Felicia Cojocnean MSN, FNP, AANP-BC Chronic Disease Management Programs

1. Felicia Cojocnean MSN, FNP, AANP-BC Chronic Disease Management Programs Wellpoint/CareMore Health Plan Orange Co/LA, California

2. CAREMORE • 1995 –Medical Group with enrolled Medicare beneficiaries • 2001-CareMore Health Plan • 2006- CareMore Special Needs Plan

3. CAREMORE

4. Health Spending & Chronic Disease CAREMORE • Five chronic diseases make up the vast majority of this category* • Diabetes • Congestive Heart Failure • Coronary Artery Disease • Asthma • Depression * Hypertension contributes to complications

5. THERE IS GREAT OPPORTUNITY • CHRONIC DISEASES CAN BE MANAGED… BUT USUALLY ARE NOT • DrPeter B. Bach (6/21/07),study of Medicare in the New England Journal of Medicine • Patients with chronic conditions do not need more doctors, they need a few who cooperate. • Patients are best served when they have at most a few physicians who work together well • Commonwealth Fund Health Care Quality Survey,Report (July 2007) • Medical Homes result in better outcome • Elizabeth A. McGlynn et al (2003) • Patients receive appropriate care only half of the time

6. THERE IS GREAT OPPORTUNITY CHRONIC DISEASES CAN BE MANAGED… BUT USUALLY ARE NOT • Diabetic complications could be cut 90% with best care and involved patients (Center for Disease Control and Prevention), yet • Diabetes related admissions have risen from 3.5 to 6.5 million since 1993 • Low income diabetics are 80% more likely to be hospitalized • Second heart attacks can be reduced 40% (J.R. Jowers) • More doctors involved in care decreases information exchange and leads to unnecessary hospitalizations (Wennberg/ Dartmouth)

7. OUR MISSION OUR MISSION Providing innovative and focused healthcare approaches to the complex process of aging.

8. WHY OUR MISSION We are here to: serve our members by prolonging active and independent life serve caregivers and family by providing support, education, and access to services protect precious financial resources of seniors and the Medicare Program through innovative methods of managing chronic disease, frailty, and end of life

9. CAREMORE A Chronic Care Special Needs Plan • >70K members nationwide • Average age = 72 years • 44% Diabetics • 40% HTN and CHF • 16% COPD and Renal Disease • 20% Medicare – Medicaid • 50% with annual income < $30,000

10. CAREMORE INTEGRATED PATIENT CARE DELIVERY SYSTEM COPD CAD Diabetes CHF Wound Clinic Chronic Disease Support Healthy Start ESRD Monitoring Hospice Secondary Prevention End of Life Care PCP Extensivist Nutritionist Palliative Care Foot care Risk Event Prevention Social / Behavioral Support ClinicalCare Centers(CCC) Case Manager/ NP Social Workers Exercise Pre-Op Mental Health Frailty Support Coumadin Extensivist Management Fall Strength Training Predictivemodeling Integrated IT infrastructure Longitudinal patient record Evidence-based protocols Point-of-care decision support

11. THE CAREMORE MODEL Summary: Integrated care involves nurses, pharmacists and others on care teams, all working together to achieve a common goal. WellPoint's recent purchase of CareMore, which provides care for 15 percent of Medicare Advantage beneficiaries who account for 75 percent of costs, is an example of successfully integrated care.

12. CareMore CLINICAL MODEL • Design: • Provide support system for PCPs • So, Chronically ill & Frail seniors receive all the services necessary to live an active & independent lifestyle • And, avoid hospitalizations & other unnecessary acute episodes

13. CAREMORE Neighborhood Clinical Model

14. CAREMORE MODEL OF CARE For the chronically ill: • The CareMore Care Center serves as a “home” for patients where questions are answered, care is delivered and coordinated. • A variety of support services are provided , designed to “fool proof” patient non-compliance with care programs • transportation • remote house monitoring through Telehealth services • home visits • social service support • Constant vigilance and use of predictive modeling to allow for early and rapid intervention • Healthy Start–complete evaluation within 30 days of enrollment • Predictive Modeling eg. CARS • Monitor risk indicators

15. CAREMORE A Chronic Care Special Needs Plan • Benefits that fit the need • Free insulin and diabetic supplies • Routine wound care • Free home-based electronic monitoring (Ideal Life) • Blood Pressure • Weight • Blood Glucose • Free Transportation to CareMore Care Centers • 24 hour help line • Caregiver support • Home Care • Respite Care • Healthy Start (comprehensive assessment within 30 days of enrollment and individual plan) • A Personal Care Plan for every member

16. RESULTS CareMore has consistently produced results that compare favorably to community norms In many cases these results have been dramatically superior CareMore has not tried to change or work “through” the conventional system but has built a new model that recognizes the increased demands of the chronically ill

17. DIABETIC MANAGEMENT CAREMORE Redesign Result Observation Many patients with out-of-control diabetes were not brought in control through insulin use. Common wisdom was that inability to correctly self administer or improper dosing were driving results. Further, insufficientsupport in the areas of nutrition and exercise were observed. Established insulin “starts” and insulin “camps”. At the “start” day, patient is trained in all aspects of self-administration of insulin. At “camps”, patients are brought to the center for a full day to observe all of their behaviors and monitor glucose levels at all points of self care. A personal nutrition counselor was assigned. Average HbA1c for those attending our diabetic clinic is 7.08, with 7.0 being considered good control. 1, 2

18. DIABETIC WOUND MANAGEMENT Observation CAREMORE Redesign Result Routine diabetic wound care was being primarily delivered by vascular and orthopedic surgeons, who were not inclined to supply the highly-repetitive, low intensity health care necessary to heal wounds. This resulted in frequent amputations. Nurse Practitioners became certified in wound care and took responsibility for high-touch wound intervention. Amputation rates are 78% less than the national average. 3

19. REDUCTION IN STROKE RISK Observation CAREMORE Redesign Result 11 High blood pressure increases risk of stroke. Hypertension is not controlled in 70% of patients with this condition. Physicians have limited ability to get correct readings between patient visits which resulted in poor control of hypertension. 12 Equip patients with blood pressure monitors with wireless cuffs for recording three times a day. Readings taken at CareMore’s Care Center. Make immediate, same day medication changes when pressure levels change. 48% of the patients had > 10mm in Hg reduction in systolic blood pressure. Patients with systolic blood pressures of 160 mm Hg or > had an average drop of 23mm Hg. Those patients with blood pressure of 150-160 mm Hg had an average drop of 19mm. Those results had shown to reduce the instances of stroke over the long term by 40% in patients. 13,14

20. CHF READMISSION Observation CAREMORE Redesign Result Congestive Heart Failure is a leading cause of hospital admissions and readmissions in the Medicare population. Primary care physicians were not able/willing to collect accurate weight on a daily basis and intervene quickly. Self-reported weights were inaccurate. Primary care physicians were not adequately responsive to immediate care needs of patients who require intervention within a few hours of onset of symptoms. 15 Equip each patient with a wireless scale that sets off alerts if weight gain is 3 lbs overnight or 1 lb per day for more than 3 days. Same-day visit with clinician if alert is triggered. Proactive hospice planning with changes in condition. 56% reduction in hospital admission rate in 3 months.

21. CAREMORE A DAY IN THE LIFE • CAREMORE SERVES 30,000 MEMBERS THROUGH 11 CARE CENTERS IN LOS ANGELES AND ORANGE COUNTY CALIFORNIA • ON AN AVERAGE BUSINESS DAY, CAREMORE… • Provides more than 900 rides to patients to and from points of care • Makes or receives 3,385 phone calls arranging for care • Sees 40 new members to assess health and establish personal care plans. • Provides more than 950 hours of homemaker services for the frail • Visits 27 homes to provide care or social support • Engages 4 families in end-of-life/hospice planning • Makes 235 follow up calls to patients in care programs • Provides 191 strength training sessions • Makes 90 care visits to patients residing in nursing homes/assisted living • Reads 567 blood pressures from monitors in the homes of hypertensive patients • Reads 369 weights from monitors in the homes of chronic heart failure patients • Sees 413 patients in our Care Centers for follow up and chronic care management

22. REFERENCES Genuth S, Eastman R, Kahn R, Klein R, Lachin J, Lebovitz H, Nathan D, Vinico F (2002). Implications of the United Kingdom Prospective Diabetes Study. Diabetes Care Volume 25, Supplement 1 National Diabetes Information Clearinghouse. DCCT and EDIC: The Diabetes Control and Complications Trial and Follow-up Study. Krop JS, Bertoni AG, Anderson GF, Brancati FL (2002). Diabetes-Related Morbidity and Mortality in a National Sample of U.S. Elder. Diabetes Care 25:471-475 USRDS Annual Data Report (2008). ESRD: Overall Hospitalization- Morbidity and Mortality. www.usrds.org Zinberg SS, Furman DS, Austin J. Older and Wiser (2007). Advance for Directors in Rehabilitation. p.39,40,48 Tinetti ME (2003). Preventing Falls in Elderly Persons. The New England Journal of Medicine. Volume348:42-49 Close J, Ellis M, Hooper R, Glucksman E, Jackson S, Swift C (2002). Prevention of Falls in the Elderly Trial (PROFET): a Randomized Controlled Trial. National Center for Biotechnology Information (NCBI) www.ncbi.nih.gov Ray WA, Thapa PB, Gideon P (2000). Benzodiazepines and the Risk of Falls in Nursing Home Residents. National Center for Biotechnology Information (NCBI) www.ncbi.hih.gov Medicare.gov Nursing Home Compare, Advancing Excellence Campaign in Nursing Facilities www.nhqualitycampaign.org Anderson G, Herbert R. Johns Hopkins University Analysis of Medicare Standard Analytical Files (SAF) 5% Inpatient Data. TheCommonwealth Fund www.commonwealthfund.org

23. REFERENCES Ostehega Y, Yoon SS, Hughes J, Louis T (2008). Hypertension Awareness, Treatment, and Control- Continued Disparities in Adults: United States, 2005-2006. NCHS Data Brief: National Center for Health Statistics Denny CH, Greenlund KJ, Ayala C, Keenan NL, Croft JB (2007). Prevalence of Actions to Control High Blood Pressure---20 States 2005www.cdc.gov/mmwr Lewington S, Clarke R, Qizilbash N, Peto R, Collins R (2002). Age Specific Relevance of Usual Blood Pressure to Vascular Mortality: A Meta-analysis of Individual Data for One Million Adults in 61 Prospective Studies The Lancet v.360, i. 9349, p.1903-1913 Canadian Hypertension Education Program Recommendations (2007). Hypertension as a Public Health Risk www.hypertension.ca HCUP Fact Book No. 1(2000). Hospitalization in the United States. AHRQ Publication No. 0031 www.ahrq.gov Garnett C (2000). Don’t Accept the Blues: Depression in the Elderly is Treatable. National Institutes of Health (NIH) www.nih.gov Depression in Late Life: Not a Natural Part of Aging (2009). Geriatric Mental Health Foundation www.gmhfonline.org NIH Senior Health (2007). Depression Frequently Asked Questions. National Institute of Mental Health www.nihseniorhealth.gov