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Technology-Assisted Care Coordination for Chronic Disease Management in the Elderly Stuti Dang, MD, MPH Clinical Director, T-Care and TLC for Dementia.

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Presentation on theme: "Technology-Assisted Care Coordination for Chronic Disease Management in the Elderly Stuti Dang, MD, MPH Clinical Director, T-Care and TLC for Dementia."— Presentation transcript:

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2 Technology-Assisted Care Coordination for Chronic Disease Management in the Elderly Stuti Dang, MD, MPH Clinical Director, T-Care and TLC for Dementia Miami VA GRECC & Medical Center University of Miami Miller School of Medicine GRECC Audio Conference, May 26 th,

3 Objectives  Understand definitions of care coordination and home telehealth  Discuss examples of technology assisted care coordination for chronic diseases  Review proposed reasons for technology- assisted care coordination to work  Recognize work ahead 2

4 Problems With Current System  Increasing number of complex older patients with chronic diseases  Disproportionate health care resources  Fee for service payment structure  Fragmentation and duplication  Rapidly escalating health care costs  Health care delivery system is under stress with shrinking resources 3

5 Bodenheimer T, et al., N Engl J Med, 2009; 361: Average Annual Per Capita Spending for Patients with Different Numbers of Chronic Conditions 4

6 Institute of Medicine Priorities for national action (2003): Transforming Health Care Quality -Increased demands -Poorly coordinated care -Inadequate implementation of information technology in health care 5

7 Care Coordination Definition  “Care coordination” is a client-centered, assessment-based interdisciplinary approach to integrating health care and social support services in which an individual’s needs and preferences are assessed, a comprehensive care plan is developed, and services are managed and monitored by an identified care coordinator following evidence-based standards of care. Brown R, in a report commissioned by the National Coalition on Care Coordination, in 2009, at 6

8 Impact of Care Coordination Interventions Nurse/SW directed, multidisciplinary interventions in high risk patients  Reduced hospital admissions  Significantly reduced cost  Improved quality of life for patients and caregivers  Improved satisfaction of care Rich MW, et al., N Engl J Med, 1995;333(18): Naylor MD, et al., JAMA, 1999;282(12):1129 – 36. 7

9 Care Coordination Interventions  Transitional care  Self-management education: short community-based programs to “activate” patients in disease self management  Coordinated care: patients with chronic conditions at high risk of hospitalization, provide care planning, monitoring of patients’ symptoms and self-care, working with the patient, PCP and caregivers Coleman EA, et al.,Arch Intern Med Sep 25;166(17): Lorig KR et al. Eff Clin Pract Nov-Dec;4(6): Peikes D, et al. JAMA Feb 11;301(6):

10 Medicare Coordinated Care Demonstration (MCCD)  Only 3 of the 15 programs effective  Six key components Targeting In-person contact with patients Timely information on admissions Close interaction between care coordinators and PCP: face-to-face and same care coordinator Services provided Staffing: nurses, social workers Peikes D, et al. JAMA Feb 11;301(6):

11 Would Adding Technology Enhance the Model??……..  Technology assisted care coordination may provide an effective and efficient alternative to providing care coordination the traditional way 10

12 Telemedicine Definition  “...the use of electronic information and communications technologies to provide and support health care when distance separates the participants...” Field MJ, et al., Institute of Medicine: Telemedicine: A Guide to Assessing Telecommunications in Health Care,

13 Telehealth Definition  Telehealth (or Telemonitoring) is the use of telecommunications and information technology to provide access to health assessment, diagnosis, intervention, consultation, supervision and information across distance.  Includes use for clinical and non-clinical services such as medical education, administration, and research. Center for Medicare and Medicaid Services, 2010, at https://www.cms.gov/Telehealth/ 12

14 Care Coordination  The Veterans Health Administration defines care-coordination as the “wider application of care and case management principles to the delivery of health-care services using health informatics, disease management, and telehealth technologies to facilitate access to care and improve the health of designated individuals and populations with the intent of providing the right care in the right place at the right time.” 13

15 Technology-Assisted Care Coordination Model for Chronic Disease Better Health Outcomes Decreased Cost Increased quality Caregivers Pharmacy Care coordination team Specialists Monitoring Education Support Technologies Peer Leaders Patients at home HTN, DM, COPD, CHF, Asthma, depression, PTSD Feedback Education Support Feedback Primary Care Providers Non VA Providers 14

16 15

17 Blood Pressure Graph For a Patient 16

18 Technology Assisted Care-Coordination Some Examples 17

19 Telephone-based Management Telephone calls with RN follow-up Biweekly automated telephone calls Maximum benefit when A1c>8% (net effect – 1.1%) Mobile phone and SMS messaging Patients sent glucose result via phone, received message from nurse Decrease in A1c by 1.1% over 12 weeks Piette JD, et al., Diabetes Care, 2001;24(2): Kim HS, et al., Int J Nurs Stud, 2007;44(5):

20 Web-based Management  104 Veterans with diabetes, HbA1 c 9.0%  Web-based care management: notebook computer, glucose and blood pressure monitoring devices, and access to a care management website, messaging system  At 12 m, lower A1C, BP, HDL (P < 0.05) More improvement in persistent users and with larger number of website data uploads McMahon G, et al., Diabetes Care, 28:1624–1629,

21 IDEATel - Informatics for Diabetes Education and Telemedicine METHODS  Telemedicine home unit with videoconferencing and case management  Randomized trial with a usual care group  Five year follow up  Medicare beneficiaries (n= 1665) Diabetes, >55 years, medically under-served areas in NY (upstate and NYC) Shea S, et al., JAMIA, 2006;13(1):

22 IDEATel Results  Modest clinical effects Small but significant changes A1c (0.29%), SBP (4.3 mm Hg), Lipids (3.8 mg/dl) Reduced waist circumference and BMI Increased diet and exercise knowledge  No mortality benefit (Likely under-powered)  Costs $622 per person per month Mean Medicare payment in UC $9040 versus IDEATel $9669 per person per yr Moreno L, et al., Diabetes Care, 2009 ;32(7): Palmas W, et al., J Am Med Inform Assoc, 2010 ;17(2): Izquierdo R, et al., Diabetes Therapeutics and Technology, 2010 ;12(3):

23 The Diatel Study  Active Care Management + Home Telemonitoring (ACM+HT=73) Vs. Monthly Care Coordination Telephone Call (CC = 77)  Blood glucose, BP, and weight daily in ACM+HT  ACM+HT had larger decrease in A1c at 3 months (1.7 vs. 0.7%) and 6 months (1.7 vs. 0.8%; P<0.001 for each)  Frequency of self monitored blood glucose did not correlate significantly with reduction in A1c Stone RA, et al., Diabetes Care, 2010;33(3):

24 Multicenter Randomized Trial on Home-based Telemanagement  460 patients with heart failure – 230 each  HBT received a portable device to transfer a one- lead trace to a nurse by telephone  HBT group had lower risk of readmission compared with the Usual Care group (RR = 0.56; 95% CI: 0.38– 0.82; p = 0.01) lower risk of heart failure-related readmission (RR = 0.49, 95% CI: 0.31–0.76; p = ) No significant difference in cardiovascular mortality Giordana A, et al., Int J Cardiology, 2009;131(2):

25 Telemonitoring to Improve Heart Failure Outcomes (Tele-HF)  1,653 recently hospitalized patients at 33 centers  Telephone-based interactive voice-response system, daily information on symptoms and weight  No difference in all-cause mortality (11% both groups) or hospital readmission for any reason (49.3% vs. 47.4%; P=0.45) at six months  14% did not use system; 55% used at 6 months  Increase contact, formal education, medication management, or peer support to enhance  Caution about investment in unevaluated disease management protocols and processes Chaudhry S, et al., NEJM, 2010;363(24):

26 Effectiveness of Home Blood Pressure Monitoring on Hypertension Control  Three-arm randomized controlled trial for 12 m  778 pts, age 25–75, with Internet access  Interventions—(1) BP monitoring and secure patient website training (BPM-Web); (2) BPM-Web plus pharmacist care management via web  Results: BPM-Web: nonsignificant increase in % with controlled BP compared to UC (36% vs 31%; P =.21) BPM-Web-Pharm: significant increase in % with controlled BP (56%) vs. UC and BPM-Web (P <.001) No difference in PCP, ER or inpatient use Increased web and phone contact in BPM-Web-Pharm Green B, et al., JAMA, 2008; 299(24): 2857–

27 Telemonitoring for COPD – a Systematic Review  9 original studies with 858 patients  Home telehealth Reduced rates of hospitalizations Reduced emergency department visits Bed days of care varied Increased mortality based on 3 studies (Risk Ratio 1.21; 95% CI ) Improved quality of life Improved patient satisfaction Polisena J, et al., J Telemed Telecare,2010;16:

28 Other Chronic Diseases  Interactive asthma education Access to a website:  Increased asthma knowledge, reduced symptom days, fewer ER visits, lower steroid doses  Weight management using e- counseling Greater weight loss with website access and e-counseling Krishna S,et al., Pediatrics 2003; 111: Tate DF,et al., JAMA 2003; 289:

29 Improvement in Cardiovascular Risk Despite Clinical Inertia Dang S, et al., Diabetes Therapeutics and Technology, 2010;12:

30 Veterans Health Administration’s Telehealth Interventions  Care Coodination Home Telehealth (CCHT) with over 40,000 Veterans  diabetes mellitus (48.4%)  hypertension (40.3%)  congestive heart failure (24.8%)  chronic obstructive lung disease (11.4%)  depression (2.3%) and PTSD (1.1%).  Reductions in admissions (19.7%) and bed days of care (25.3%) Darkins A, et al., Telemed J E Health, 2008 Dec;14(10): Hill RD, et al., Am J Manag Care, 2010;16, e302-e

31 Reduction in Utilization by Condition Monitored in the VHA Condition# of Patients% Decrease Diabetes Hypertension Chronic Heart Failure Chronic Obstructive Pulmonary Disease Post Traumatic Stress Disorder Depression Other Mental Health Condition Single Condition Multiple Conditions Darkins A, et al., Telemed J E Health, 2008 Dec;14(10): Hill RD, et al., Am J Manag Care, 2010;16, e302-e310.

32 Key Contributions of VHA to Teleheath Care Coordination  Broadest spectrum of veteran patients  Targeting the non institutional care (NIC) patients  Standardized procedures for ensuring the security of patient data  Highlighted the role of the computerized patient record as a fundamental prerequisite  National training program focused on rapidly training staff in care coordination  Standardization of the clinical, educational, technical, business, and organizational elements 31

33 Why Might Technology- Assisted Care Coordination for Chronic Disease Management Work? 32

34 33

35 Chronic Care Model ~ Care Coordination + Technology Benefits stem from re-engineering care, not from addition of technology Patients self-manage Just-in-time versus just-in-case care Proactive not reactive Continuous not episodic Integrate technology into care system Integrate available resources Redesign the system 34

36 Interactive Behavior Change Technology (IBCT)  Any hardware and software to promote and sustain behavior change Assists patients and clinicians in monitoring Assists enhanced frequent communication b/w patients and providers and caregivers Provides ongoing self-management education and support Enables patients’ efforts to change behavior Feedback to providers enables changes in treatment regimens and without office visits Piette JD,et al., Diabetes Care, 2007;30(10):

37 Other Potential Benefits of Technology in Care Coordination Case management by exception Enhanced efficiency of care provision Cost effective approach to manage large populations Centralized data management Potential cost savings Access to care Decrease travel time 36

38 Technology-Assisted Care Coordination –Where does it stand?  Establishing programs is feasible  Can complement the ability to assess, monitor, educate, and support patients  Technology has limitations  Some clinical benefits demonstrated  Limitations in study design  Questions regarding impact on health care utilization, mortality, and cost  Questions regarding design  Technology is a tool 37

39 Technology is a tool – Circle of Management  Reliable measure of the correct physiological variable(s)  Efficient transmission of information  Information received by personnel qualified to recommend an appropriate and effective intervention  Patient must correctly implement the intervention  Reassessment Desai A and Stevenson LW. NEJM, 2010; 363:

40 Current and Perceived Challenges  People: politics, relationships, provider, patients  Cost: capitalization, operations, sustainability  Difficult outside an integrated delivery model  Reimbursement: unaligned incentives/payments  Regulatory: licensure, credentialing, malpractice liability and jurisdiction, protected health information  Limitations of technology  Systematic protocols, best practices, and standards  Lack of adequate outcome data Kang,et al., J Am Geriatr Soc, 2010; 58:1579–1586. Dang, et al., Telemedicine and e-Health, 2006; 12(1):14–23. 39

41 Work Ahead…  Evidence on cost, effectiveness, and best practices, and guidelines  Collaboration between clinicians, patients, academia, industry, and health policy-makers  Healthcare system reform Integrated delivery models Payment reform and aligned incentives  Regulatory and licensure changes  Interoperability of systems and devices Robust, fail-safe systems and operating procedures Interoperability of systems and devices with the creation of a single end user interface interoperable with multiple applications and providers Kang, et al., J Am Geriatr Soc,2010; 58:1579– doc.gov/reports/telemed/privacy.htm 40

42 Interoperability of Systems and Devices 41

43 Work Ahead… Issues for Ongoing Research  Ideal design: t echnology, professional, patients, protocols Ideal parameter(s) to monitor Episodic vs. continuous enrollment/eligibility For what purpose: prevention, disease management Frequency of monitoring Frequency of communication  How to assess technology’s contribution as distinct from other components of care  Impact on health care utilization, mortality, and cost 42 Dang, S., et al., (2009). Telemedicine and e-Health. 15 (10),1-14.

44 Health Care Costs are Rising Source: CBO 43

45 The Health Care Imperative Improve Outcomes /Quality Decrease Cost 44

46 Patient Protection and Affordable Care Act – Public Law  Accountable Care Organizations  Patient Centered Medical Home  Partially Capitated  Fully Capitated  Independence at Home Project 45

47 “I don’t want to talk to the doctor, I want my symptoms to go straight through to your computer!” 46

48 Special Thanks to:  Office of Telehealth, VISN 8, and Sunshine Training Center Adam Darkins, MD Pat Ryan, MSN Rita Kobb, MSN  Office of Geriatrics and Extended Care and GRECC Tom Edes, MD Ken Shay, DMD  Miami VAHS Bernie Roos, MD Adam Golden, MD, MBA Hermes Florez, MD, MPH, PhD Jorge Ruiz, MD Enrique Aguilar, MD Herman Cheung, PhD  Past and present care coordinators, fellows, and students 47

49 48

50 Technology-Assisted Care Coordination: Design Questions  Ideal intervention Technology Professional Patients Protocols  Ideal parameter(s) to monitor  Duration  Frequency of monitoring  Frequency of communication  Relative contribution of technology vs. coordination 49 Dang, S., et al., (2009). Telemedicine and e-Health. 15 (10),1-14.

51 It's Not About The Technology  Most patients are comfortable and adapt to technology  Technology has its limitations Patients’ willingness ability to use Providers willingness to be part of it  Health informatics and sufficiently robust  IT infrastructure can be implemented 50

52 Issues Plaguing TeleCare Coordination Evaluation Issues  Lack of adequate outcome data Few systematic comparative studies that assess effect on quality, accessibility, or cost of health care Unmatched retrospective analyses using a single-group study design  regression to the mean Quazi experimental design

53 52 Essential Transformational Elements: Patient (Veteran) Centered Care  Delivering “health” in addition to “disease care”  Veteran as a partner in the team Empowered with education Focus on health promotion and disease prevention Self-management skills  Efficient Access Visits Non face-to-face  Telephone  Secure messaging  Telemedicine  Others?

54 53 ACP Medical Home Builder Modules  Patient-Centered Care & Communication  Access & Scheduling  Organization of Practice  Care Coordination & Transitions of Care  Use of Technology  Population Management  Quality Improvement & Performance Improvement

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56 Technology-Assisted Care: Research Questions Who benefits most? And from which technologies? How long? In which setting? For what purpose, e.g., prevention, disease management? How to assess technology’s contribution as distinct from other components of care  Chronic disease management (T-Care and TLC)  Health promotion and disease prevention (MOVE)  Patient safety and medication reconciliation for community-based dependent elderly

57 U.S. Health Care Spending In 2009, the U.S. spent $2.53 TRILLION on Health Care 56

58 Home Telemonitoring for Heart Failure: Systematic Review  Twenty-five original studies (3062 patients)  A random effects model was used to compute average treatment efficacy  Reduced mortality (RR 0.66, 95% CI 0.54 to 0.81, P < ) compared with usual care and CHF- related hospitalizations (RR 0.79, 95% CI 0.67 to 0.94, P = 0.008)  Several studies suggested lower the number of hospitalizations, improved quality of life and satisfaction Polisena J, et al., J Telemed Telecare, 2010;16(2):

59 Patient Protection and Affordable Care Act – Public Law  Accountable Care Organizations  Patient Centered Medical Home  Partially Capitated  Fully Capitated  Independence at Home Project 58

60 Communication Links that could be Targeted by Interactive Behavior Change Technology Piette JD, Diabetes Care, 2007;30(10):

61 Care Coordinator Role  Licensed health care professionals who assess and monitor patients using home telehealth  Detect changes in chronic diseases and conditions  Identify and coordinate services across a continuum of care  Provide education and emotional support for frail patients with complex clinical needs 60

62 Care Coordination Definition Veterans Health Administration definition: “process of assessment and on–going monitoring of selected patients using telehealth to proactively enable prevention, investigation, and treatment that enhances the health of patients and prevents unnecessary and inappropriate use of resources. This process allows for the appropriate information to be communicated to providers and the healthcare system to assure the right care, at the right place, and at the right time. ” 61

63 Types of Applications  Store and Forward  Remote Monitoring  Interactive Services 62

64 Patient Centered Goals of Care Coordination  Medical, preventive and psychosocial needs  Ensure appropriate and comprehensive care  Make the patient a partner in his/her care  Promote communication  Guide through a maze of services  Match need with funding and resources  Maximum cost effective use of resources  Maintain function and independence to enable person to remain in the most independent environment 63

65 REMOVE Care Coordination Definition “the deliberate organization of patient care activities between two or more participants (including the patient) involved in a patient's care to facilitate the appropriate delivery of health care services. Organizing care involves the marshalling of personnel and other resources needed to carry out all required patient care activities, and is often managed by the exchange of information among partici- pants responsible for different aspects of care. Closing the Quality Gap: A Critical Analysis of Quality Improvement Strategies. Agency for Healthcare Research and Quality (US); 2007 Agency for Healthcare Research and Quality (US) 64

66 Current and Perceived Challenges  Physician skepticism of new healthcare models  Coordination outside of an integrated delivery model  Reimbursement - Payment reform and aligned incentives  Interoperability of systems and devices  Developing the evidence  Caution about increased use and investment in unevaluated technologies  Integrate into existing practice and process  Identify best practices Kang,et al., J Am Geriatr Soc,2010;58:1579–

67 Challenges Ahead…Technology  Robust, fail-safe systems and operating procedures for lay people  Hardware and software with the creation of a single end user interface interoperable with multiple applications and providers  Safe, reliable, and secure  FDA approval doc.gov/reports/telemed/privacy.htm Mahoney DM, et al. Telemed J E Health 2008;14:224–

68 The Future…….  Dialogue between clinicians and patients and between academia, industry, and health policy-makers regulatory and licensure needs  Early real-world testing of technology and collection of cost effectiveness data  Guided by geriatrics providers, patients and caregivers Kang, et al., J Am Geriatr Soc,2010; 58:1579–

69 Care Coordination  The Veterans Health Administration defines care-coordination as the “wider application of care and case management principles to the delivery of health-care services using health informatics, disease management, and telehealth technologies to facilitate access to care and improve the health of designated individuals and populations with the intent of providing the right care in the right place at the right time.” 68

70 But Needs Caution…….  Nurse care management patients, A1c 9.3% - Nurse care management using algorithms; follow-up over 18 months - No difference in A1c, BP, lipids - Intervention resulted in greater satisfaction with diabetes care Gagnon AJ, et al., J Am Geriatr Soc, 1999;48(5): Boult C, et al. J Am Geriatr Soc, 2000;48(8):

71 70

72 IDEATEL – Change in A1c Shea S, et al., JAMIA, 2009;16(4):

73 Technology-Assisted Care: Some Recent Answers  Real Time Transmission of Data  1 year controlled parallel group trial  Intervention group assigned to teleassistance system using real time transmission of FSBG with immediate reply when needed + Telephone consultation  Control Group  328 T2D from 35 family practices in Spain  At 12 months Intervention group with in A1c (7.62 ±1.60 to 7.40 ±1.43; P=0.025) and significant in blood pressure, total and LDL cholesterol, and BMI Control Group with in A1c (7.44 ±1.31 to 7.35 ±1.38; P=0.303) and only decrease in LDL cholesterol  Feasible in primary care setting Rodriguez-Idigoras MI, et al., Diabetes Therapeutics and Technology, 2009 ;11(7):

74 Care Coordination Definition Veterans Health Administration definition: "the ongoing monitoring and assessment of selected patients using telehealth technologies to proactively enable prevention, investigation, and treatment that enhances the health of patients and prevents unnecessary and inappropriate utilization of resources. Care Coordination uses best practices derived from scientific evidence to bring together health care resources from across the continuum of care in the most appropriate and effective manner to care for the patient“ Case management is the foundation of care coordination. VHA Office of Care Coordination,

75 SBP mmHg p=0.09 p=0.03 Improvement in Cardiovascular Risk Factors Despite Clinical Inertia n = 46; Clinical Inertia is the lack of dose adjustment or initiation of a new medication for BP or lipid management when indicated according to practice guidelines. For BP medication: 10.8%; for lipid medication: 15.5%. Dang S, et al., Diabetes Therapeutics and Technology,

76 E-Health  e-Health is broader than either telemedicine or telehealth and can be described as an emerging field in the intersection of medical informatics, public health and business, that enables health services and information to be delivered or enhanced through the Internet and related technologies. ( ormatics/ telemedicine/telemed.aspx ) ormatics/ telemedicine/telemed.aspx 75

77 Reduction in Utilization by Condition Monitored Condition# of Patients% Decrease Diabetes Hypertension Chronic Heart Failure Chronic Obstructive Pulmonary Disease Post Traumatic Stress Disorder Depression Other Mental Health Condition Single Condition Multiple Conditions

78 Reimbursement  Provider - same Common Procedural Terminology (CPT) code, and add Healthcare Common Procedure Coding System (HCPCS) modifier code ‘‘GT’’  Patient site: Telehealth Originating Site Facility Fee - CPT/HCPCS code Q3014 Appropriate clinical code for a separate face-to- face visit to account for clinical activities  Store and forward - CPT

79 Reimbursement – Medicare Limitations ‘‘Originating site’’ - non-Metropolitan or a rural health professional shortage area Specific CPT codes - consultations, general office visits, psychiatry, psychotherapy, pharmacological management, end-stage renal disease services, and nutrition Particular providers - physician, mid-level practitioner, nurse–midwife or clinical nurse specialist, psychologist, social worker, and registered dietitian or nutritionist List of Medicare Telehealth Services. Vol Pub Medicate Claims Processing: CMS Manual System;

80  Issues for Ongoing Research  While much has been learned since the earliest care coordination efforts and the components  of effective interventions can now be specified with a substantial probability of success, much  remains to be learned. The key issues for which greater clarity is required are:  How to identify the optimal target population: using only data readily available to  most clinics or programs, is there a simple way of identifying a mix of individuals who  are at high enough risk to benefit from the intervention, but not so high risk that little can  be done to help reduce their need for a hospitalization? While one of the successful  MCCD programs risk-stratified very successfully, the assessment form used requires a  substantial amount of data that can be obtained only by interviewing the patient. What  targeting criteria provide the optimal tradeoff between identifying a group for which the  likelihood of generating savings is high, while not limiting the target population so  severely that the impact on total Medicare costs is small?  Episodic vs. continuous enrollment/eligibility for care coordination: while the  transitional care and self- management interventions engage patients for a limited duration  of about 1 to 3 months, the successful MCCD programs kept patients enrolled for the life  of the program (up to 6 years). The advantage of continuous enrollment is that the  relationship between care coordinator and patient remains intact, and the intervention can  change as the patient’s needs change. On the other hand, continuous enrollment is  expensive. Most programs that maintain continuous enrollment classify patients into  specific risk tiers based on their assessed level of need for monitoring and coaching at  any given time and move patients among tiers as their health and situation change. What  is still undetermined is whether programs should be paid different rates for patients in  different tiers or a single rate for all patients that on average will cover program costs.  How best to provide the transitional care intervention: should all care coordinators be  trained in the transitional care intervention or is this intervention more effective if it is  6  provided by limited set of nurses who would specialize in transitional care? Do these  nurses need to be advanced practice nurses, as in the most successful transitional care  models? Could social workers be included in the pool of health professionals who can  provide effective transitional care interventions, as is currently being tested in the  Enhanced Discharge Planning Program at Rush University Medical Center?  How to provide care coordination as efficiently as possible: given the difficulty of  generating large savings, this is a very important area for further investigation. A key  issue is determining the optimal frequency and nature of ongoing contacts with  participating patients and how this would vary with patients’ characteristics and length of  time in the program.  What mix of nurse-oriented interventions and social service supports is most  effective: as the baby boom generation ages into Medicare and life spans continue to  grow, programs may need to adjust their service mix and staffing to meet the social  support needs of frail individuals with chronic illnesses. The extent to which patients  should be moved from care coordination programs to long term care-oriented programs  versus extending the continuum of care to meet these needs is a key issue to address. 79

81 Major Forces Driving Health Care into the Home  Aging of the U.S. population  Epidemics of chronic diseases  Technological advances  Health care consumerism  Rapidly escalating health care costs 80

82 . The LifeMasters Demonstration program is a population-based program targeting people dually eligible for Medicare and Medicaid with particular diagnoses and is also at financial risk for program fees. Enrollment through January 2006 was 50,654 (36,182 of whom were in the treatment group). LifeMasters’ fees are lower because it is not providing prescription drug coverage. The Medicare Health Support Program (formerly called the Chronic Care Improvement Program) provides DM on a population scale to all eligible beneficiaries in a geographic area – again, bearing risk for financial performance. The nine providers began operating in 2004 and are expected to serve 180,000 beneficiaries. 81

83 SBP mmHg p=0.09 p=0.03 Improvement in Cardiovascular Risk Factors Despite Clinical Inertia Clinical Inertia is the lack of dose adjustment or initiation of a new medication for BP or lipid management when indicated according to practice guidelines. For BP medication: 10.8%; for lipid medication: 15.5%.

84 TLC and Caregiver Burden Zarit Burden Interview Score p<0.05 n=113 n=60 * * Dang et al. J Telemed Telecare 2008;14:

85 TLC and Caregiver Depression CES-D Score n=113 n=60 Dang et al. J Telemed Telecare 2008;14:


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