Caring for Older Persons with Multiple Chronic Conditions

1. 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

2. 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 Hans Nijpels

3. In the past year, he has had.. 8 Physicians, 6 Social Workers, 5 Physical Therapists, 4 Occupational Therapists, 37 Nurses 22 scripts 6 community referrals 8 meds 19 outpatient visits 2 home care agencies Mr. Hamond 3 hospital admissions 5months homecare 6 weeks sub- acute care 2 nursing homes

4. 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

5. Chronic care is: Fragmented Discontinuous Difficult to access Inefficient Unsafe Expensive

6. The ¼ of older persons who have 4+ chronic conditions account for 80% of health care spending

7. “Every system is designed perfectly to produce the results it gets” Donald Berwick, MD

8. What’s Wrong Here? Health care system designed to provide acute care Chronically ill population

9. “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

10. What Can We Do?

11. Health System Health Care Organization Community Resources and Policies ClinicalInformationSystems Self-Management Support DeliverySystem Design Decision Support Prepared, Proactive Practice Team Monitoring Coaching Informed, Activated Patient Chronic Disease Self-Management, Caregiver Support, Action Plan Productive Interactions - T Bodenheimer et al JAMA, 2002 Improved Outcomes

12. 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”

13. Methods Literature search: Medline,1987-2011 Tabulation of evidence for promising models Classification of the strength of the evidence Consensus ratings of models’ diffusability

14. 2,714 titles identified 2,409 excluded 305 abstracts read 174 excluded 131 articles read 51 articles added from bibliographies 59 excluded 123 articles met inclusion criteria

15. 10 Successful Diffusable Models

16. Successful Diffusable Models

17. Summary Four types of successful, diffusablemodels: 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

18. Guided Care:Comprehensive 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

19. 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 caresites 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

20. Who is Eligible? All Patients Age 65+ 25% High-Risk 75% Low-Risk Review previous year’s insurance data with PM software

21. 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

22. Baseline Characteristics

23. 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

24. Effects on Caregiver Strain Wolff et al. J Gerontology Med Sci, 2009

25. Effects on Physician Satisfaction Change in Satisfaction Marsteller et al. Ann Fam Med, 2010

26. 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

27. Comments by Guided Care Nurses “The best job I’ve ever had” “I love this role.”

28. Annual Costs of Guided Care

29. Effects on Costs of Care(per caseload, 55 patients) Leff et al. Am J Manag Care, 2009

30. Health Service Use, 1st 20 Mos 8% 9% -7% -15% -17% -21% -47% -49% -52% Boult et al. Arch Intern Med, 2011

31. 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

32. 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.

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