Caring for Older Personswith Multiple Chronic Conditions

Chad Boult, MD, MPH, MBADirector, Improving Healthcare Systems,

Patient-Centered Outcomes Research Institute

Leyden Academy on Vitality and Ageing9 April 2013

79 year old widowerRetired teacher, lives

aloneIncome: small pensionDaughter lives 10 km

away, has three teenagers

Five chronic conditionsThree physiciansEight medications

Hans Nijpels

In the past year, he has had..

6 community

referrals

2home care agencies

5 months

homecare

2 nursing homes

6 weeks sub- acute care

3 hospital

admissions

19 outpatient

visits

8 meds

22 scripts

Mr. Hamond

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

Chronic care is:

FragmentedDiscontinuous

Difficult to accessInefficient

UnsafeExpensive

5+ Conditions

68%

01%

26%

310%

412%

13%

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

care spending

“Every system is designed perfectlyperfectlyto produce the results it gets”

Donald Berwick, MD

What’s Wrong Here?

Chronically ill

population

Health care system

designed to provide acute

care

“We simply cannot afford to postponehealth care reform any longer.

We must attack the root causes of the inflation in health care.”

Barack ObamaJune 2, 2009

What Can We Do?

Informed,ActivatedPatient

Chronic Disease Self-Management,Caregiver Support,

Action Plan

ProductiveInteractions

Prepared,ProactivePractice

Team

MonitoringCoaching

Improved Outcomes

DeliverySystemDesign

DecisionSupport

ClinicalInformation

SystemsSelf-

Management Support

Health System

CommunityResources and Policies

Health Care Organization

- T Bodenheimer et al JAMA, 2002

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”

Methods

Literature search: Medline,1987-2011

Tabulation of evidence for promising models

Classification of the strength of the evidence

Consensus ratings of models’ diffusability

2,714 titles identified

305 abstracts read

131 articles read

51 articles added from bibliographies

123 articles met inclusion criteria

2,409 excluded

174 excluded

59 excluded

10 Successful Diffusable Models

Model Improves health care quality or outcomes

Improves health care efficiency

Diffusability score (6-30)

APN-physician team (for dementia pts)

1 cluster RCT None 19

IDT (for CHF)1 meta-analysis

2 reviews1 meta-analysis

2 reviews25

Guided Care (for multi- morbid pts)

1 cluster RCT1controlled trial

1 cluster RCT1 controlled trial

23

Care mgmt (for CHF) 3 RCTs 3 RCTs 21

Pharmaceutical care 4 RCTs 2 RCTs 19

Self-management training

1 meta-analysis9 RCTs

4 RCTs 24

Proactive rehabilitation 4 RCTs 2 RCTs 19

Caregiver support/education

1 meta-analyses1 RCT

2 meta-analyses2 RCTs

19

Successful Diffusable Models

ModelImproves health care quality or

outcomes

Improves health care efficiency

Diffusability score(6-30)

Transitional care1 meta-analysis

1 RCT1 meta-analysis

2 RCTs20

APN-physician dyads (for NH residents)

3 quasi-experimental

studies

3 quasi-experimental

studies21

SummaryFour types of successful, diffusable models:

Primary care by interdisciplinary teamsAdjuncts to traditional primary careTransitional careDyadic 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

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

Nurse/physician teamAssesses needs and preferencesCreates an evidence-based “care guide”

and a patient-friendly “action plan”Monitors the patient proactivelySupports chronic disease self-

managementSmoothes transitions between care sitesCommunicates with providers in EDs,

hospitals, specialty clinics, rehab facilities, home care agencies, hospice programs, and social service agencies in the community

Educates and supports caregiversFacilitates access to community services

Boyd C et al. Gerontologist, 2007

Who is Eligible?

AllPatientsAge 65+

25%High-Risk

75% Low-Risk

Review previous year’s insurance

data with PM software

Patient Selection13,534 Patients of 14 teams/49 physicians

3,383 (25% highest-risk)

904 = Consenting Patients(Baseline

Evaluation)Random Allocation

419 in seven Control teams

485 in seven Guided Care

teamsBoult C et al. J Gerontology, 2008

Baseline CharacteristicsGuided Care Usual Care

Age 77.2 78.1Race (% white) 51.1 48.9Sex (% female) 54.2 55.4Education (12+) 46.4 43.4Living alone 32.0 30.6Chronic conditions

4.3 4.3

Risk of utilizaton 2.1 2.0*

ADL difficulty 30.9 29.3

AGGREGATE

Activation

Decision Support

Problem Solving

Coordination

Goal Setting

0 1 2 3 4

aOR

Effects on Quality of Care2.1

1.3

1.3

1.5

1.5

1.8

Quality rated in the highest category on PACIC

PACIC

Boyd et al. J Gen Intern Med, 2009

Effects on Caregiver Strain

Wolff et al. J Gerontology Med Sci, 2009

Effects on Physician Satisfaction

Marsteller et al. Ann Fam Med, 2010

Cha

nge

in S

atis

fact

ion

Very satisfied

Very dissatisfied

Satisfaction Items1= Familiarity with patients2= Stability of patient relationships3= Comm. w/ patients; availability of clinical info; continuity of care for patients4= Efficiency of office visits; access to evidence based guidelines5= Monitoring patients; communicating w/ caregivers; efficiency of primary care team6= Coordinating care; referring to community resources; educating caregivers7= Motivating patients for self management

GCNs' Satisfaction with Clinical Activities

1

2

3

4

5

6

1 2 3 4 5 6 7

Satisfaction Items

SatisfiedSomewhat satisfied

Somewhat dissatisfied

Dissatisfied

Comments by Guided Care Nurses

“The best job I’ve ever had”“I love this role.”

Annual Costs of Guided Care

Guided Care Nurse Salary $71,500 Benefits (@ 30%) 21,450 Travel (to pts’ homes, hospitals)

588

Communication services Internet, cell phone 1,800Equipment (amortized over 3 years) Computer 500 Cell phone 67TOTAL $95,905

Effects on Costs of Care(per caseload, 55 patients)

GC – UC Difference

AverageExpenditure

CostDifference

Hospital days -76.1 $1,519/day -115.6 SNF days -99.1 $305/day -30.2 Home health episodes -20.1 $1331/episode -26.8

Physician visits 40.0 $41/visit 1.7

Gross savings ----- ----- -170.9

Cost of GCN 95.9NET SAVINGS ----- ----- -75.0

Leff et al. Am J Manag Care, 2009

Health Service Use, 1st 20 Mos

Boult et al. Arch Intern Med, 2011

Hospital admits

Hospital re-admits

Hospital days

SNF admits

SNF days

ED visits

Primary care visits

Specialist visits

Home health

episodes

-60

-50

-40

-30

-20

-10

0

10

20Pe

rcen

t diff

eren

ce

**

-15%

-49%

-21%

-47%-52%

-17%

8%

-7%

9%

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

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.

How could these lessons be used to improve chronic care

in the Netherlands?