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?
