national council on aging - pfcd hill briefing presentation

7/27/2019 National Council on Aging - PFCD Hill Briefing Presentation

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2A nonprofit service and advocacy organization 2013 National Council on Aging

Presentation Outline

1) Chronic Illness

2) Self-Management

3) Who is responsible for teaching and supporting

Self-Management?

4) Community Integrated Health Care systems

5) The Role of Policy and Quality Indicators


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Challenge of Multiple Chronic Conditions

90% of Medicare beneficiaries today have at least onechronic condition, and 68% have two or more

Challenge of chronic health conditions major contributor to health care costs, represents 75 % of

the $2 trillion in U.S. annual health care spending

accounts for nearly 70% of all deaths

restricts daily living activities for 25 million people


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Differences: Acute vs. Chronic Illness

Acute Illness Chronic Illness

Usually isolated to one

bodily area

Frequently involve multiple

organ systems

Responds to Treatment Uncertain future

Requires less care and

resources because it is

temporary

Requires more care and

resources to normalize lifestyle

Often runs its course with

little patient involvement

Requires patient to make long-

term changes to lifestyle andtake a major role in managing

their health care

(self-management)


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Most Common Chronic Conditions among Seniors

Figure 1.1a Percentage of Medicare FFS Beneficiaries with the 15 Selected Chronic Conditions: 2010

High blood pressure 58%

High cholesterol 45%

Ischemic heart disease 31%

Arthritis 29%

Diabetes 28%

Heart failure 16%

Chronic kidney disease 15%

Depression

COPD

Alzheimer's disease

Atrial fibrillation

Cancer

Osteoporosis

Asthma

14%

12%

11%

8%

8%

7%

5%

DATA HIGHLIGHTS:

The most common chronic conditionsamong Medicare beneficiaries were:

High blood pressure (58%), High cholesterol (45%),

Heart disease (31%),

Arthritis (29%) and

Diabetes (28%).


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Managing Chronic Illness is Challenging for Patients

They see multiple providers, makingcoordination difficult

Treatment for one condition may exacerbateanother

Multiple medications means greater likelihood ofadverse drug reactions

Fatigue, activity and role limitations, financial

impact, and depression create additionalchallenges


7/277A nonprofit service and advocacy organization 2013 National Council on Aging

What is Self-Management?

The tasks that individuals must

undertake to live with one or more

chronic conditions.

What people do 99.9% of the time.

Oregon Living Well



Self-management tasks

Medical Management: Managing the elements of achronic disease: medication adherence, diet, exercise,treatments, self-testing and record keeping.

Role Management: Maintaining roles, responsibilitiesand functions in life.

Emotional Management: Dealing with the emotionaldemands of life with chronic illness.



Who is Responsible for Teaching / Supporting Self-

Management?

Traditional Medical Model Community Based Model

Education and support for SM

embedded in clinical practice

Education and support provided in

community settings such as senior

centers, churches, and senior housing

Provided by health care professionals May be provided by trained lay persons

Often disease specific Focused on problem solving and

developing confidence (self efficacy)

Information and Skills taught, tools

provided

Skills to solve patient-identified

problems and reach patient-set goals

are taught

Compliance to a treatment plan is main

goal

Self-Efficacy is the main goal



Community Models provide support close to home.

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CDSMP Reach by US County(as of September 2011)

Total Coverage: 46 states, DC,

and Puerto Rico

Total Unique Sites: 4,936

Total Participants: 82,429

Total Completors: 61,505


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More than 140,208 Enrolled in CDSMP

3,6369,273 12,192

16,507

49,891 49,989

0

10,000

20,000

30,000

40,000

50,000

60,000

2006-2007 2007-2008 2008-2009 2009-2010 2010-2011 2011-2012


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CDSMP Participant Racial/Ethnic

Demographics

66.9%

20.8%17.8%

3.5% 2.6% 6.2%

17.4%

0.0%

10.0%

20.0%

30.0%

40.0%

50.0%

60.0%

70.0%

80.0%


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CDSMP Participant Characteristics

Characteristic Percent of Total

Age 60+ 74%

Gender Female 78%

Living Alone 47%

Racial/Ethnic Minority Group 33%Multiple Chronic Conditions 60%


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CDSMP Participants - Chronic Conditions

60.3%

42.9% 41.1%

29.8%

19.3%16.3% 16.1%

11.9%8.9%

4.6%

25.8%

0.0%

10.0%

20.0%

30.0%

40.0%

50.0%

60.0%

70.0%


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CDSMP Implementation Sites

More than 8,828 workshops held at over unique5,597implementation sites

24%

23%

16%

8%

29%

Senior Center

Health Care

Organization

Residential Facility

Faith-Based

Organization

Other


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CDSMP National Study: Better Care

Baseline

Mean

12-month

Mean % Improvement

Communication with MD (0~5) 2.6 2.9 9%**Medication compliance (0~1) 0.25 0.21 12%**Health literacy (Confidence filling

out medical forms) (0~4) 3.0 3.1 4%**

Notes. These statistics control for covariates gender, age, race/ethnicity, education, number of chronic conditions.Indicates that larger scores are better for this measureIndicates that smaller scores are better for this measure.

**p


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CDSMP: Better Outcomes

Baseline

Mean

12-month

Mean

%

Improvement

Self-assessed health (1~5) 3.2 3.0 5%**PHQ depression (0~3) 6.6 5.1 21%**Quality of life (0~10) 6.5 7.0 6%**Unhealthy physical days (0~30) 8.7 7.2 15%**

Unhealthy mental days (0~30) 6.7 5.6 12%**Notes. These statistics control for covariates gender, age, race/ethnicity, education, number of chronic

conditions.Indicates that larger scores are better for this measureIndicates that smaller scores are better for this measure. **p


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CDSMP: Lower Health Care Costs

Baseline 12-month AdjustedRatios

Percentage with Emergency Room (ER) Visits in

the Past 6 Months* 18% 13% 0.68**Number of ER visits among those with any ER

visit

1.5 1.4 1.00

Percentage Hospitalized in the Past 6 Months 14% 14% 1.01

Number of hospitalizations among those with any

hospitalization1.4 1.4 1.00

Notes. Odds Ratio or Mean Ratio after controlling for covariates gender, age, race/ethnicity, education,

number of chronic conditions.

Indicates that larger scores are better for this measureIndicates that smaller scores are better for this measure. **p


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So How do we link Health Care systems with

Community Organizations?


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Health Care Delivery System Transformation

High quality acute care Accountable care systems

Shared financial risk

Case management and

preventive care systems

Population-based quality and

cost performance

Population-based healthoutcomes

Care system integration with

community health resources

Acute Health Care

System 1.0

Community

Integrated Health

Care System 3.0

Coordinated

Seamless Health

Care System 2.0

High quality acute care

Accountable care systemsShared financial riskCase management and


Population-based quality andcost performance





Accountable caresystems


Case management andpreventive care systems

Population-based quality

and cost performancePopulation-based health

outcomes

Care system integrationwith community healthresources


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Role of Quality Standards in Assuring Linkage

and Self-Management Support

Key expectations of patient-centered

medical homes (PCMH)

Self-management support

Team-based care

NCQA Standards designed to assure Self-

management support and integration with

community resources for patients withchronic conditions


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NCQA 2011 Certification Guidelines for PCMH

PCMH 4A: Support Self-Care Process- MUST PASS

1. Requires practice to develop and document self-management plans/goals(CRITICAL FACTOR) in at least 50% of patients/families.

2. Documents self-management abilities for at least 50% of patients/families.

3. Provides self-management tools to record self-care results for at least 50%percent of patients/families.

4. Counsels at least 50% of patients/families to adopt healthy behaviors.

5. Provides educational resources or refers at least 50 % of patients/families toassist in self-management.

6. Uses an EHR to identify patient-specific education resources and providethem to more than 10% of patients/families.


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PROPOSED: PCMH 3E: Support Self-Care and

Shared Decision Making

1. Uses an EHR to identify patient-specific education resources andprovide them to more than 10 percent of patients

2. Provides educational materials and resources

3. Provides self-management tools to record self-care results

4. Adopts shared decision making aids

5. Offers or refers to structured health education programs such asgroup classes and peer support

6. Maintains a current resource list on five topics or key communityservice areas of importance to the patient population includingservices offered outside the practice and its affiliates

7. Monitors frequency or feedback on usefulness of referrals toidentified community resources


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PCMH 3B: Care Planning and Self-Care Support

The care team, along with the patient/family/caregiver, collaboratively

develops and updates at relevant visits individualized care plans

including the following features for at least 75 percent of the patients

identified in Element 3A:

1. Incorporates patient preferences and functional/lifestyle goals2. Identifies treatment goals

3. Assesses and addresses potential barriers to meeting goals

4. Includes self-management plan

5. Provided in writing to patient/family/caregiver


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Health Care Delivery System Transformation

High quality acute care Accountable care systems


Case management and


Population-based quality and

cost performance




Acute Health Care

System 1.0

Community

Integrated Health

Care System 3.0

Coordinated

Seamless Health

Care System 2.0


Accountable care systemsShared financial riskCase management and


Population-based quality andcost performance




High quality acute care Accountable care

systems


Case management andpreventive care systems

Population-based quality

and cost performancePopulation-based healthoutcomes

Care system integrationwith community healthresources


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27A nonprofit service and advocacy organization 2013 N ti l C il A i

[email protected]

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