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ChronicCareManagementintheElderly
Siobhan Sundel, DNP, GNP‐BC, ANP
No Financial disclosures
Objectives
• Understand principles and applications of the Chronic Care Model.
• Identify key components and benefits of team‐based care.
• Understand reimbursement for chronic care management activities.
• Identify special considerations to be aware of when applying clinical guidelines to elderly patients.
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WhyisChronicCareManagementImportant?
StatisticsonChronicIllness• In the United States, 60% of adults have at least one chronic illness.
• Over 80% of Americans 65 years or older have multiple chronic illnesses.
• Individuals with five or more co‐morbidities account for 40% of healthcare spending.
Buttorff, C., Ruder, T., & Bauman, M. (2017). Multiple chronic conditions in the US. Rand Corporation. Retreived from https://www.buttorfetal.2017.org/pubs/tools/TL221.thml
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ChronicIllness
• Characterized by slow progression and long duration
• Usually degenerative and incurable
• Examples of chronic illness:
• Hypertension (HTN)
• Congestive Heart Failure (CHF)
• Diabetes Mellitus (DM)
UnitedStatesHealthcareSystem
• Historically focused on acute, episodic care of infections, trauma and disease‐specific illness, resulting in a cure.
• Medicare fee‐for‐service reimbursement was designed to work with event‐driven episodic care.
• However, as the population aged, event‐driven care did not adequately meet the ongoing needs of chronically ill older adults.
DeficienciesintheCurrentHealthcareSystem
• Providers unable to perform comprehensive exams due to time limitations.
• Lack of care coordination within and between provider practices, resulting in fragmented care.
• Lack of active follow‐up between visits.
• Patients inadequately educated to manage their illnesses.
• Healthcare system designed to reimburse face‐to‐face caregiving, focused on a cure rather than facilitating preventive and long‐term management of chronic illness.
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ChangeinHealthcare
ChronicCareModel(CCM)
• “Wagner Model”
• Developed by Edward Wagner and his team at The MacColl Center for Healthcare Innovation in the late 1990s.
• CCM focused on team‐based care providing comprehensive support to patient in self‐managing their chronic illness.
www.maccollcenter.org
AimsofCCM
• Promote development of healthcare teams
• Team members work closely with the patient during and between office visits
• Patient access to community resources
• Patient takes more responsibility for their own health
• Results in slowing progression of disease process and reduced development of co‐morbidities
Wagner, E. H. (1998). Chronic disease management: What will it take to improve care for chronic illness? Eff Clin Prac, 1, 2‐4
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ElementsoftheCCM
• Self‐management support (“activated” patient)
• Delivery system design (team‐based care)
• Decision support (best practice information for patient and family members)
• Clinical information systems (using registries that can provide patient‐specific and population‐based support to the care team)
• Community (engage local social service resources)
• Health system: institutional, statewide and national (changes need to flow across the system, clinically, administratively and financially)
TeamMembers
TeamMembers
• Attending Physician (MD)
• Advanced Practice Registered Nurse (APRN)
• Registered Nurse (RN) or Licensed Practical Nurse (LPN)
• Social Workers (SW)
• Medical Assistant (MA)
• Psychological counselors and Certified Diabetic Educators can also be reimbursed under new CMS rules
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CCMGeriatricModelsProgram for All‐Inclusive‐Care
for the Elderly (PACE)
• Clients enrolled in PACE program must have Medicare and Medicaid
• Services include:• Day care• Physical therapy• Home care• Emergency care• Medication and equipment
The Hospital at Home Program
• Developed by the Johns Hopkins Schools of Medicine and Public Health
• Patient usually evaluated in ER by provider with Hospital at Home
• Providers and team members treat patients for acute infections, dehydration, wound care
Medicare.govwww.hospitalathome.org
Third‐PartyReimbursementandChronicCareManagement
• Historically, Medicare and Medicaid only reimbursed for face‐to‐face encounters.
• Management of chronic illness occurred during the office visit.
• The patient was left to manage their illness between office visits.
• This resulted in poor care coordination, emergency room visits, readmission to the hospital and increased financial burden to the healthcare system.
ReimbursementforCCM
• In January 2015, Center for Medicare and Medicaid Services (CMS) created billing codes that allowed for reimbursement for chronic care management services provided to Medicare beneficiaries with two or more chronic illnesses.
• Services included:
• 24/7 access to address patient’s urgent chronic care needs
• Increased communication between patient, caregiver and provider (phone calls, emails, text messages)
CMS (2016)
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ReimbursementforCCM• 2015
• CPT code: 99490 – required elements:
• Two or more chronic conditions expected to last at least 12 months or until the patient dies
• Chronic conditions place the patient at risk of death, acute exacerbation/decompensation or functional decline
• Comprehensive care plan established, implemented, revised or monitored
• Introduced reimbursement for non face‐to‐face management via phone, email or text messaging:
• Medication reconciliation• Preventive services• Monitoring of patient’s condition
CMS (2016)
ReimbursementforCCM2017
• These guidelines were updated in January 2017, with new codes for additional reimbursement.
• CPT code: 99487 – required elements:
• Two or more chronic conditions expected to last at least 12 months or until the patient dies
• Chronic conditions place the patient at risk of death, acute exacerbation/decompensation or functional decline
• Establishment or substantial revision of a comprehensive care plan
• Moderate or high complexity medical decision making
• 60 minutes of clinical staff time (APRN, MD, RN, SW)
ReimbursementforCCM2017
• 2017 updates ‐ new code added:
• 99489 ‐ each additional 30 minutes of clinical staff time directed by provider, RN or SW
• Report 99489 in conjunction with 99487
• Payment for initial care plan
• Time can be entered by any clinical staff member (APRN, MD, RN, SW)
• One‐time patient consent to the services can be verbal
CMS 2016
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CCM
* in 2017
CCM:Requirements
• Applies to Medicare Fee‐for‐Service Program
• Beneficiaries with 2 or more chronic conditions
• At least 20 minutes of qualifying time/month
• Only one practitioner can bill per month (for example the geriatrician can bill or the cardiologist – not both)
• The following services cannot be billed in the same month:
• Transitional Care Management
• Care Plan Oversight for Hospice Services
• Certain ESRD services
PhrasesforCCMConsent
• Dot‐phrase we use at Mount Sinai:
• Chronic Care Management services were explained to (patient’s name) the Patient, who accepts Chronic Care Management services
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CCMCarePlan• Must include:
• Patient Active Problem List
• Medications
• Allergies
• Current Diagnoses with Plan
• For example:
• Diabetes• a1c 6.7• continue lifestyle modification• HTN• Blood pressure well controlled on current medications
TheProcess
• Identify eligible patients
• Obtain verbal consent and document in patient’s record
• Document a care plan in patient’s record
• Document all non‐face‐to‐face encounters in patient’s record (telephone, email contacts) noting time spent
ExampleofCCMTimeSpent
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ExampleofBillingforCCM
• PCP will receive monthly Epic message regarding patients eligible for CCM billing (consent and time spent)
• PCP will also receive PDF report of their patients who had time listed for CCM or have CCM consent
• If appropriate for CCM billing, PCP contacts front desk staff to schedule/arrive patient on last day of month
• Once arrived on Epic schedule, PCP opens encounter, documents care plan if not done in last 12 months, documents CCM note, enters CPT codes (99490, 99487 and 99489) in level of service area and closes encounter
CMSResources
• CCM
• https://www.coms.gov/Outreach‐and‐Education/Medicare‐Learning‐Network‐MLN/MLNProducts/Downloads/ChronicCareManagement.pdf
• FAQ: https://www.cms.gov/Outreach‐and‐Education/medicare‐Learning‐Network‐MLN/MLNMattersARticles/Downloads/SE1516.pdf
SpecialConsiderations
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SpecialClinicalConsiderations
• Elderly patients frequently present with atypical symptoms, which can complicate accurate diagnosis.
• Elderly patients often develop geriatric syndromes, which can undermine effective care management.
• Commonly used best practice guidelines for both diagnosis and treatment might not always be appropriate for the geriatric patient.
AtypicalPresentation
• Geriatric patients may present with signs and symptoms for common conditions that differ from those standardly seen in the broader population.
• Example: a younger patient with pneumonia would likely present with fever and productive cough, whereas an older patient might be afebrile and lethargic.
• Important because failure to accurately diagnose can lead to failure to properly treat.
WhyDoesThisOccur?
• Age‐related changes
• Age‐related loss of physiologic reserve such as loss of muscle strength, otherwise known as sarcopenia
• Patient may underreport symptoms of acute illness believing they reflect their chronic condition
Liang, S. Y. (2016). Sepsis and other infectious disease emergencies in the elderly. Emerg Med Clin North Am; 34(3); 501‐522Navaratnarajah, A. & Jackson, S. H. D. (2017). The physiology of aging. Medicine; 45(1); 6‐10.
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Typicalvs.AtypicalSigns&SymptomsforInfections
Typical Presentation Atypical Presentation
• Fever • Afebrile
• Productive cough• Shortness of breath• Purulent sputum
• Absence of cough• Anorexia• Altered mental status• Functional decline
• Dysuria• Urinary frequency• Urinary urgency
• No complaint of dysuria• Altered mental status• New onset of urinary
incontinence
Liang (2016)Michels, T. C. & Sands, J. E. (2015). Dysuria: Evaluation and differential diagnosis in adults. Am Fam Physician; 92(9); 778‐788Niederman, M. S. (2015). Community acquired pneumonia. Ann Intern Med; 163(7); itc1‐17Norman, D. C. (2000). Fever in the elderly. Clini Infect Dis; 31(1); 148‐151
CaseStudy
• AC is a 95‐year old Hispanic female with history of AF, CHF, HTN, CAD, CVA, and dementia
• Seen by the NP in the geriatric practice for nausea, failure to thrive and shortness of breath
• PE: crackles and expiratory wheezing base to top bilaterally, pulse oximetry=82%
• Patient sent to ER for evaluation of hypoxia
• Diagnosed with Community‐Acquired Pneumonia
GeriatricSyndromes
• Common conditions that occur in the elderly such as falls and urinary incontinence
• These syndromes have multiple causes, involving multiple organ systems with multiple risk factors
• Frequently misdiagnosed and/or undertreated
• Associated with poor health outcomes and functional decline
• May impact or worsen normal age‐related changes
Inouye, S. K., Studenski, S., Tinetti, M. E., & Kuchel, G. A. (2007). Geriatric syndromes: Clinical, research and policy implications of a core geriatric concept.J Am Geriatr Soc; 55(5); 780‐791
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CommonlySeenGeriatricSyndromes
Geriatric Syndromes Common Causes Risk Factors
Falls • Dizziness• Medication• Polypharmacy• Chronic Conditions
• Age• Gender• Vision/hearing problems• Environmental• Dementia• Frailty
Urinary Incontinence
• Age• Menopause• BPH• Medication• Neurological disorders
• Age• Gender• Obesity• Family History• Smoking
PatientswithGeriatricSyndromes
• Should be seen by the same provider (MD or APRN)
• Steps taken to reduce the incidence of geriatric syndromes could result in preventing or reducing the impact of these syndromes
• Should be evaluated several times per year during routine office visits
ImpactofGeriatricSyndromes
• One fall can significantly impact the life of an elderly patient
• Patients with osteoporosis or osteopenia who fall can require surgery and rehabilitation for an extensive period of time
• Prolonged hospitalization can increase a patient’s risk for developing a hospital acquired infection such as pneumonia or urinary tract infections
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CaseStudy:SFBefore
• 84 year old female with mild dementia, HTN, Asthma, living alone, completely independent in her ADLs/IADLs, managed her own finances
• Fell into furniture while getting out of chair
• Broke distal aspect of her right femur and right wrist
• Transported to a local ER, then to a trauma hospital for surgery on complex fracture of right femur
• Transferred to Sub‐acute Rehab, discharged home after 100 days
• SF’s bathtub was converted to a walk‐in shower to accommodate her walker
• After discharge, had HHA 28 hours per week to assist with ADLs and IADLs
CaseStudy:SFin2018
• Still has HHA 28 hours per week
• Uses quad cane when outside and walker at home
• Does not prepare her own meals
• Unable to do any of her finances due to worsening dementia
• Daughter visits frequently
SF:Before,AfterandNow
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PrescribingfortheGeriatricPatient
GeriatricPrescribing
• Elderly patients are more vulnerable to possible toxic effects of medications and sometimes less responsive to therapeutic benefit, due to physiological changes of aging.
• Example, most elderly patients have chronic kidney disease starting at stage 3
• Since many medications are metabolized by the kidneys, important to calculate Creatinine Clearance when determining if patient should be prescribed a certain medication
Pretorius, R. W., Gataric, G., Swedlund, S., & Miller (2013). Reducing the risk of adverse drug events in older adults. Am Fam Physician; 87(5); 331‐336
ImportantConsiderations…
• Understand the physiology of aging and increased organ system vulnerability
• Be aware of the common causes of adverse drug events
• Conduct comprehensive medication review at each visit including over‐the‐counter medications and herbal supplements
.
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InappropriateMedicationsforGeriatricPopulation
• The Beers Criteria serves as a guide for geriatric prescribing
• Updated in 2015 by the American Geriatric Society
• Available for download at https://www.priorityhealth.com/provider/clinical.../cms‐high‐risk‐medications.pdf
AGS (2015)
AGSBeersCriteria:AvoidingMedicationsInappropriateforOlderAdults
• Divides medications into five categories:
1. Inappropriate for older adults
2. Potentially inappropriate for older adults (due to drug–disease or drug–syndrome Interactions that may exacerbate the disease or syndrome)
3. Possibly inappropriate, to be used with caution in older adults
4. Potentially clinically important non‐anti‐infective drug–drug interactions that should be avoided in older adults
5. Medications to avoid or adjust dose in older patients based on kidney function
AGS (2015)
ClinicalGuidelinesandElderlyPatients
• Clinical guidelines are commonly used for diagnosing and treating specific chronic illnesses
• These guidelines often apply to a much younger population (< 75 yo)
• Guideline recommendations may not be applicable to an elderly patient with multiple co‐morbidities
• Examples: • HTN• CHF• DM
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Hypertension(HTN)
• There are many hypertension guidelines available
• This presentation will review guidelines from:
• The American College of Cardiology (ACC) and the American Heart Associates (AHA) Task Force published in 2017
• JNC 8
BloodPressureGuidelines:Normalvs.Hypertensive
Status of Patient’s Blood Pressure Blood Pressure Reading
Normal 120/80
Elevated 120‐129/<80
Stage 1 Hypertension 130‐139/ or/ 80‐89
Stage 2 Hypertension ≥ 140/ or /≥ 90
Whelton, P, Carey, R. M., Arono, W. S., Casey, D.E., Collins, K. J., Dennison Himmelfarb, C. D. …Wright, J. T. (2017). ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA guidelines for the prevention, detection evaluation, and management of high blood pressure in adults: Executive sumary: a report of the american college of cardiology /american heart association task force on clinical practice guidelines. Hypertension, Nov, 481p.
TreatmentofHTN
• 65 years or older adults living in the community with limited number of co‐morbidities, treatment goal is <130
• Older adults (≥65 years of age) with HTN, multiple comorbidities and limited life expectancy; considerations should be given to patient preference and patients should be assessed using a team‐based approach to determine the risk vs benefit regarding choice of antihypertensives
Whelton et al. (2017)
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HTNinOlderAdults
HTN:Non‐pharmacologicalInterventions
• Low sodium diet, Dietary Approaches to Stop Hypertension (DASH) diet
• Increased intake of potassium
• Limit alcohol use
• Increased physical activity and weight loss
• Smoking cessation
Kithas, P. A., & Supiano, M. A. (2015). Hypertension in the geriatric population. Med Clin North Am, 99(2), 379‐389Oza, R., & Garcellano, M. (2015). Nonpharmacologic management of hypertension: What works? Am Fam Physician, 91(11), 772‐776
ChallengestoNon‐PharmacologicalApproach
• Can be difficult to get an 80 year old patient to change their diet
• Certain ethnicities use seasoning which contains a lot of salt (i.e. Adobo)
• Fresh fruit and vegetables are more expensive
• Elderly patients may not be able to do regular exercise due to other co‐morbidities
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Team‐BasedApproach
• Team members, such as nursing staff, can educate patient on alternate dietary options
• Patient can be referred to physical therapy
• Social worker can provide information on community resources
HTN:PharmacologicalApproach
HTN:ImportantConsiderations….
• Diagnostic and treatment recommendations may not apply to elderly patients• An elderly patient with urinary incontinence should not be started on a diuretic
• Consider patient’s co‐morbidities when prescribing medications
• According to the JNC 8 guidelines, a patient with HTN and Congestive Heart Failure or HTN and Diabetes, optimal blood pressure is < 130/80
• However, this may be to low for an elderly patient who has dizziness or lightheadedness
Whelton et al. (2017)
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HTN:Follow‐up
• Always assess how the patient feels on the medication and if they are experiencing any side effects
• Maximize one medication before initiating another medication
• Elderly patients should have follow‐up within 1 to 2 weeks after starting or changing dose on medication
• Monitor basic metabolic panel when initiating ace inhibitors, angiotensin receptor blockers or diuretics
CongestiveHeartFailure(CHF)
Duke Center for Research on Personalized Health Care
CHF
• Usually diagnosed based on patient’s symptoms, health history, physical exam and diagnostic testing
• Diagnostic tests include:
• Chest x‐ray – pulmonary vascular congestion
• Brain Natriuretic Peptide (BNP) (>100 pg/mL) or N‐terminal pro‐B‐type natriuretic peptide (NP‐pro BNP) (<300 pg/mL)
• Electrocardiogram
• Echocardiogram
Yancy, C. W., Jessup, M. Bozkurt, B., Butler, J. Casey, D.E., Colvin, M. M….Westlake, C. (2017). ACC/AHA/HFSA focusedUpdate on the 2013 ACCF/AHA guideline for the management of heart failure: A report of the american college of cardiology/American heart association task force on clinical practice guidelines and the heart failure society of america. Circulation, 136(6), e137‐316
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CHFManagement
• Management of CHF requires combination of medication and lifestyle modification
• Patients can be taught to modify their lifestyle by learning to apply principles of self‐care
• CHF outpatient multidisciplinary programs focus on teaching patients to improve self‐care and medication compliance
• Effective management of HTN can reduce progression of CHF
CHFTeam‐BasedApproach
• Assess patient’s social support to promote treatment adherence and lifestyle modification
• Patient education on symptom management, sodium restriction and medication
• Sodium restriction of at least 1,500 mg/dl according to the American Heart Association
• Promote physical activity and weight loss
• Avoidance of certain medications (non‐steroidal anti‐inflammatory drugs)
• Smoking cessation
Yancy, C. W. , Jessup, M., Bozkurt, B., Butler, J., Casey, D.E., Drazner, M. H….Sam, F. (2013). 2013 ACCF/AHA guidelineFor the management of heart failure: A report of the american college of cardiology foundation/ american heart associationTask force on practice guidelines. Circulation, 128(16), 1810‐1852
MedicationsforCHF
• Diuretics: Furosemide, Torsemide, Metolazone
• ACE inhibitors: Lisinopril, Enalopril, Accupril
• Angiotensin receptor blocker (ARB): Losartan, Valsartan, Olmesartan
• Angiotensin Receptor Neprilysin Inhibitor (ARNi): Sacubitril /Valsartan (brand name: Entresto)
• Aldosterone antagonists: Spironolactone
• Beta Blockers: Carvedilol, Metoprolol
• Digoxin
• Nitrates: Isosorbide, Nitroglycerin
Azad & Lemay (2014)Roscoe, M., Lampkins, A., Harper, S., & Niemeier, G. (2018). Heart failure: A dynamic approach to classification and management. ClinicianReview, 28(5): 32‐43.
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CHF:Follow‐up
• Patients should be seen in 1 to 2 weeks after initiating therapy
• Monitor weight
• Check for adverse side effects
• Check basic metabolic panel if initiating diuretics, ACE inhibitors, ARBs or ARNI
DiabetesMellitus
DiagnosisofDM
• Fasting plasma glucose ≥ 126 mg/dl
• 2‐hour plasma glucose ≥ 200 mg/dl after an oral glucose tolerance test
• Hemoglobin A1c ≥ 6.5%
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AmericanDiabetesAssociation(ADA)Recommendations
• These recommendations reflect principles of the CCM
• Management of DM requires evaluation of the social, medical and emotional aspects of an elderly patient
• Patient centered communication that takes into account:
• Patient preferences
• Patient’s health literacy
• Addresses cultural barriers
ADA (2016)
DMManagementGoals
• Goals for A1c and blood glucose should be based on:
• Age
• Co‐morbidities
• Life expectancy
• Years of having DM
• Risk of hypoglycemia/hyperglycemia
• Patient motivation and compliance
• Cost of medication and diabetic supplies
Garber, A. J., Abrahamson, M. J., Barzilay, J. I., Blonde, L., Bloomgardent, Z. T., & Bush, M. A. (2017). Consensus statement by the american association ofclinical endocrinologists and american college of endocrinology on the comprehensive type 2 diabetes management algorithm – 2017 executive summary.Endocr Pract, 23(2), 207‐238
DM:LifestyleModification
• Medical Nutrition Therapy (MNT):
• Promote healthy eating patterns based on individual’s personal and culture preference
• Health Literacy
• Access to health foods
• Physical activity and behavioral support
• Promotion of sleep hygiene
• Smoking cessation
ADA (2016)Garber et al., (2017)
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DM:Team‐BasedApproach
• Social work and nursing staff can assess patient’s food preferences
• Social work can evaluate patient’s ability to afford healthy foods
• Available community resources include: Meals on Wheels, local senior centers and U. S. Department of Agriculture’s Older Americans Nutrition Program
• Referral to certified diabetes educator or nutritionist
Kirkman, M. S., Jones Briscoe, V., Clark, N., Florez, H., Haas, L. B., & Halter, J. B. (2012). Diabetes in older adults. Diabetes Care,35(12), 2650‐2664
ADARecommendationsforA1c
Individual Impairments or co-morbidities
Target A1c
Healthy Individual Limited co-morbidities Cognitively intact and
functional
<7.5%
Individual with: Multiple co-morbidities Impairment in 2+ IADLs Mild-to-moderate
cognitive impairment
<8.0%
Individual with poor health
End stage disease Dependent in 2+ ADLs or Moderate to severe
cognitive impairment
<8.5%
ADA (2017)
DM:MedicationConsiderations
• Elderly individuals are at risk for hypo/hyperglycemia, especially if they have dementia and multiple co‐morbidities
• Assess renal function before initiating medication
• Consider the cost of medication, delivery method and the frequency – daily medication dosing works best
• Review Beers Criteria for medications to avoid in the elderly
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DM:Metformin(Glucophage)
• ADA recommends Metformin as an initial treatment for elderly individuals with DM
• Long term use of Metformin maybe associated with Vitamin b12 Deficiency
• Review side effects with patient
• Should be avoided in patients with CHF and advanced kidney disease
ADA 2018
MedicationstoAvoid
• Thiazolidinedione (Actos or Avandia) should be avoided in patients with CHF
• Insulin Secretagogues such as Sulfonylureas (Amaryl, Glucotrol) can cause hypoglycemia
• α‐glucosidase Inhibitors (Acarbose) should be avoided in patients with creatinine clearance ≤ 24 ml/min
• Dipeptidyl Peptidase 4 Inhibitors (Januvia, Tradjenta) are well tolerated but expensive
• Januvia can cause fluid retention and shortness of breath, should be avoided in patients with CHF
ADA (2017)Bansal, N., Dhaliwal, R., & Weinstock, R. S. (2015). Management of diabetes in the elderly. Med clin North America, 99(2), 351‐377
CaseStudy:SR
• 87 year old male with AD, Anxiety/Depression, DM and constipation
• 2/18 A1c=7.9, 5/18 A1c=7.9, 6/18 A1c=10.7
• DM previously controlled by diet
• Per aide, patient eats a lot of sweets
• 6/18: glucose=400
• Started on metformin 500 mg daily
• 7/18: glucose=250, creatinine=0.84
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UnitedStatesHealthcare
• Is undergoing a fundamental shift in how chronic care is defined, practice and financed.
• All healthcare providers will need to develop competencies in how to deal with a growing elderly population.
• The number of new physicians entering the health care system has been declining and few are specializing in geriatrics due to poor reimbursement, time constraints and patient complexity.
• It is expected that by 2025, the demand for physicians will exceed supply by a range of between 46,000‐to‐90,000
Association of American Medical Colleges (2017)
UnitedStatesHealthcare
• As the number of physicians declines, there has been an increase in the number of APRNs entering the field.
• 86.6% of APRNs are certified in an area of primary care, and 77.8% of all APRNs deliver primary care.
• APRNs hold prescriptive privileges, including controlled substances, in all 50 states and D.C.
• APRNs working closely with physicians can provide more cost effective comprehensive care to an aging population.
American Association of Nurse Practitioners (2017)
Summary
• Patients are living longer with multiple chronic medical problems.
• These problems require a team‐based approach to provide more comprehensive care.
• Medicare has started to reimburse for this care coordination.
• APRNs working closely with physician staff and other members of the healthcare team can provide more comprehensive care for patients with chronic medical problems.
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Questions