point-of-service Dx, TX monitoring,
  communications technologies
• Goals Care in the least expensive setting
• Paid for through shared savings

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Acute Care Hospitals / EDs
Technological Capability
1 Office-Based Care
Capability Demanded for 1 Patient Care
Home-Based Care
1960
1970
1980
1990
2000
2010
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Tomorrows Health Care System
Physician Centered Patient Centered
Institution Centered Home Centered
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Independence at Home

• Passed as Sec 3024 of H.R. 4872, The Health Care
  Education Affordability Reconciliation Act of
  2010
• Implementation by January 1, 2012
• Only Demo outside the Center for Medicare
  Medicaid Innovation
• Limited to 10,000 beneficiaries
• Savings sharing formula still a

?
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Independence at Home

• AAHCP preparing a template for CMS RFP
  implementation guidelines
• Structure and organization of IAH Programs
• Data requirements and analytic strategies
• Approach to calculating savings shares
• Legislative fixes
• Public awareness
• The IAH University

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The IAH UniversityEmerging Insights

• Success depends increasingly on
• external and internal teamsmanship

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Better Care for Older People With Chronic Diseases

• Care must be personalized to meet each patient's
  goals, values, and resources.
• Care should be provided in accordance with best
  practices.
• Physicians cannot do the job alone.
• Care must be coordinated among those caring for
  patients.
• Care must consider the resources and environment
  of the person.
• Older persons must be included as active partners
  in their care, if possible

Reuben DB. JAMA. 2007298(22)2673-2674.
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Perspectives From The World In Which I Practice
Excellent Medical Care Planning And Delivery
Socio-Economic Community Resources Supportive
Services
Caregiver and Environmental Support of
Functional Independence
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Home Health Agencies Skilled Nursing Physical/Occu
p/Speach Therapies Home Infusions Services
Primary Geriatric Care Specialty Services Site
Specific Providers Hospitalists
Institutionalists Ancillary Care Services
Nursing Care
Medical Care
The External Multidisciplinary Team
Social Work Services
Pharmacy Services
Social Services Personal Care Legal
Services Transportation Adult Protective Services
Pharmacies Durable Medical Equipment
Supplies Oxygen Services
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Whats the culture of your Health Care Team?

• Whats really interesting to me is that we
  educate health care professionals in silos and
  then put them together in the practice setting
  and expect them to function as a team.
• So it is amazing to me that some teams can
  function well, rather than teams are not
  functioning.

Elizabeth A. Ayello, 1978
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TeamsmanshipA Sociologic Perspective

• Requires breaking barriers that stand in the way
  of quick, high-quality customer service.
• Shared leadership
• Feeds on sharing information
• Common values and ethical beliefs
• Capacity to repair broken relationships

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Hierarchical Leadership
V L E E R A T D I E C R A S L H I P
H O R I Z O N T A L L E A D E R S H I P
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Horizontal Leadership

• Each member is valued for their own professional
  knowledge and expertise
• Each member is valued for their own personal
  insights and empathy
• Responsibility both floats and is assumed by all
  members

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The Goal of Team Building
Multi-Disciplinary CPG
Inter-Disciplinary CGA
Trans-Disciplinary IAH
Non-hierarchical blending of professional
roles Consensus building Shared vision, plan of
care Flexible leadership
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Your Team is Working When

• A visitor is not sure who the leader is, nor are
  the professional alignments clear
• Although each task is assumed by one, the
  responsibility is shared by all
• Success is individualized, but failure is a
  group process
• Everyone is comfortable in their environment
• There is protected time for group reflection
• Outsiders are envious

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Better is possible. It does not take genius. It
takes diligence. It takes moral clarity. It takes
ingenuity. And above all, it takes a
willingness to try.
Atul Gawande, MD
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Hospitals Are a Big Part of the US Economy
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The Change Timeline
The Thin Line Between Brilliance and
Stupidity Sure, that would be nice, but its
impossible to pull off!
The Bleeding Edge Only a few crazies are
trying that and theyre bound to fail. (Many
do)
The Leading Edge Some people are doing it
and Ive been considering it
Acceptance Whats the big deal, Ive been
doing that for years!
0
2
3
5
6
4
1
7
Years