1. Integrated Chronic Care Disease Management: Elevating Practice, Engaging Patients and Driving Best Outcomes
What are we doing from a home care perspective that is a value of leading our system
What is ICCDM at a high level
Why it is a value at a high level
Re-admissions
Transitions
ACO- high quality and low cost
Patient-centered integrated care system using a patient centered model.
Monique Reese, ARNP, MSN, FNP-C, ACHPN, Vice President, Clinical Services and Chief Clinical Officer, Iowa Health Home Care
Vicki Wildman, RN, MSN, Edu, Statewide Education, Integrated Chronic Care Disease Management Specialist Trainer
IHS Spring Symposium
2011

2. Objectives Review the incidence and prevalence of chronic diseases
Discover the importance of patient-centered care concepts
List the components of Integrated Chronic Care Disease Management model
List the positive outcomes to enhance clinical practice, increase quality and improve patient outcomes
Describe the impact of decreasing re-hospitalization rates

3. Purpose A Broken Healthcare System Envision a New Care Delivery System
If we can agree—the health care system of today is broken and does not meet everyone’s needs and is not sustainable
If we can envision- A patient centered healthcare system that is accessible, affordable, sustainable and provides the best care in the world
If we can embrace- a blueprint for genuine reform that has immediate real-world applicability with specific action steps for today, clearly defined long-term objectives for the future
If we can embark – take a journey with colleagues in the pursuit of excellence for those we are privleged to serve
If we can propose that we need to work together to refine the details of a transformed healthcare system leaving a lasting legacy for generations to come
When we succeed- we will have delivered the Healthcare Future and restored hope for millions
Embrace, Embark, and Succeed!

4. A Year in the Life of a Patient5
Hospital Admissions 6
Weeks SNF Care 37
Nurses 13
Meds 6
Social
Workers 2
Nursing Homes 22 4
Occupational Therapists 5
Months of Home Care 19
Clinic Visits 5
Physical Therapists
Example of current health care system
Currently, the health care system is fractured. One study discovered, “ chronically ill patients often see multiple physicians and one study found a median of 7 different physicians per year who may be incompletely aware of each other’s care, prescribe incompatible or contraindicated treatments, provide conflicting advice and often no one physician is responsible for a beneficiary’s care” (Peikes, Chen, Schore, and Brown, 2009). The future of health care will be shaped by the technology of medical homes and electronic medical records. 16
Physicians 6
Community
Referrals 2
Home Care Agencies
Source Johns Hopkins, RWJ 2010 (G Anderson) 4

5. “Patients can undo a month’s worth of expensive and intensive care just going home and going about their normal routines.” John Charde, MD VP Strategic Development, Enhanced Care Initiatives, Inc (April 2006)
The cause of our crisis is directly attributable to the poor management of chronic conditions.
As the incidence of chronic illnesses escalate- our current system collapses.
The successful management of chronic disease must occur on a daily basis in the home, workplace and community of the individual with chronic illnesses.
? How many of you or your family know someone with a chronic disease?
Approximately 75% of our healthcare funds are spent on the treatment of chronic disease
We need a solution that decreases costs by improving chronic care management.
Early part of this decade, about 30 % of our patients had one or more chronic disease diagnosis.
By 2008, that number had risen to 55 %. 5

6. Incidence of Chronic Disease
Total U.S. population
133 million Americans (45%)
have one or more chronic
diseases
Source: Wu S, Green A. Projection of Chronic Illness Prevalence and Cost Inflation. RAND Corporation, October 2000.

7. The Number of People With Chronic Conditions Is Rapidly Increasing
Source: Anderson, G.; Chronic Conditions: Making the Case for Ongoing Care; Johns Hopkins University; November 2007

8. Epidemic of Chronic Diseases
Increasing incidence of chronic disease
Complexity of care
Poor transitions
Telehealth data: poorly controlled disease
Lack of evidenced based care
“Non compliant” patients
Reviewing home care agencies- there is increasing incidence of chronic diseases, care is often complex, there are poor transitions, and we poorly control diseases based upon evidenced-based care.
Patients “getting treatment” for Telehealth data but care is not well coordinated and managed per evidenced-based guidelines. For example, there are current standards of practice for Diabetes, Heart Failure, Lung disease and depression. Our processes, expectations and policies are often lacking the implementation of these chronic disease management practices.
?How many of our patients day in and day out have blood pressures outside the recommended parameters and outside the blood pressure guideline recommendations? ?How many staff actually know the evidenced-based guideline standards and implement them into practice.
Often patient’s are documented in the record the lack of compliance or labeled “non-compliant” with our health care plan for services and treatment. Non-compliant patient’s do not exist. How many of you set a new year’s resolution? How many are still doing what you set out to do? We are all non-compliant. Rather, our patient’s are not-adherent to our plan of care.

9. Think of Your New Year’s Resolutions
Are you non compliant?

10. Cost of Chronic Disease
People with chronic conditions are the heaviest users of healthcare services.
The more co-morbid conditions the heavier the use.

11. Potentially preventable 30-day readmission rates
The following list shows what patient diagnosis are being re-admitted to the hospital within 30 days of discharge, average Medicare Payment for Readmissions and Total spending on potentially preventable re-admissions
Result of poor transitions---
Med PAC report to Congress – 18 percent of Medicare hospital admissions result in readmissions within 30 days
$15 Billion spent on readmissions
$12 Billion spent on preventable hospital readmissions

12. COMMONWEATLH STUDY New England Journal of Medicine April 2009
FINDINGS:
1 in 5 discharged patients are readmitted within 30 days
50% of discharged patients are readmitted within 1 yr
In 2004, $17.4 billion was spent by Medicare in unplanned rehospitalizations
Maintaining continuity in patients' medical care is especially critical following discharge from the hospital, and for older patients with multiple chronic conditions, this "handoff" period takes on even greater importance. Research shows that one-quarter to one-third of these patients have to return to the hospital due to complications that could have been prevented. (IHI)
Medicare patients report more dissatisfaction around discharge then any other time point in care
CMS, JCAHO, would health org, national transition of care coalition, all recommending strategies for improving care
Med PAC Recommendations
1. Direct adjustments to DRG payments for preventable readmissions
2. Make adjustments to payment that are performance based
3. Publicly report readmission rates
4. Test feasibility of “bundling” payments that span across provider types

13. So what about coordination?
This applies to us and the patient.
Think about JT: JT has 12 new medications, has to change the way he eats.
-Historical background
-Hospitalization
What we ask our patient’s to do is complex!
What we ask clinicians to do is complex.
These patient’s take a lot of care coordination.
The issue of care coordination is complex!

14. Chronic Disease Management is Becoming More Complex
Increased incidence of patients with multiple co-morbidities
Elderly patients with age-related complexities
Fewer resources to care for an ever increasing number of patients all seeking care in an acute environment
We are providing care to:
-More people
-Older People
-Less resources
-Increased chronic illness
Is that how you feel?

15. Non-adherence: Significant for those with chronic disease
Increase in number and length of acute care visits (25% of hospitalizations due to medication errors)
Increase in ED visits
Unnecessary changes in treatment
Overuse of scarce and expensive medical resources
Loss of productivity and decreased quality of life
When patient’s are non-adherent there is an increase in number and length of acute hospitalizations, patients increase use of ED visits, often unnecessary changes in treatment and ultimately decreased quality of life.
We as a home care organization need to arise to this challenge to implement a care delivery model that will meet our patient’s expectations, transform the home health care delivery system out of a silo and into integration.
Source: Anderson, G.; Chronic Conditions: Making the Case for Ongoing Care; Johns Hopkins University; November 2007

16. Additional Focus Area : Medication Non-Adherence
Lower for patients with chronic diseases
Lower medication persistence with chronic disease
Low adherence = twice the healthcare expenditures
83% of your patients would never tell you if they didn’t plan to fill their prescriptions
50% of patients with chronic diseases will stop taking their medications

17. Do Non-Adherent People Care Less About Their Health?
NIH Grant - Meta analysis of studies related to health behaviors
Included interviews with adherent and non-adherent patients
Major difference: non-adherent patients had lower self-efficacy but cared just as much about their health
Butterworth, Prochaska, Redding –NIH CDC Grant -1-ROI DP000103/DP CDC HHS/United States

18. The State of Chronic Care Management
Health care systems act as silos
No uniform way to share knowledge
Lack of care coordination
Rushed practitioners
Lack of active follow-up
Pts inadequately trained to
manage their illnesses
Pts seeking care via ER visits & hospitalizations

19. Integrating “The Best of the Best”
New Healthcare
Delivery Paradigm
Redesigned
Care
Delivery
Models
60 Years
Experience
Disease Management
Components
Behavioral
Management
Lessons Learned
CMS Demo
Projects
Evidenced
Based Care
Healthcare of the future:
Redesigned Care Delivery Model
Patient’s supported by a proactive team that guides them through the healthcare system and equips them to accept personal responsibility for their health
All providers work as part of the proactive team to coordinate the patient’s care across the healthcare spectrum even as they continue to raise the bar of excellence in their own practice
Experts
Subject and clinical experts assist with collective best-practice design and patient care practices. We support each other to take care of the patient holistically.
Disease Management Components:
Implementation of disease specific standards of practice-there are standards in place the healthcare system is not following. Example-diabetics standards say HBgA1C every 3-6 months with tight control—is this occurring?
Behavioral Management:
Training and implementation of new communication styles and attitudes and expectations—staff will need to implement motivational interviewing into practice. Staff will have to learn techniques to transition to a patient-centered care model.
CMS demo project
Implementation and data tracking of CMS outcomes and processes for home health and hospitals.
OASIS C was the beginning of this—depression screens, fall risk screens, wounds, and imbedded questions for agency practice and agency policies to impact positive patient-centered care and agency practices.
Evidenced-Based Care
Implementation of evidenced based care throughout all transitions and care continuums.
Use of clinical guidelines
New Healthcare Delivery Paradigm
Payers both public and private reward care that is coordinated, evidenced-based and tied to patient outcomes. Keeping patients at the optimum level of their health condition permits
Policy makers define healthcare as a right for all Americans and draft policies and regulations that enable and support a workable system which emphasizes shared responsibility by all stakeholders.

20. Redesigning Care Delivery
Current healthcare systems cannot do the job
Trying harder will not work
Changing care systems will work
?What needs to be done to bridge the gaps in quality care?
We need to realize we need to better and improve the current healthcare delivery system to get the results we need!
Historically we have heard about this book Crossing the Quality Chasm. It focused on the quality gaps in healthcare with the recommendation to implement quality and process changes through PI initiatives, use of LEAN, and Six Sigma. While these are valuable tools, we need to focus our efforts on the re-design of the healthcare delivery model with the use of these recommended tools.
While we will always measure Quality and Cost (carrots or what ever we measure) the measurement of the outcomes solely will not change how we deliver healthcare. We have to change how we deliver healthcare 20

21. Wagner’s Chronic Care Model
One model of integrated chronic care disease management includes the implementation of Wagner’s care model.
Dr Wagner realized the need for a practice re-design
With integrated chronic care disease management, the model framework chosen was Wagner’s Chronic Care Model. Arkansas Baptist implemented this patient-centered integrated chronic care model approximately 1 year ago with astounding results. Results include significant improvement with acute care hospitalization rates, emergent care rates, decrease in staff turn-over, increased staff confidence in practice, improvement in patient satisfaction scores.
This model is different because it focuses on Productive interactions between the informed and activated patient and the prepared practice team

22. Informed, Activated Patient Prepared Practice Team
Motivation
Information
Skills
Confidence
Prepared
Practice
Team
Patient information
Decision support
Resources
Prepared
Practice
Team
Informed and activated patients : have the motivation, information, skills and confidence necessary to effectively make decisions about their health and manage it!
With transformation of home healthcare practice, we together will be able to change care delivery practice to focus on providing true patient centered care where our patients, are informed and activated. The patient needs to be at the very center of what we do! We as providers need to be able to do the following items to improve patient-centered care.
Prepared Practice Team: At the time of interaction they have the patient information, decision support, and recourses necessary to deliver high-quality care.
Adopting Wagner’s model for home care agencies is the best way to impact transformation of integrated chronic care disease management. 22

23. Key Derivatives: Wagner’s Model
Informed,
Activated
Patient
Productive
Interactions
Prepared
Practice
Team
The bulk of the work is not to be just a physician– the bulk of the work is a care team
In order to achieve outcomes:
-visible support at all levels
-Redesign care delivery model
-Proactive/prepared practice team
-Financial support to sustain
The new model incorporates strong patient and provider relationships, behavior change and adult education principles, clinical specialist oversight and extensive use of advanced technology as part of a proactive practice team under the direction of a physician.
One way to implement this model is to review and require clinicians to practice at the highest of their professional level.
Implement an integrated chronic care certification program is the key to implement this model successfully across the state and Iowa Health System.
Training is one component of implementing this model- our staff need to implement and sustain this model.
Think about the implementation of OASIS C. We didn’t just train the staff, we trained, changed processes, audited records, monitored progress and reviewed outcomes and retrained as necessary.
The same transformation will need to occur to successfully implement a patient centered model to transform healthcare. 23

24. Vision of a Provider with Value
Expert in disease specific
guidelines and care
Expert in care
coordination
Shares
responsibility
for outcomes
Competent communication
& ability to share data
Facilitates effective transitions
Highly trained in behavior change techniques
We need to have access to experts in disease specific guidelines and care
We need to have highly trained individuals in behavior change techniques
We need to have experts in care coordination
We need to be willing to share responsibility for outcomes
We need facilitate effective transitions
We need communication, competencies and ability to share data.
Success of the model depends on the competency of clinicians
Courses to educate clinicians will need to be implemented
Staff will move towards certification: Home-based chronic care professionals
Comprehensive assessment tools, scoring and evidenced –based interventions and decision support
We want to retain, recruit the sought after partner that brings value to the health care system and our agencies.
“sought after” partner
that brings value

25. Home-Based Chronic Care Model
Self-Management Support
High Touch Delivery
Institute of Medicine report – Make the Right Thing to do the Easy Thing to Do! Implementation of the Home-Based Chronic Care Model through the following methods:
High Touch Delivery
Use of Evidenced-based practices
Clinician’s practicing at the highest level
Use of patient-centered care
Comprehensive assessments
Proactive planned visits
Interdisciplinary Team
Telehealth/phone visits
Transition experts
Self-Management Support- 99% is self management 1% is medical management
The systematic provision of education and supportive interventions to increase patients’ skills and confidence in managing their health problems, including regular assessment of progress and problems, goal setting and problem solving support.
Think about it as simple as that---Improving Patient Skill s and Confidence. Patients with chronic disease are often ambivalent about their ability and confidence to make behavioral changes.
Research has demonstrated patients hold the key to manage their chronic disease and research has also shown if patients improve skills and confidence they will be able to manage their chronic disease. Putting the person being served and his needs above all else – at the center of everything Giving patient choices and enabling them to make decisions about their health. An emphasis of the patient’s goals coupled with evidenced based care.
Technology
Electronic medical records
Dashboard indicators
Health coaching with telephone visits
Use of video/telemonitoring
Medication dispensing machines
Lifeline
Specialist Oversight
Implementation of interdisciplinary team meetings
Communication with specialists
Implement evidenced-based practice
Patient-centered focus
Automatic review of patients that sought emergent care/acutely hospitalized
Review of patients with multiple chronic diseases
Specialist Oversight
Technology

26. Healthcare Providers Role: Explore Barriers to Change
Understanding
Financial constraints
Energy level (depression)
Support system
Problem solving ability
Relationship with healthcare provider
Importance and confidence
Ambivalence: Many patients simply lack confidence in their abilities and that contributes to ambivalence
To enable patients to take information that they have or have learned about their illness, and then solve problems related to condition management.

27. Technology to Support High Quality Chronic Care
Comprehensive Assessments
Examples:
Re-hospitalization risk to identify
high risk/ high cost patients
PHQ-9
Assessments by disease
Medication Risk Assessment
Multi-faceted Fall Risk Assessment
Evidence-based care plans
High quality educational materials 27

28. Example of Telehealth Unit

29. Defining Care Transitions
“ ‘Care transitions’ refers to the movement patients make between healthcare practitioners and settings as their condition and care needs change during the course of a chronic or acute illness.”
Eric A. Coleman, MD, MPH
Care Transitions ProgramSM

30. Implications for Healthcare Delivery
Coordination of care in the first 30 days critical
Coordination of care is traditional role of homecare
Developing a standard approach to care coordination should be a key strategic objective
In a follow-up study, one of every five hospitalized patients experienced adverse events due to inadequate medical care after leaving the hospital and returning home. Prescription drugs accounted for the most injuries after discharge, affecting 66 percent of the 400 patients involved in the study. According to the researchers, one-third of the post-discharge events could have been avoided and another third could have been less severe if patients had received proper medical care. Adverse events ranged from unnoticed abnormal laboratory results to consequences resulting in permanent disability. More than half of the patients (64 percent) had symptoms for several days, while three percent of patients suffered permanent disabilities.8, 9
Evidence suggests that several specific interventions reduce the rate of avoidable rehospitalization: improving core discharge planning and transition processes out of the hospital; improving transitions and care coordination at the interfaces between care settings; and enhancing coaching, education, and support for self-management.
Medication lists do not match
Complex discharge instructions
Lack of knowledge regarding red flags
Poor connections/ understanding of care post hospital discharge

31. Homecare’s Unique Role in Transitions
Comprehensive assessments
Evidenced-based screening tools
Interdisciplinary team assessments
Interdisciplinary approach to care intervention
Medication reconciliation
Process & outcome measures
ICCDM : Skills for effective health coaching in self mgt support & evidenced based guideline care
depressionhealth literacy, rehospitalization risks, etc
“Patient is a puzzle”

32. Community-Based Transitions Model™ (CBTM)
Medication
Management
Early
Follow-up
Symptom
Management
Appt
Scheduled
within a wk
AND
able to get
there
Comprehend
S&S that require attention
AND
whom to contact
Is patient familiar&
competent
AND
have access
Change in
RX or TX
Change in
RX or TX
Adherence
& Persistence

33. Sustaining ICCM Job description expectations Performance Appraisals
Training of all staff on ICCM
Computer Based-Learning training
Demonstration of skills
Competency of skills
Case conference meetings
Certification

34. Certification Course Content
Self-Management Support Concepts
Working collaboratively with patients
Behavior change theories and tools
Adult Learning
Evidence-based guidelines as they relate to disease self-management
Use of telehealth and technology to support care
Transitions of care
Health literacy

35. Showing an Improvement
Data collection of outcomes
Data collection of process measures
Tracking certification
Tracking use of tools

36. Bringing All Concepts Together Multidisciplinary Case Conference
Physician ST OT PT
Model Champion
ICCM
Team Leader
RN - NCM SW
CPS- PC
Telehealth
Pharmacist 36

37. Training Curriculum Making the Case for Integrated Chronic Care
Principles of Adult Education and Health Literacy
Problem Solving 101
Evidenced-Based facilitation of Behavior Change
Theory –Based Telehealth
Integrated Care Transitions
Model Implementation into Practice
8 Hour class provides knowledge, practice and application of the vital skills for all clinical staff to become successful at implementing this model.

38. Computer-Based Modules
Evidenced-based training:
Heart Failure
Chronic Obstructive Lung Disease
Diabetes
Depression
Each module contains:
Pathophysiology/ incidence
Treatment Modalities
Self Management Support Behaviors

39. Vision : Develop Strategies to Achieve Clinical Information Systems
Proactive follow-up
Planned visit
Visit system changes
Leadership support
Provider participation
Guidelines
Provider education
Expert support
Delivery
System
Design
Decision
Support
Health System Organization
Self-Management
Support
Clinical Information Systems
Links to Community Resources
Telemonitoring
Guidelines embedded
Dashboard
Patient activation
Self-management assessment
Self-management resources
Guidelines to patients
Source: Pearson, M. et. al. Chronic Care Model Implementation Emphases, Rand Health Presentation to Academy Health Meeting, 2004 39

40. Best Outcome for Every Patient Every Time
Home care will be a recognized leader in providing patient-centered, expert, quality care in the comfort of home.
Our challenges are our opportunities of the future.
Our clinicians, quality and leadership needs to be prepared for leading and providing patient-centered care.
Home health care is currently driven by regulations. Currently regulations drive our practice--
For example, if a patient is not adherent or not homebound we discharge- regulations drive our practice
We say we are patient centered- but the regulations drive the care we deliver
?What does a patient really need?
? What does patient-centered care mean? Patient centered care is what patient’s need compiled with Evidenced-Based Practice.
Home Health will be a recognized leader in providing patient-centered, expert, quality care in the comfort of home.

41. QUESTIONS?