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Enhancing Care in the Community ALBERTA HEALTH SERVICES 1 Dr. Richard Lewanczuk Senior Medical Director Enhancing Care in the Community
Enhancing Care in the Community
ALBERTA HEALTH SERVICES 1
Dr. Richard LewanczukSenior Medical Director
Enhancing Care in the Community
Faculty/Presenter Disclosure
• Faculty: Dr. Richard Lewanczuk
• Relationships with financial interests:– Grants/Research Support: none– Speakers Bureau/Honoraria: none– Consulting Fees: none– Patents: none competing– Other: Employee of University of Alberta
Disclosure of Commercial Support• This program has received financial support from [organization name] in
the form of [describe support here – e.g. an educational grant].• This program has received in-kind support from [organization name] in
the form of [describe support here – e.g. logistical support].
• Potential for conflict(s) of interest:– Dr. Lewanczuk has not received [payment/funding, etc.] from [organization
supporting this program AND/OR organization whose product(s) are being discussed in this program].
– [Supporting organization name] [developed/licenses/distributes/benefits from the sale of, etc.] a product that will be discussed in this program: [insert generic and brand name here].
Mitigating Potential Bias Sponsor representatives are not members of the Planning
Committee of the program
The Planning Committee carefully chooses the topics for the program in order to ensure that the principles of scientific integrity, objectivity and balance have been respected
The Planning Committee chair and members have individual discussions with each speaker regarding expected learning outcomes and teaching formats
The Planning Committee communicates the course learning objectives and requirement for scientific integrity, as well as instruction on conflict of interest disclosure and managing bias, to each speaker, facilitator and moderator
What is ECC ?
Why is it important ?
What does it mean to me ?
What is ECC ?
“Enabling people to be as healthy, well and independent as they can
be in their homes and communities”
Why is it important ?What does it mean to me ?
What is the most expensive intervention in health care ?
“Hospitals are the biggest expense in the health care system and the costliest place to treat and care for patients. In 2018/19, Alberta spent $8.7 billion on hospitals, which represents 42.6% of Health's operating expense” - Blue Ribbon Panel
0-25th CostPercentile ($10)
25-50th CostPercentile ($131)
50-75th CostPercentile ($369)
75-90th CostPercentile ($911)
90-95th CostPercentile ($2288)
95-99th CostPercentile ($6367)
99-100th CostPercentile ($34407)
% Of Population 25% 25% 25% 15% 5% 4% 1%% Of Costs 0% 3% 9% 14% 12% 26% 35%
0%
5%
10%
15%
20%
25%
30%
35%
40%
Alberta Population Proportions Versus Health Care Cost Proportions – 2009/10
Notes: 1)Costs only include direct costs for inpatient, emergency, and urgent care and total physician costs for these same sectors and community primary care (approx. $3.7 billion). Costs in paranthesesare average costs per person for the group.2)Total population includes anyone active as of April 2010 or anyone who died within 2009/10.3)Cost percentiles were: 90th=$1,511; 95th=$3,504; 99th=$13,977. In other words 5% of folks used $3,504 or more and consumed 61% of total reported costs.Source: Strategic Analytics - DIMR - Alberta Health Services
Determinants of cost
sex, age group, days spent in inpatient, death, number of previous years in the HC5, average rank in previous years, and the 6 Group A CACP chronic diseases included in model – on IP days had any significant bearing
Who are these people?
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Complex High Needs Patients - Financial Impact
Chart1
Complex Infants/Toddlers
High Needs Children
High Needs Youth
High Needs Young Adults
Reproductive Health
Complex Older Adults
Frail Elderly
Total Costs
Total Costs (in Millions$)
411
143
96
174
583
1640
2684
Sheet1
Total Costs
Complex Infants/Toddlers$411
High Needs Children$143
High Needs Youth$96
High Needs Young Adults$174
Reproductive Health$583
Complex Older Adults$1,640
Frail Elderly$2,684
Frailty - definitions
• Unable to function independently – Mild: help needed with complex functions (e.g.
taxes, banking)
• Walking speed
Total adult population Three or more chronic diseases, no functional limitations
Health Care Spending Was Higher at Every Level for Adults with High Needs Than for Adults with Multiple Chronic Diseases Only
Three or more chronic diseases, with functional limitations
(high need)
Source: S. L. Hayes, C. A. Salzberg, D. McCarthy, D. C. Radley, M. K. Abrams, T. Shah, and G. F. Anderson, High-Need, High-Cost Patients: Who Are They and How Do They Use Health Care? The Commonwealth Fund, August 2016.
Note: Noninstitutionalized civilian population age 18 and older.Data: 2009–2011 Medical Expenditure Panel Survey (MEPS). Analysis by C. A. Salzberg, Johns Hopkins University.
frailty
Chart1
Total adult populationTotal adult populationTotal adult populationTotal adult populationTotal adult population
3+ Chronic Diseases, No Functional Limitation3+ Chronic Diseases, No Functional Limitation3+ Chronic Diseases, No Functional Limitation3+ Chronic Diseases, No Functional Limitation3+ Chronic Diseases, No Functional Limitation
3+ Chronic Diseases, With Functional Limitation (High Need)3+ Chronic Diseases, With Functional Limitation (High Need)3+ Chronic Diseases, With Functional Limitation (High Need)3+ Chronic Diseases, With Functional Limitation (High Need)3+ Chronic Diseases, With Functional Limitation (High Need)
Median
Top 25%
Top 10%
Top 5%
Top 1%
1154
4362
11738
20895
55962
3688
8194
17218
27573
61500
10710
26376
51380
73087
133083
Sheet1
MedianTop 25%Top 10%Top 5%Top 1%
Total adult population$ 1,154$ 4,362$ 11,738$ 20,895$ 55,962
3+ Chronic Diseases, No Functional Limitation$ 3,688$ 8,194$ 17,218$ 27,573$ 61,500
3+ Chronic Diseases, With Functional Limitation (High Need)$ 10,710$ 26,376$ 51,380$ 73,087$ 133,083
Can we predict who will be a high needs patient?
Michael Sanderson, Alberta Health 2016
Can we predict hospitalization ?
Loneliness and Health Care Costs in Seniors
Cost data AHS; health status courtesy of City of Edmonton
Chart1
24
20
17
14
12
Column2
Loneliness Score
Percentage in HC5
31
23
18
12
12
Sheet1
Column1Column2
2431
2023
1718
1412
1212
To resize chart data range, drag lower right corner of range.
Prospective associations of social integration with biomarkers of physiological functioning over the life course.
Yang Claire Yang et al. PNAS 2016;113:578-583
©2016 by National Academy of Sciences
Genetic effects of loneliness
Cole et al, Genorm Biol 8:R189, 2007
Of the “5/65”:
55% are significantly lonely
Maslow’s hierarchy of needs
Why are they being admitted into hospital?
Alberta hospitalizations
1 Giving birth 50,822 15.2
2 Respiratory disease (COPD) 7,995 2.4
3 Convalescence, typically following treatments/procedures 6,392 1.9
4 Heart attack 6,335 1.9
5 Pneumonia 5,738 1.7
6 Gonarthrosis (arthrosis of knee) 5,711 1.7
7 Heart failure 5,303 1.6
8 Other medical care (e.g., palliative care, chemotherapy) 4,563 1.4
9 Fracture of lower leg, including ankle 4,323 1.3
10 Acute appendicitis 4,194 1.3
n %
“Medically, this person didn’t need to be in hospital but…
- I couldn’t send them home…- I knew they couldn’t manage at home…- I knew that if I sent them home they
would be right back…”
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Heard time and time again in physician interviews regarding hospitalization in Alberta
“How often do you have someone you can ask for help when you need it?”
Courtesy of Joyce Anderson – PEGASIS project
Where do you think these people go to seek help?
Variation in Inpatient Admissions by Community
Variation in Inpatient Admissions by Community
How does this apply to me ?
Complex High-Needs Patients
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Diabetes prevalence
Material Deprivation
Low primary Care continuity
40
Top diseases by cost in Alberta
1. Hypertension2. Diabetes3. Depression4. Asthma5. Dyslipidemia6. Coronary artery disease
Case 1:• A 62 year old woman with a 4 year history of type 2
diabetes is seen in your office. Her most recent HbA1c is 10.8 % - it has never been below 9%
• She is on metformin, gliclazide and bedtime Lantus insulin
1. What are some possible explanations for why her diabetes is not controlled?
2. What would you do now?
3. What factors in people with diabetes do you think predict who will be uncontrolled vs controlled?
Risk of having diabetes out of control by neighbourhood income in Alberta
K. A. McBrien et al. Diabet Med 33:1499, 2016
Chart1
1
2
3
4
5
Column1
Income Quintile – low to high
Relative Risk
1.22
1.16
1.1
1.04
1
Sheet1
Column1
11.22
21.16
31.1
41.04
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Health (a long term goal) is not a priority for people who need to focus on shorter term goals of
survival.
Dr. Angela Donkin, Institute of Health Equity
In 2014, Feeding America and the National Foundation to EndSenior Hunger2 found that food insecure seniors were atan elevated risk for a number of chronic health conditions:
60% greater chance of depression 53% greater chance of heart attack 52% greater chance of asthma 40% greater chance of congestive heart failure 50% greater chance of diabetes 14% greater chance of high blood pressure
Tackling hunger to improve health in America, 2016
HbA1c drop with second or third drug: 0.5 – 1.0%HbA1c drop with food security: 2.1% (Geissinger)
Case 2:
• A 71 year old woman presented with concerns about her weight and type 2 diabetes
• BMI 42, HbA1c 6.4% on metformin alone• History of mild colitis, mild asthma, diffuse mild CAD• Claims she eats little, but cannot exercise due to deconditioning• Is a lawyer who have up her practice a number of years ago to look
after her husband who had severe CHF• He passed away 3 months previously• Cannot walk very far, cannot step up curbs, depressed, no social
contacts• On 15 medications and had 13 specialist visits in the last 6 months,
all at her request
What is going on?
Case 3:• An 83 year old man presents dizziness and falls• History of two TIA’s, atrial fibrillation, hypertension• Smokes 5-6 cigarettes a day• Lives alone, speaks very little english, wife passed away
3 years ago• Prescribed ramipril, hydrochlorothiazide, metoprolol,
dabigatran, acetominophen, rosuvastatin•He refuses to take these medications
How would you approach this case?
Shared Decision MakingGoals of Care
What is the evidence?
From: Rubin et al, Rand Research Reports 2016, DOI: 10.7249/RR1252 Document Number: RR-1252-RC
The greater the social spending, the better the health
If poverty is the problem, is money the answer?
Effect of social vs medical spending on health outcomes
Stuckler et al, BMJ 2010;340:c3311
What can be done about this?
ALBERTA HEALTH SERVICES 56
What percentage of hospitalizations are
theoretically preventable ?
Housing, Transportation, And Food: How ACOs Seek To
Improve Population Health By
Addressing Nonmedical Needs
Of Patients
Fraze et al. Health Aff35:2109, 2016
e.g. C2C
Which is the largest hospital in Alberta ?
11.4%
3.4%
Are there hospitals in heaven?
Evaluation of Doncaster Social Prescribing ServiceCentre for Regional Economic and Social Research, Sheffield Hallam University 2016
15%
Who provides care in the community?
formal care
90%
10%
30%
70%
informal carevolunteer
“system”
Healthy London Partnership 2017
WIIFM ?
(i.e. the 97%)
What next ?
Healthcare
Social Services
EducationVolunteerGroups
MunicipalitiesJustice
Communities
Families
Questions, Comments ?
Slide Number 1Faculty/Presenter DisclosureDisclosure of Commercial SupportMitigating Potential BiasSlide Number 5Slide Number 6What is the most expensive intervention in health care ?Slide Number 8Determinants of costWho are these people?Complex High Needs Patients - Financial ImpactFrailty - definitionsHealth Care Spending Was Higher at Every Level for Adults with High Needs Than for Adults with Multiple Chronic Diseases OnlyCan we predict who will be a high needs patient?Slide Number 15Can we predict hospitalization ?Slide Number 17Loneliness and Health Care Costs in SeniorsSlide Number 19Slide Number 20Of the “5/65”:Slide Number 22Slide Number 23Maslow’s hierarchy of needsSlide Number 25Why are they being admitted into hospital?Alberta hospitalizations“Medically, this person didn’t need to be in hospital but…��- I couldn’t send them home…�- I knew they couldn’t manage at home…�- I knew that if I sent them home they� would be right back…”“How often do you have someone you can ask for help when you need it?” �Slide Number 30Slide Number 31Slide Number 32Variation in Inpatient Admissions by CommunityVariation in Inpatient Admissions by CommunityHow does this apply to me ?Complex High-Needs PatientsDiabetes prevalenceSlide Number 38Slide Number 39Top diseases by cost in AlbertaCase 1:Risk of having diabetes out of control by neighbourhood income in AlbertaSlide Number 43Slide Number 44Slide Number 45Slide Number 46Case 2:Case 3:Slide Number 49What is the evidence?The greater the social spending, the better the healthIf poverty is the problem, is money the answer?��Effect of social vs medical spending on health outcomesSlide Number 53Slide Number 54What can be done about this?Slide Number 56What percentage of hospitalizations are theoretically preventable ?Slide Number 58Slide Number 59Slide Number 60Housing, Transportation, And Food: How ACOs Seek To Improve Population Health By Addressing Nonmedical Needs Of Patients���Fraze et al. Health Aff 35:2109, 2016Which is the largest hospital in Alberta ?Slide Number 63Are there hospitals in heaven?Slide Number 65Slide Number 66Slide Number 67Evaluation of Doncaster Social Prescribing Service�Centre for Regional Economic and Social Research, Sheffield Hallam University 2016Slide Number 69Who provides care in the community?Slide Number 71Slide Number 72Slide Number 73What next ?Questions, Comments ?
