Objectives

1. Integrated Chronic Care Disease Management: Elevating Practice, Engaging Patients and Driving Best Outcomes Monique Reese, ARNP, MSN, FNP-C, ACHPN, Vice President, Clinical Services and Chief Clinical Officer, Iowa Health Home Care Vicki Wildman, RN, MSN, Edu, Statewide Education, Integrated Chronic Care Disease Management Specialist Trainer IHS Spring Symposium 2011

2. Objectives • Review the incidence and prevalence of chronic diseases • Discover the importance of patient-centered care concepts • List the components of Integrated Chronic Care Disease Management model • List the positive outcomes to enhance clinical practice, increase quality and improve patient outcomes • Describe the impact of decreasing re-hospitalization rates

3. Purpose A Broken Healthcare System Envision a New Care Delivery System Embrace, Embark, and Succeed!

4. A Year in the Life of a Patient 19 Clinic Visits 5 Physical Therapists 6 Social Workers 2 Home Care Agencies 6 Community Referrals 37 Nurses 13 Meds 22 16 Physicians 5 Hospital Admissions 4 Occupational Therapists 2 Nursing Homes 6 Weeks SNF Care 5 Months of Home Care Source Johns Hopkins, RWJ 2010 (G Anderson)

5. “Patients can undo a month’s worth of expensive and intensive care just going home and going about their normal routines.”John Charde, MDVP Strategic Development, Enhanced Care Initiatives, Inc (April 2006)

6. Incidence of Chronic Disease Total U.S. population 133 million Americans (45%) have one or more chronic diseases Source: Wu S, Green A. Projection of Chronic Illness Prevalence and Cost Inflation. RAND Corporation, October 2000.

7. The Number of People With Chronic Conditions Is Rapidly Increasing Source: Anderson, G.; Chronic Conditions: Making the Case for Ongoing Care; Johns Hopkins University; November 2007

8. Epidemic of Chronic Diseases • Increasing incidence of chronic disease • Complexity of care • Poor transitions • Telehealth data: poorly controlled disease • Lack of evidenced based care • “Non compliant” patients

9. Think of Your New Year’s Resolutions Are you non compliant?

10. Cost of Chronic Disease People with chronic conditions are the heaviest users of healthcare services. The more co-morbid conditions the heavier the use.

11. Potentially preventable 30-day readmission rates

12. COMMONWEATLH STUDYNew England Journal of Medicine April 2009 • FINDINGS: • 1 in 5 discharged patients are readmitted within 30 days • 50% of discharged patients are readmitted within 1 yr • In 2004,$17.4 billionwas spent by Medicare in unplanned rehospitalizations

13. So what about coordination?

14. Chronic Disease Management is Becoming More Complex • Increased incidence of patients with multiple co-morbidities • Elderly patients with age-related complexities • Fewer resources to care for an ever increasing number of patients all seeking care in an acute environment Is that how you feel?

15. Non-adherence: Significant for those with chronic disease • Increase in number and length of acute care visits (25% of hospitalizations due to medication errors) • Increase in ED visits • Unnecessary changes in treatment • Overuse of scarce and expensive medical resources • Loss of productivity and decreased quality of life

16. Additional Focus Area : Medication Non-Adherence • Lower for patients with chronic diseases • Lower medication persistence with chronic disease • Low adherence = twice the healthcare expenditures

17. Do Non-Adherent People Care Less About Their Health? • NIH Grant - Meta analysis of studies related to health behaviors • Included interviews with adherent and non-adherent patients • Major difference: non-adherent patients had lower self-efficacy but cared just as much about their health Butterworth, Prochaska, Redding –NIH CDC Grant -1-ROI DP000103/DP CDC HHS/United States

18. The State of Chronic Care Management • Health care systems act as silos • No uniform way to share knowledge • Lack of care coordination • Rushed practitioners • Lack of active follow-up • Pts inadequately trained to • manage their illnesses • Pts seeking care via ER visits & hospitalizations

19. Integrating “The Best of the Best”

20. Redesigning Care Delivery Current healthcare systems cannot do the job Trying harder will not work Changing care systemswill work

21. Wagner’s Chronic Care Model

22. Informed, Activated Patient Prepared Practice Team • Motivation • Information • Skills • Confidence • Patient information • Decision support • Resources Prepared Practice Team

23. Key Derivatives: Wagner’s Model Prepared Practice Team Productive Interactions Informed, Activated Patient

24. Vision of a Provider with Value • “sought after” partner • that brings value

25. Home-Based Chronic Care Model Self-Management Support High Touch Delivery Specialist Oversight Technology

26. Healthcare Providers Role: Explore Barriers to Change • Understanding • Financial constraints • Energy level (depression) • Support system • Problem solving ability • Relationship with healthcare provider • Importance and confidence • Ambivalence: Many patients simply lack confidence in their abilities and that contributes to ambivalence

27. Technology to Support High Quality Chronic Care Comprehensive Assessments Examples: Re-hospitalization risk to identify high risk/ high cost patients PHQ-9 Assessments by disease Medication Risk Assessment Multi-faceted Fall Risk Assessment Evidence-based care plans High quality educational materials

28. Example of Telehealth Unit

29. Defining Care Transitions “ ‘Care transitions’ refers to the movement patients make between healthcare practitioners and settings as their condition and care needs change during the course of a chronic or acute illness.” Eric A. Coleman, MD, MPH Care Transitions ProgramSM

30. Implications for Healthcare Delivery • Coordination of care in the first 30 days critical • Coordination of care is traditional role of homecare • Developing a standard approach to care coordination should be a key strategic objective

31. Homecare’s Unique Role in Transitions Comprehensive assessments Evidenced-based screening tools Interdisciplinary team assessments Interdisciplinary approach to care intervention Medication reconciliation Process & outcome measures ICCDM : Skills for effective health coaching in self mgt support & evidenced based guideline care “Patient is a puzzle”

32. Appt • Scheduled • within a wk • AND • able to get • there Comprehend S&S that require attention AND whom to contact Change in RX or TX Change in RX or TX Community-Based Transitions Model™ (CBTM) Medication Management Early Follow-up Symptom Management Is patient familiar& competent AND have access Adherence & Persistence

33. Sustaining ICCM • Job description expectations • Performance Appraisals • Training of all staff on ICCM • Computer Based-Learning training • Demonstration of skills • Competency of skills • Case conference meetings • Certification

34. Certification Course Content • Self-Management Support Concepts • Working collaboratively with patients • Behavior change theories and tools • Adult Learning • Evidence-based guidelines as they relate to disease self-management • Use of telehealth and technology to support care • Transitions of care • Health literacy

35. Showing an Improvement • Data collection of outcomes • Data collection of process measures • Tracking certification • Tracking use of tools

36. Bringing All Concepts Together Multidisciplinary Case Conference Physician ST OT PT Model Champion ICCM Team Leader RN - NCM SW CPS- PC Telehealth Pharmacist

37. Training Curriculum • Making the Case for Integrated Chronic Care • Principles of Adult Education and Health Literacy • Problem Solving 101 • Evidenced-Based facilitation of Behavior Change • Theory –Based Telehealth • Integrated Care Transitions • Model Implementation into Practice

38. Computer-Based Modules • Evidenced-based training: • Heart Failure • Chronic Obstructive Lung Disease • Diabetes • Depression • Each module contains: • Pathophysiology/ incidence • Treatment Modalities • Self Management Support Behaviors Each module contains: • Pathophysiology/ incidence • Treatment Modalities • Self Management Support Behaviors

39. Vision : Develop Strategies to Achieve Proactive follow-up Planned visit Visit system changes Leadership support Provider participation Guidelines Provider education Expert support Delivery System Design Decision Support Health System Organization Self-Management Support Clinical InformationSystems Links to Community Resources Telemonitoring Guidelines embedded Dashboard Patient activation Self-management assessment Self-management resources Guidelines to patients Source: Pearson, M. et. al.Chronic Care Model Implementation Emphases, Rand Health Presentation to Academy Health Meeting, 2004

40. Best Outcome for Every Patient Every Time Home Health will be a recognized leader in providing patient-centered, expert, quality care in the comfort of home.

41. QUESTIONS?