Chronic Disease and Aging The 21 st Century Healthcare Challenge

1. Chronic Disease and Aging The 21st Century Healthcare Challenge Howard Bergman, MD, FCFP, FRCPC Chair, Department of Family Medicine Professor of Family Medicine, Medicine and Oncology The Dr. Joseph Kaufmann Chair of Geriatric Medicine McGill University • Family Medicine • Médecine de famille 17.3.12

2. The Shifting Face of Health Care • From acute to chronic disease • From institutions to networks of care; from a single site (hospital, nursing home) to many sites: home, assisted living, supportive housing, physician’s office, community clinics, ambulatory care centers, community hospitals, academic health centers, rehabilitation facilities, nursing homes, palliative care centers • From a single professional, generally a physician to many health care professionals: family doctors, specialists, nurses, physical therapists, nutritionists, social workers, psychologists, etc. • Expectations/knowledge/Involvement of patients and family

3. The Shifting Face of Health Care • ↑ Complexity • ↑ Interdependency • ↑ Uncertainty • Increasing preoccupation with costs and performance leading to increased government intervention/control/reform • Continuous change

4. Aging and Chronic DiseaseThe Challenge for the 21st Century Dramatic increase in the number of old, in particular old/old Increase in prevalence of chronic disease 1 in 5 baby boomers will develop dementia Cardiovascular: most important cause of hospital admission Diabetes: increasing prevalence with age: 10% over 65 Cancer: increasing incidence and mortality with age

5. Growth will be greater at older ages …

6. Aging and Chronic DiseaseThe Challenge for the 21st Century Complex relationship Increase in chronic diseases due to aging as a result of longer exposure to chronic disease risk factors in a vulnerable population Cumulative impact of chronic disease throughout the life course contributes to frailty and ultimately disability and dependency A global challenge ↑ chronic diseases +↑ life expectancy = Aging with↑ disability

7. Heath care systems and the challenge of aging • Potential for promotion/prevention promoting healthy aging and in at least delaying onset of frailty and disability • ↑ complex interventions (technology/surgery/medication) in increasingly older persons • Health care systems poorly adapted to the management of chronic disease, frailty and dependency; complexity of treating chronic diseases and frail older persons

8. Prevalence of Diabetes in Montreal

9. Prevalence of Heart Failurein Montreal

10. Aging and Chronic DiseaseThe Challenge for the 21st Century People $$$ Those w/multiple chronic conditions 33% 6% 31% 21% Those w/one chronic condition 36% Those w/no chronic conditions 72% • drivers of morbidity, mortality, utilization and costs • A challenge to quality of life of elderly and healthcare system sustainability Source: Kaiser Permanente Northern California commercial membership, DxCG methodology, 2001. http://www.natpact.nhs.uk/uploads/BobCrane.ppt#270

11. Increasing prevalence of chronic disease • but.. are we getting it right

12. Optimizing Quality and Best Practice in Primary Care

13. What seniors receive?Jencks et al., JAMA, 2003; 289:305ACOVE, Ann Int Med, 2003; 139:740 • AMI – 50-75% receive B-blockers, 43-50% counseled for smoking • CHF – 65-68% ACE on discharge • Stroke – 57% of A-fib on anti-coagulants • Diabetes – 48-70% have eye exam • Falls – 3% of fallers have fall examination • Depression – 26% of those with depressive symptoms treated or referred • Medications – 18% of those prescribed new drug had documented education • Cognition – 52% of new patients tested

14. Health and functional status of cancer patients, aged 70 years and older referred for chemotherapy- preliminary findings Retornaz F, Monette J, Monette M, Sourial N, Wan-Chow-Wah D, Puts M, Small D, Caplan S, Batist G, Bergman H. Usefulness of frailty markers in the assessment of the health and functional status in older cancer patient referred for chemotherapy Journal of Gerontology:medical sciences. 2008

15. Life expectancy percentiles for men. Top 25th percentile vulnerable 50th percentile Lowest 25th percentile Healthy With ADL disabilities Walter LC et al. JAMA 2001, 285, 2750-2756

16. Embracing the heterogeneity and complexity • Healthy older persons • Primary medical care, Health assessment/promotion/prevention • Early frail/low risk/chronic disease • Primary medical care, Chronic disease management, detection of vulnerability, preventive home visits • Medium risk/mild-moderate disability • Primary medical care and home care, chronic disease management. Specialized Geriatric care, • ↑ Disability and “complex” systems of integrated care • End of life care

17. Implementation in a coherent system: challenges to explore Prevention and chronic disease management • Programs for health promotion/prevention • Chronic disease management for clinical priorities in older persons • Diabetes, CHF, hypertension, depression, cancer, dementia • Potential role of frailty/vulnerability markers

18. Implementation in a coherent system: challenges to explore • Population Health Approach • Primary Care Reform • The Family Medicine Group(GMF): basis for integration • Example of proposed Quebec Alzheimer Plan • Collaborative care model ; Partnership MD-Nurse-Patient-caregiver; Nurse navigator • Community social care (AD support centre) • Intensive team based case management and multidisciplinary community based services • Role of specialty care • End of life care http://www.rqrv.com/en/document/alzheimer_report.pdf http://www.rqrv.com/fr/document/rapport_alzheimer.pdf

19. Primary Care Medical Reform in Canada • GMF (Qc); Family Health Teams (Ont); Medical Home (College of family Physicians of Canada • May or may not be in the same building eg BC and Alberta • Group practice; interdisciplinary practice; continuity of care with population and healthcare system responsibility; evolving remuneration; IT infrastructure: evolving integration of other healthcare professionals

20. Priority Action 2 Provide access to personalized, coordinated assessment and treatment services for people with Alzheimer’s and their family/informal caregivers • Implementation of a service structure based on the chronic-care model and the collaborative-practice model, introduced gradually, starting in Family Medicine Groups (FMGs) and Network Clinics (NCs). • The primary care physician and the nurse clinician responsible for continuity of patient services establish a partnership with each patient and his or her family for the process of assessment, diagnosis, treatment, monitoring, and follow-up. • Approximately 10 to 15 patients with AD per MD = 100-150 per FMG with 10 MDs • The nurse clinicianplays the role of Alzheimer’s nurse care navigator.

21. Chronic Disease and Aging in the Acute Care Setting • ↑ of chronic diseases • ↑ hospitalization • ↑ hospitalization for Ambulatory Case-Sensitive (ACS) conditions • ↑ hospitalization associated with avoidable and costly complication • > 65 • 37% of admissions • 50% of hospital days • ↑ readmission Siu et al: Health Affairs 2008

22. Change in profile ofhospitalized patients • Profile of patients on admission • demography/health promotion and prevention/medical care • Treatment/intervention in ambulatory and primary care • Increasingly complex medical and surgical interventions on older and older patients

23. The Challenge of the Aging Population • Frailest elderly ~3% of population are the major client group, use 30% of health-care resources • Seniors use 1/3 of all hospital admissions & 1/2 of inpatient days (2002/2003 Hospital morbidity database) • Readmission rates 42% in patients >75 years • Seniors have higher rates of return visits to emergency • Disconnect between patient needs and hospital practices = “hostile environment” • Frail elderly experience further functional decline not related to acute episode but to hospital practices (Inouye et al 2000) • Adverse effects are higher in frail elderly even when adjusted for age/co-morbidity

24. High Resource Hospital Patients: 2/3 are Seniors Majority go home after hospitalization; Account for up to 80% of ALC days; 30%-40% have a mental health co-morbidity Health Region: Hospital Inpatient Data 06/07 5% 11% 36% Source: DAD database CIHI 1Defined as discharges not coded as emergency, direct or clinic; excludes stillborns, newborns and day surgery

27. Disconnect between patient needs and hospital environment • The loss of independent functioning during hospitalization has been associated with: • (Inouye et al 2000) • Prolonged lengths of hospital stay • Increased readmission • A greater risk of institutionalization • Higher mortality rates • Myth: Elderly patients with chronic diseases are blocking the system • It’s only an outflow problem

28. An appropriate approach …60 years ago • Structured to support continued action on single disease strategies and approaches; disjuncture and repetition of activities • Based on reducing LOS of uncomplicated acute admissions • Patients too complex to fit into standard critical pathways and treatment models • The complex patients (“acute on chronic”; functional decline; decreased reserve with age) get lost: • ↑ LOS;↑ LTC; ↑ Readmissions Siu et al: Health Affairs 2008: The ironic case for the chronic disease model in the acute care setting

29. The Acute Care settingRe-thinking the approach in a coherent system of care • Engagement with primary medical and community care: a collaborative care approach • Transition in and out of the hospital • Specialty care supporting primary care • Not necessarily within the hospital • Engagement with LTC • Smooth transitions • Prevention of admissions Counsell JAMA 20007; Callahan JAMA 2008; Boult Journal Geronto Med sciences 2008; Béland, Bergman et al Journal Geronto Med sciences 2007 Naylor

30. Present system of care • Poor communication of best practices • Innumerable programs and models • The national disease strategies

31. The Acute Care settingRe-thinking the approach in a coherent system of care • From the traditional medical and surgical wards to the collaborative care wards • Clinical processes and organization of care within the hospital • Interdisciplinary team directed care based on best practices • Integrate holistic older person evaluation within the acute care process • Physical organization • Hospital environment • Patient and family engagement • Training including end of life care

32. The Acute Care settingRe-thinking the approach: the key elements • Aggregating the 3 components in a coherent system • Pre-hospital • Intra Hospital • Post-hospital • Inter disciplinary rather than disciplinary • Partnership: clinicians, managers, the community • Research: a key component

33. The Chronic Disease Modelquestions and issues • Can the Chronic Disease Model be implemented without primary medical reform • Family Medicine Groups in Quebec • How can the Chronic disease(S) model be integrated into primary care

34. Beyond the ModelsReflections on key elementsPrimary care What seems to work/needs to be tested Primary med care: org infrastructure/remuneration The multi disciplinary care integrated into primary medical care Evolution of relationships among professionals Rapid access to intensive professional services (professional and social); access to a wide range of assisted/supportive housing Population data/ responsibility What does not seem to work Primary med care: organization /infrastructure/remuneration not suited to complex continuing care The programmatic, budgetary and geographic cleavage between primary medical and multidisciplinary care Parallel play among professionals Sporadic responsibility There are no emergencies

35. Specialized Geriatric Program hospital ER/wards ACE/GAU BEDS ER/WARD CONSULTATIONDAY HOSPITALREHAB OUTPATIENT Transition beds MD/nurse clinician geriatric consultation team Primary medical care Primary multidisciplinary care INTENSIVE TEAM BASEDCASE MANAGEMENT DAY PROGRAMS ASSISTED LIVING COMMUNITY PROGRAMS

36. Critical role of research in change • Understanding the health and functional status, on trajectory and costs of the population • Data to help understand why change is necessary and to make evidence based decisions • Understanding attitudes and expectations of both clinicians, patients and families • Clinical research and hospital and community based studies • Evaluative research • Synthesising evidence

37. Conclusion • A shared vision of the challenge • A complex challenge • data • The long haul • a multi disciplinary approach and a multi-dimensional integrated strategy • Do not try and boil the ocean