Steve H. Landers MD, MPH

1. Community-based Chronic Illness Management:Strategies and Tools to Reduce Costs and Improve Outcomes April 5, 2010 Steve H. Landers MD, MPH Director, Cleveland Clinic Center for Home Care and Community Rehabilitation landers@ccf.org Brent T. Feorene, MBA President, House Call Solutions bfeorene@housecallsolutions.com

2. Today’s Agenda • Welcome and Introduction • Current trends • What is on the table? • Future tense • Programs that hold promise • CCF: Today and Tomorrow • Q&A

3. Powerful Trends Impact Medical Practice

4. Demographic Imperative Administration on Aging. A Profile of Older Americans: 2007. Accessed at www.aoa.gov

5. Activity Limitations Administration on Aging. A Profile of Older Americans: 2007. Accessed at www.aoa.gov

6. Chronic Illness Epidemic Johns Hopkins University, Partnership for Solutions. Chronic Conditions: Making the Case for Ongoing Care, A Chartbook. September 2004 Update

7. Aging + Chronic Illness Johns Hopkins University, Partnership for Solutions. Chronic Conditions: Making the Case for Ongoing Care, A Chartbook. September 2004 Update

8. Costly Congressional Budget Office

9. “High Risk” 2005 MCR FFS stats from MedPAC DataBook June 2008 Johns Hopkins University, Partnership for Solutions. Chronic Conditions: Making the Case for Ongoing Care, A Chartbook. September 2004 Update

10. Readmissions Half of Medicare Patients Rehospitalized Without Seeing Doctor After Discharge ~60% of Rehospitalized HF patients hospitalized due to another problem Jencks SF et al. N Engl J Med 2009;360:1418-1428

11. Physician Frustration • “Train Wrecks” “Gomers” • Frustration with the complexity, communication barriers, and administrative burdens… Adams WL, McIlvain HE, Lacy NL, et al. Primary Care for Elderly People: Why Do Doctors Find it So Hard? The Gerontologist. 2002;42(6):835-42. Adams WL, McIlvain HE, Geske JA, et al. Physicians’ Perspectives on Carring for Cognitively Impaired Elders. The Gerontologist. 2005;45(2):231-9.

12. Quality Concerns • “suffering in spite of spending” • “silo care” “no care zone” • avoidable readmissions • hospital acquired conditions • the “hidden patient” • frustration

13. Patient Centered Medical Home Bundled Payments Penalties for Re-hospitalizations “Accountable Care Organizations” What’s On the Table?

14. Chronic Care is Different • Engaging community • Self-management support • Advanced information systems/ tracking Bodenheimer T, Wagner EH, Grumbach K. Improving primary care for patients with chronic illness: the chronic care model, Part 2. Jama 2002;288(15):1909-14.

15. ‘New Model’ Primary Care • Practice “Redesign” • Team Approach • Advanced Information Systems • “Patient-Centered” • “Healing Relationships” 14. Martin JC, Avant RF, Bowman MA, et al. The Future of Family Medicine: a collaborative project of the family medicine community. Ann Fam Med 2004;2 Suppl 1:S3-32.

16. Patient-Centered Medical Home • Whole-Person • Team Based • Accessible • Advanced Information Systems • NCQA Certification Process Kellerman R, Kirk L. Principles of the patient-centered medical home. Am Fam Physician 2007;76(6):774-5.

17. The Case of Mrs. Jones • 82 year old woman, h/o HF and OOP • “Tired and weak and swollen ankles x 5 days” • Walker, Oxygen, Son’s Assistance

18. Bringing Home Medical Home? • Highest risk patients may not be able to access offices • Permanent • During time of vulnerability • Accessibility and whole person approach enhanced when care is done at home • Scalability of team Landers SH. The other Medical Home. Jama 2009;301(1):97-9.

19. “Secret Weapons” Enhances view of patient and caregivers Reduces barriers to care Strengthens patient relationships Avoids hazards of hospitalization Costs less Desired more Enabling technology emerging

20. Workforce Estimates • Annual FFS MCR HHA Visits > 110,000,000 • Medicare Home Health FTEs >250,000 • Annual FFS MCR Physician Visits < 2,000,000 • Home Care Physician and Mid-Level FTE’s ? • Total Primary Care Physician FTEs ~270,000

21. Role for Home Health Home health is likely the (only) truly scalable infrastructure for improving quality and access for the low-mobility, high risk Medicare beneficiaries who drive the majority of program expenditures and suffer the most---1st step in impacting quality for this group may be conceptualizing home health as THE central architecture/ platform to deliver transitional, post-acute, and primary care/ chronic care management for these individuals

22. Programs that hold promise • Transitional Care • Multi-level targeting patients with the right provider at the right time • House call programs • Reserved for the frailest, most complex patients Technology in the form of EMR/EHR and telehealth among others is not an absolute necessity, but has proven itself to be an excellent enabler to improve productivity, reduce costs and enhance outcomes.

23. A Role for Chronic Care Management Risk Factors Death High Adapted from, “The Glide Path” Kyle R. Allen, DO Medical Director, Post-Acute and Senior Services Summa Health System Long-term Care Primary Care Acute Care Public Health Normal Aging Health Capacity Accelerated Loss of Health Disability Disease Management Chronic Care Management Acute Event Time • Hip fracture • Stroke • CHF • COPD • Incontinence • Dementia • Caregiver burnout • IADL/ADL decline • Obesity • Tobacco and alcohol • Environmental • Hypertension • Rapid weight gain/loss • Hyperglycemia Cumulative, inter-related risk factors require ongoing, coordinated care interventions.

24. Transitional Care • Goal • Ensuring a smooth transition for the patient from one site or level of care to another that meets goals of care • Why? • Limits of traditional disease and case management in preventing adverse events and unnecessary utilization/costs

25. Rates of Rehospitalization within 30 Days after Hospital Discharge Jencks SF et al. N Engl J Med 2009;360:1418-1428

26. Who to target? • Community dwelling • Admitted for ambulatory sensitive conditions, such as COPD, CHF, Diabetes, Pneumonia and Dementia • Frequent flyers – two or more admissions in the past six months to one year • Individuals currently enrolled in case management

27. Patient Factors Contributing to Poor Post-Discharge Outcomes • Multiple conditions/therapies* • Functional deficits • Emotional problems • Poor general health behaviors • Poor subjective health rating* • Lack of support • Cognitive impairment** • Language, literacy and culture

28. Level I • A health coaching model using RNs • 25 – 30 patients per coach • Not a “doing” model • Lowest-intensity, lowest-cost model • Target thirty day duration • Enroll patients who are able to be “coached” to effectively self-manage through the transition

29. Level I • Five Principals • Medication self-management • Nutrition management • Patient health record • Physician follow-up • Red flag awareness

30. Level IProcess • Health coach visits while I/P • Introduce the program and gain acceptance • Prepare patient and family for follow-up • Home visit • One visit within 48 – 72 hours of discharge • Structured • Review the program in detail • Environmental scan • Medication reconciliation • Review discharge instructions • Introduce PHR • Discuss physician follow-up • Educate on red flags

31. Level IProcess • Key follow-up phone calls • 2 – 3 calls as needed • Ensures compliance and continuity • Modify plan • Plan to call after major post-acute events • Physician visit • Home health/therapy • Change in Rx regimen • Graduation

32. Level II • Use RNs in a more active model of care • RN must balance “coach” and “do” • Patient capabilities • Support systems • More extended time frames up to 6 months • Criteria are the same as Level I, but add • Significant ADLs/IADLs • Psycho-social concerns

33. Level IIProcess • Builds on Level I activities • RN visits while I/P • Initial home visit within 48 – 72 hours of discharge • Key follow-up phone calls • Coaches and provides care • May need additional home visit(s) • Graduation date can be extended based on situation

34. Level III • Highest level of intensity and care provision using NPs and/or PAs • A hybrid model, but weighted more toward medical than nursing • SNF-level patient able to remain community dwelling • Geriatric syndromes • ADLs/IADLs • Polypharmacy • Risk loss of functionality and/or exacerbation of chronic condition(s) • Most likely to bridge “at-risk” period successfully with effective, coordinated care

35. Level IIIProcess • Builds on concept of Levels I & II • Initial visit within 48-72 hours of discharge from SNF or hospital • Key follow-up phone call(s) • Typical 30 days enrollment to graduation • Back to office-based practice • Enrollment in house call program

36. House Call Program • Provide a patient-centered medical home to frail, low-mobility elderly • Physician and NP serve as the patient’s in-residence PCP • Primary care house calls • Urgent care visits • Collaborate with hospitalists on IP care • Coordinate specialty care, ancillaries and other health services, as needed • Offer counseling and social service coordination for patient and family/caregivers

37. House Call Programs • Typical profile • Difficulty getting to/from the PCP office • Have not seen PCP in 12 -18 months • ED most likely access point for healthcare services • 2+ deficiencies in ADLs • Complicated, chronic medical conditions and polypharmacy not likely responsive to other programs • Disruptive to PCP office flow • Physical/facility issues • Time and resource intensive • Difficult to meet the full spectrum of patient’s needs

38. What are the outcomes? • Community-based chronic illness management programs have demonstrated positive outcomes • Reduced utilization • Lower costs • Improved outcomes • Health • Quality of life/Goals of care

39. Transitional Care • Eric Coleman, MD • Randomized controlled trial of a Level I program • Outcomes • Reduced readmissions • Lower costs • In use by over 135 health systems nationally

40. House CallsMontefiore Medical Center Results for Medicare Advantage Enrollees

41. How are these programs paid?Managed Care/Payer Perspective • The economic incentives are aligned and the programs produce positive ROI • Montefiore • Summa Health System • Inspiris • United

42. How are these programs paid?Medicare FFS environment • Programs’ downstream benefits • Capacity management • Avoided admission • Reduced ALOS • Less pressure on ED • Fewer re- admissions • Increased market share • Provider professional billings • Partial contribution • MDs, NP & PAs • Community agencies

43. Cleveland ClinicCenter for Home Care and Community RehabToday: Gaining a beach head • System-wide recognition • Oversight and Strategy Board • Department of Home Care Physicians • Services • Mobile physician services • Geriatric consults • PCP • Home care, hospice, home infusion, etc. • Expansion of MPS • First to a specific CCF member hospital in development for 2010

44. Cleveland ClinicCenter for Home Care and Community RehabThe future: Strategic tool for CCF • Seamless delivery and coordination of care • Regardless of location • Regardless of age/time in life • Care transitions • New roles for home care staff • Use of telehealth and remote technologies

45. Transitional Care Resources • Eric Coleman, MD • www.caretransitions.org • National Transitions of Care Coalition • www.NTOCC.org • Better Outcomes for Older adults through Safer Transitions (BOOST) • www.hospitalmedicine.org/ResourceRoomRedesign/RR_CareTransitions/CT_Home.cfm

46. House Call Resources • American Academy of Home Care Physicians • www.aahcp.org • American Geriatrics Society • http://www.americangeriatrics.org/products/positionpapers/housecall.shtml

47. Thank You “The future belongs to those who believe in the beauty of their dreams” - Eleanor Roosevelt