new models of comprehensive care for patients with chronic conditions: guided care katherine frey,...
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New Models of comprehensive care for patients with chronic
conditions: Guided Care Katherine Frey, MPH
March 20, 2009Supported by the John A. Hartford Foundation,
the Agency for Healthcare Research and Quality, the National Institute on Aging, and
the Jacob and Valeria Langeloth Foundation
Aging Trends in Spain
• Two Demographic Processes Declining Birth Rate Increasing Life Expectancy
• By 2015 the labor force will contract and the population over 65 will grow.
Sandell, Documento del Real Instituto, 2003
The population is aging.
Funding Health Care in Spain
• Taxes main source of finance• Health care expenditures 7.4% GDP (1997) and
growing• Mix of public (89%) and private (21%)
expenditures• Among people with private insurance (12%
population) Private expenditures primarily for outpatient and
specialist expenses Public expenditures primarily hospitalizations
• 48% hospital expenditures attributable to over 65Rodriguez et al, Health Policy, 2000
Complex care is:
FragmentedDiscontinuous
Difficult to accessInefficient
UnsafeExpensive
5+ Conditions
68%
01%
26%
310%
412%
13%
Source: Medicare 5% Sample, 2001
The ¼ of Beneficiaries Who Have 4+ Chronic Conditions Account for 80% of Medicare Spending
Failing System
Patient Perspective:• Poor quality of care• Low levels of patient satisfaction• High cost of care
Physician Perspective:• Low levels of satisfaction• Low levels of reimbursement
Usual Care
• Mr. Jackson Has 8 medical conditions Takes 8 medications 1 primary care physician 4 specialists
• Effect on Life Confused by his care Out of pocket costs are
high Quality of life is poor Wife is stressed out
Is our system working?
How can we improvechronic care?
What alternatives have been tested?How effective are they?
How can they be useful in the real world?
GEM (Geriatric Evaluation and
Management)• Home visit by social worker• Two inpatient examinations; one by an NP, one by a
geriatrician/nurse pair• Multidisciplinary Care Planning• Monthly care received at the GEM clinic; average 6
months treatment per study participant• Randomized trial
Decrease in loss of function, decreased rate of depression and caregiver burnout
Improved patient and physician satisfaction cost $1,350 per person treated
Boult JAGS 2001
Transitional Care for CHF
• Education about CHF by a nurse, using book specifically written for geriatric HF patients
• Dietary assessment and planning by dietician, with nurse follow-up
• Referral to social services• Medication adjudication by physician• Follow-up by study nurse post-discharge• Randomized clinical trial
Increased quality of life Reduced hospital admissions for CHF reduced costs
- Rich N Engl J Med 1995
Transitional Care for Multiple Chronic
Conditions• Advanced Practice Nurse (APN) visited patient
with 48 hrs admission and then at least every 48 hours during hospital course
• APN visits twice (at least) post-hospitalization, once within 48 hours, once within 7-10 days.
• Telephonic support, including weekly calls• Randomized trial
Fewer re-admissions Lower hospital charges
- Naylor JAMA 1999
Self-Management
• Evaluation of 6-week Chronic Disease Self-Management Course Subjects covered: cognitive symptom management;
nutrition, fatigue and sleep management; use of community resources; medication management; exercise; dealing with emotions; communicating with physicians; problem-solving; decision making
• Randomized clinical trial Improved function, general health, energy Reduced hospital days and costs
Lorig Med Care 1999
Health Enhancement Program
• Community-based exercise intervention, nutrition counseling, and home evaluation
• Randomized trial Reduced disability Reduced hospital days
Wallace JGMS 1998
Summary of Effects
Effect on:
GEM T. Care(CHF)
T. Care(multi)
SM HE
Health ↑ ↑ ↑ ↑ ↑
Hospital admits and Cost
↑ ↓ ↓ ↓ ↓
Guided Care Strategy: To Translate Knowledge to
Practice
Combine successful innovationsIntegrate them into primary careMake the model diffusable
The Guided Care Model
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
Foundation of Guided Care
Motivational InterviewingSelf-Management
Guided Care Nurses’ Activities
Assess needs and preferencesCreate an evidence-based “care guide”Monitor patients proactivelySupport chronic disease self managementSupport caregiversCommunicate with providers in EDs, hospitals, specialty clinics,
rehab facilities, home care agencies, hospice programs, and social service agencies in the community
Smooth transitions between sites of careFacilitate access to community services
Boyd et al. Gerontologist 2007
Electronic Health Record
Creates: Evidence-based “Care Guides” RemindersProvides: Decision support: drug interactions Documentation of GCN-pt/cg encounters
Guided Care Nurse & Mr. Jackson
• Using a computerized data collection tool, assesses Mr. Jackson’s clinical needs and preferences
• With the physician and electronic decision support, creates an evidence-based comprehensive care plan and patient friendly Action Plan
• By telephone, monitors Mr. Jackson proactively• Around the care plan, coordinates efforts of providers in
primary care, EDs, hospitals, specialty clinics, rehab facilities, home care agencies, social services, and community agencies (with emphasis on facilitating transitions between sites of care)
• Through a self-management course and access to educational materials, informs and empowers Mr. Jackson (and his wife) to participate in his care
• By telephone, supports Mrs. Jackson in her role as a caregiver to Mr. Jackson.
Mr. Jackson is Hospitalized
• Exacerbation of CHF Cardiac catheterization reveals occlusion LAD
coronary artery CABG x 3 + mitral valve replacement
• New medications Change from hydrochlorothiazide to furosemide Oxycodone for pain management Warfarin
• New providers Cardiac rehabilitation Home care nurse
GCN Transitional Care Activities
• Visits him within 48 hours of admission and delivers Care Guide
• Prepares Mr. and Mrs. Jackson for his discharge, including explanation of new drugs
• Reviews the updated Action Plan within 48 hours of discharge
• Coordinates services with new providers• Updates primary care provider of all changes
Mr. Jackson’s Perspective• Two-hour interview with the nurse at home• Seven-session self-management course• Educational materials (verbal, written, Internet)• Telephone inquiries and reminders from nurse• Assistance in accessing the services of health care
providers and community agencies• Assistance in integrating all health-related services• Direct access to a nurse during normal business hours• Assistance making the transition from the hospital home
Physician’s Perspective
Assistance with most difficult patients Creating/implementing comprehensive plans Proactive follow-up Responding promptly to patients’/families’ calls Communicating with other providers Facilitating transitions from hospitals Minimal time requirement
Randomized Trial
High-risk older patients (n=904) of 49 community-based primary care physicians practicing in 14 teams
Physician/patient teams randomly assigned to receive Guided Care or “usual” care
Outcomes measured at 8, 20 and 32 months
Supported by the John A. Hartford Foundation, the Agency for Healthcare Research and Quality, the National Institute on Aging,
and the Jacob and Valeria Langeloth Foundation
Baseline CharacteristicsGuided Care Usual Care
Age 77.2 78.1
Race (% white) 51.1 48.9
Sex (% female) 54.2 55.4
Education (12+) 46.4 43.4
Living alone 32.0 30.6
Conditions 4.3 4.3
HCC score 2.1 2.0*
ADL difficulty 30.9 29.3
Cognition (SPMS) 9.1 9.0
Effects on Quality of Care
PACIC scales: GC UC aOR* 95% CI P
Goal setting 24.6 11.6 2.4 1.5-3.7 <0.001
Coordination 14.2 7.1 2.3 1.3-4.0 0.005
Decision support 42.7 33.1 1.5 1.1-2.1 0.014
Problem solving 33.4 24.7 1.4 1.0-1.9 0.096
Patient activation 26.6 23.0 1.1 0.7-1.5 0.763
Aggregate 17.4 8.5 2.0 1.2-3.4 0.006
Boult et al. J Gerontol Med Sci 2008
Effects on Physician Satisfaction
• Compared with Usual Care, Guided Care physicians were significantly more satisfied with their: Communication with their patients Caregiver education Ability to motivate patients Knowledge of patient medications
Annual Costs of Guided CareGuided Care Nurse
Salary $71,500
Benefits (@ 30%) 21,450
Travel (to pts’ homes, hospitals) 588
Communication services
Internet, cell phone 1,800
Equipment (amortized)
Computer 500
Cell phone 67
TOTAL $95,905
Annualized Use of Servicesper Caseload (55
Beneficiaries)
Leff et al. (in press)
Guided Care Usual Care
Hospital days 241 317
SNF days 170 270
Primary care visits 558 557
Specialist visits 473 434
Home health care episodes
50 70
Annualized Cost of Servicesper Caseload (55 Beneficiaries)
GC – UC Difference
Average Expenditure
Difference inExpenditures
Hospital days -76 $1,519/day -115,600
SNF days -99 $305/day -30,200
Primary care visits
-1.3 $41/visit -100
Specialist visits
39 $41/visit 1,600
Home health episodes
-20 $1331/episode -26,800
Gross savings ----- ----- -170,900
Net Savings ----- ----- -75,000
Future of Guided Care
• Diffusion Activities Online course for nurses Online course for physicians Guided Care Implementation Textbook Technical Assistance for practices seeking to adopt
Guided Care (www.medhomeinfo.org)
Conclusion
Guided Care is an innovative approach to efficiently managing
caseloads of older, complex patients living in the
community.
Patient, physician and nurse satisfaction is high.
Compared to usual care, Guided Care appears to improve the
quality and the efficiency of health care for patients with
chronic conditions.
References• Boult C et al. A randomized trial of outpatient geriatric evaluation and
management. JAGS, 2001;49:351-359.• Boult C et al. Early effects of "Guided Care" on the quality of health
care for multimorbid older persons: A cluster-randomized controlled trial. Journal of Gerontology: Medical Sciences 2008;63A(3):321-327.
• Boyd C et al. Guided Care for multimorbid older adults. The Gerontologist 2007;47(5):697-704.
• Leff B et al. Guided Care and the cost of complex health care (in press) • Lorig K et al. Evidence suggesting that a chronic disease self-
management program can improve health status while reducing hospitalization: A randomized trial. Medical Care 1999;37:5-14.
• Naylor M et al. Comprehensive discharge planning and home follow-up of hospitalized elders: A randomized clinical trial. NEJM 1999;281:613-620.
• Rich M et al. A multidisiplinary intervention to prevent the readmission of elderly patients with congestive heart failure. NEJM 1995;333:1190-1195.
• Wallace J et al. Implementation and effectiveness of a community-based health promotion program for older adults. Journal of Gerontology: Medical Sciences 1998;53:M301-306.
Thanks to:
• Dr. Charles Boult• Lisa Reider, MHS• Tracy Novak, MHS• The Guided Care Nurses• The Guided Care research Team• The Guided Care Patients• Johns Hopkins HealthCare and Kaiser
Permanente• The John A. Hartford Foundation, the Agency
for Healthcare Research and Quality, and the Joseph and Valeria Langeloth Foundation
www.guidedcare.org
Katherine Frey, [email protected]