Richard Birkel, Senior VP for Health PFCD Briefing, July 26, 2013

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 one chronic 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 Usually isolated to one bodily area Responds to Treatment Requires less care and resources because it is temporary Often runs its course with little patient involvement Chronic Illness Frequently involve multiple organ systems Uncertain future Requires more care and resources to normalize lifestyle Requires patient to make longterm changes to lifestyle and take a major role in managing their health care (self-management)

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Most Common Chronic Conditions among Seniors

Figure 1.1a
High blood pressure High cholesterol Ischemic heart disease Arthritis Diabetes Heart failure Chronic kidney disease Depression COPD Alzheimer's disease Atrial fibrillation Cancer Osteoporosis Asthma 5% 8% 8% 7% 16% 15% 14% 12% 11% 31% 29% 28% 45%

Percentage of Medicare FFS Beneficiaries with the 15 Selected Chronic Conditions: 2010
58%

DATA HIGHLIGHTS:
The most common chronic conditions among 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, making coordination difficult Treatment for one condition may exacerbate another Multiple medications means greater likelihood of adverse drug reactions Fatigue, activity and role limitations, financial impact, and depression create additional challenges

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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.

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Self-management tasks
Medical Management: Managing the elements of a chronic disease: medication adherence, diet, exercise, treatments, self-testing and record keeping. Role Management: Maintaining roles, responsibilities and functions in life. Emotional Management: Dealing with the emotional demands of life with chronic illness.

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Who is Responsible for Teaching / Supporting SelfManagement?

Traditional Medical Model Education and support for SM embedded in clinical practice Provided by health care professionals Often disease specific Community Based Model Education and support provided in community settings such as senior centers, churches, and senior housing May be provided by trained lay persons Focused on problem solving and developing confidence (self efficacy)

Information and Skills taught, tools provided

Compliance to a treatment plan is main goal

Skills to solve patient-identified problems and reach patient-set goals are taught
Self-Efficacy is the main goal

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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

60,000 50,000

40,000
30,000 49,891 20,000 10,000 0 3,636 9,273 12,192 16,507 49,989

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

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CDSMP Participant Racial/Ethnic Demographics

80.0% 70.0% 60.0% 50.0% 40.0% 30.0% 20.0% 10.0% 0.0%
20.8% 17.8% 3.5% 2.6% 6.2% 17.4% 66.9%

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CDSMP Participant Characteristics

Characteristic Age 60+ Percent of Total 74%

Gender Female Living Alone

Racial/Ethnic Minority Group Multiple Chronic Conditions

78% 47%
33% 60%

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CDSMP Participants - Chronic Conditions

70.0%

60.0%
50.0% 40.0% 30.0% 20.0% 10.0% 0.0%
60.3% 42.9% 41.1% 29.8% 19.3% 16.3% 16.1% 11.9% 25.8% 8.9%

4.6%

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CDSMP Implementation Sites

More

than 8,828 workshops held at over unique 5,597 implementation sites

Senior Center 29% 24% Health Care Organization Residential Facility 8% 16% 23%

Faith-Based Organization
Other

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CDSMP National Study: Better Care

Baseline Mean Communication with MD (0~5) Medication compliance (0~1) Health literacy (Confidence filling out medical forms) (0~4) 2.6 0.25

12-month Mean 2.9 0.21

% Improvement
9%** 12%**

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 measure Indicates that smaller scores are better for this measure. **p<0.01, *p<.05

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CDSMP: Better Outcomes

Baseline Mean
Self-assessed health (1~5) PHQ depression (0~3) Quality of life (0~10) Unhealthy physical days (0~30) 3.2

12-month Mean
3.0

% Improvement
5%**

6.6 6.5 8.7

5.1 7.0 7.2

21%** 6%** 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 measure

Indicates that smaller scores are better for this measure. **p<0.01, *p<.05
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CDSMP: Lower Health Care Costs

Baseline
Percentage with Emergency Room (ER) Visits in the Past 6 Months* Number of ER visits among those with any ER visit Percentage Hospitalized in the Past 6 Months 18%

12-month
13%

Adjusted Ratios
0.68**

1.5

1.4

1.00

14%

14%

1.01

Number of hospitalizations among those with any hospitalization

1.4

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 measure Indicates that smaller scores are better for this measure. **p<0.01, *p<.05

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So How do we link Health Care systems with Community Organizations?

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Health Care Delivery System Transformation

Acute Health Care System 1.0

High quality acute care

Coordinated Seamless Health Care System 2.0

Community Integrated Health Care System 3.0

High quality acute care

High quality acute care Accountable care systems Shared financial risk Case management and preventive care systems Population-based quality and cost performance outcomes

Accountable care systems Shared financial risk Case management and preventive care systems Population-based quality and cost performance Population-based health outcomes Care system integration with community health resources

Accountable care systems Shared financial risk Case management and

preventive care systems

Population-based quality and

cost performance

Population-based health outcomes Care system integration with community health resources

Population-based health Care system integration

with community health resources

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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 Selfmanagement support and integration with community resources for patients with chronic 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.
3. 4. 5. 6.

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

Provides self-management tools to record self-care results for at least 50% percent of patients/families. Counsels at least 50% of patients/families to adopt healthy behaviors. Provides educational resources or refers at least 50 % of patients/families to assist in self-management. Uses an EHR to identify patient-specific education resources and provide them to more than 10% of patients/families.

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PROPOSED: PCMH 3E: Support Self-Care and Shared Decision Making

1. 2. 3. 4. 5. 6. 7. Uses an EHR to identify patient-specific education resources and provide them to more than 10 percent of patients Provides educational materials and resources Provides self-management tools to record self-care results Adopts shared decision making aids Offers or refers to structured health education programs such as group classes and peer support Maintains a current resource list on five topics or key community service areas of importance to the patient population including services offered outside the practice and its affiliates Monitors frequency or feedback on usefulness of referrals to identified 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 goals 2. 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

Acute Health Care System 1.0

High quality acute care

Coordinated Seamless Health Care System 2.0

Community Integrated Health Care System 3.0

High quality acute care

High quality acute care Accountable care systems Shared financial risk Case management and preventive care systems Population-based quality and cost performance outcomes

Accountable care systems Shared financial risk Case management and preventive care systems Population-based quality and cost performance Population-based health outcomes Care system integration with community health resources

Accountable care systems Shared financial risk Case management and

preventive care systems

Population-based quality and

cost performance

Population-based health outcomes Care system integration with community health resources

Population-based health Care system integration

with community health resources

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2013 National Council on Aging

26

richard.birkel@ncoa.org

Thank You for the Opportunity to Speak to You Today!

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