Presentation on theme: "Integrated Chronic Care Disease Management: Elevating Practice, Engaging Patients and Driving Best Outcomes What are we doing from a home care perspective."— Presentation transcript:
1 Integrated Chronic Care Disease Management: Elevating Practice, Engaging Patients and Driving Best OutcomesWhat are we doing from a home care perspective that is a value of leading our systemWhat is ICCDM at a high levelWhy it is a value at a high levelRe-admissionsTransitionsACO- high quality and low costPatient-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 CareVicki Wildman, RN, MSN, Edu, Statewide Education, Integrated Chronic Care Disease Management Specialist TrainerIHS Spring Symposium2011
2 Objectives Review the incidence and prevalence of chronic diseases Discover the importance of patient-centered care conceptsList the components of Integrated Chronic Care Disease Management modelList the positive outcomes to enhance clinical practice, increase quality and improve patient outcomesDescribe 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 sustainableIf we can envision- A patient centered healthcare system that is accessible, affordable, sustainable and provides the best care in the worldIf 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 futureIf we can embark – take a journey with colleagues in the pursuit of excellence for those we are privleged to serveIf 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 comeWhen we succeed- we will have delivered the Healthcare Future and restored hope for millionsEmbrace, Embark, and Succeed!
4 A Year in the Life of a Patient 5Hospital Admissions6Weeks SNF Care37Nurses13Meds6SocialWorkers2Nursing Homes224Occupational Therapists5Months of Home Care19Clinic Visits5Physical TherapistsExample of current health care systemCurrently, 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.16Physicians6CommunityReferrals2Home Care AgenciesSource 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 diseaseWe 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. population133 million Americans (45%)have one or more chronicdiseasesSource: 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 diseaseComplexity of carePoor transitionsTelehealth data: poorly controlled diseaseLack of evidenced based care“Non compliant” patientsReviewing 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-admissionsResult 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 days50% of discharged patients are readmitted within 1 yrIn 2004, $17.4 billion was spent by Medicare in unplanned rehospitalizationsMaintaining 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 careCMS, JCAHO, would health org, national transition of care coalition, all recommending strategies for improving careMed PAC Recommendations1. Direct adjustments to DRG payments for preventable readmissions2. Make adjustments to payment that are performance based3. Publicly report readmission rates4. 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-HospitalizationWhat 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-morbiditiesElderly patients with age-related complexitiesFewer resources to care for an ever increasing number of patients all seeking care in an acute environmentWe are providing care to:-More people-Older People-Less resources-Increased chronic illnessIs 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 visitsUnnecessary changes in treatmentOveruse of scarce and expensive medical resourcesLoss of productivity and decreased quality of lifeWhen 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 diseasesLower medication persistence with chronic diseaseLow adherence = twice the healthcare expenditures83% of your patients would never tell you if they didn’t plan to fill their prescriptions50% 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 behaviorsIncluded interviews with adherent and non-adherent patientsMajor difference: non-adherent patients had lower self-efficacy but cared just as much about their healthButterworth, 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 silosNo uniform way to share knowledgeLack of care coordinationRushed practitionersLack of active follow-upPts inadequately trained tomanage their illnessesPts seeking care via ER visits & hospitalizations
19 Integrating “The Best of the Best” New HealthcareDelivery ParadigmRedesignedCareDeliveryModels60 YearsExperienceDisease ManagementComponentsBehavioralManagementLessons LearnedCMS DemoProjectsEvidencedBased CareHealthcare of the future:Redesigned Care Delivery ModelPatient’s supported by a proactive team that guides them through the healthcare system and equips them to accept personal responsibility for their healthAll 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 practiceExpertsSubject 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 projectImplementation 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 CareImplementation of evidenced based care throughout all transitions and care continuums.Use of clinical guidelinesNew Healthcare Delivery ParadigmPayers 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 permitsPolicy 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 jobTrying harder will not workChanging 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 healthcare20
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-designWith 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 MotivationInformationSkillsConfidencePreparedPracticeTeamPatient informationDecision supportResourcesPreparedPracticeTeamInformed 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,ActivatedPatientProductiveInteractionsPreparedPracticeTeamThe bulk of the work is not to be just a physician– the bulk of the work is a care teamIn order to achieve outcomes:-visible support at all levels-Redesign care delivery model-Proactive/prepared practice team-Financial support to sustainThe 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 specificguidelines and careExpert in carecoordinationSharesresponsibilityfor outcomesCompetent communication& ability to share dataFacilitates effective transitionsHighly trained in behavior change techniquesWe need to have access to experts in disease specific guidelines and careWe need to have highly trained individuals in behavior change techniquesWe need to have experts in care coordinationWe need to be willing to share responsibility for outcomesWe need facilitate effective transitionsWe need communication, competencies and ability to share data.Success of the model depends on the competency of cliniciansCourses to educate clinicians will need to be implementedStaff will move towards certification: Home-based chronic care professionalsComprehensive assessment tools, scoring and evidenced –based interventions and decision supportWe want to retain, recruit the sought after partner that brings value to the health care system and our agencies.“sought after” partnerthat brings value
25 Home-Based Chronic Care Model Self-Management SupportHigh Touch DeliveryInstitute 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 DeliveryUse of Evidenced-based practicesClinician’s practicing at the highest levelUse of patient-centered careComprehensive assessmentsProactive planned visitsInterdisciplinary TeamTelehealth/phone visitsTransition expertsSelf-Management Support- 99% is self management 1% is medical managementThe 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.TechnologyElectronic medical recordsDashboard indicatorsHealth coaching with telephone visitsUse of video/telemonitoringMedication dispensing machinesLifelineSpecialist OversightImplementation of interdisciplinary team meetingsCommunication with specialistsImplement evidenced-based practicePatient-centered focusAutomatic review of patients that sought emergent care/acutely hospitalizedReview of patients with multiple chronic diseasesSpecialist OversightTechnology
26 Healthcare Providers Role: Explore Barriers to Change UnderstandingFinancial constraintsEnergy level (depression)Support systemProblem solving abilityRelationship with healthcare providerImportance and confidenceAmbivalence: Many patients simply lack confidence in their abilities and that contributes to ambivalenceTo 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 AssessmentsExamples:Re-hospitalization risk to identifyhigh risk/ high cost patientsPHQ-9Assessments by diseaseMedication Risk AssessmentMulti-faceted Fall Risk AssessmentEvidence-based care plansHigh quality educational materials27
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, MPHCare Transitions ProgramSM
30 Implications for Healthcare Delivery Coordination of care in the first 30 days criticalCoordination of care is traditional role of homecareDeveloping a standard approach to care coordination should be a key strategic objectiveIn 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, 9Evidence 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 matchComplex discharge instructionsLack of knowledge regarding red flagsPoor connections/ understanding of care post hospital discharge
31 Homecare’s Unique Role in Transitions Comprehensive assessmentsEvidenced-based screening toolsInterdisciplinary team assessmentsInterdisciplinary approach to care interventionMedication reconciliationProcess & outcome measuresICCDM : Skills for effective health coaching in self mgt support & evidenced based guideline caredepressionhealth literacy, rehospitalization risks, etc“Patient is a puzzle”
32 Community-Based Transitions Model™ (CBTM) MedicationManagementEarlyFollow-upSymptomManagementApptScheduledwithin a wkANDable to getthereComprehendS&S that require attentionANDwhom to contactIs patient familiar&competentANDhave accessChange inRX or TXChange inRX or TXAdherence& Persistence
33 Sustaining ICCM Job description expectations Performance Appraisals Training of all staff on ICCMComputer Based-Learning trainingDemonstration of skillsCompetency of skillsCase conference meetingsCertification
34 Certification Course Content Self-Management Support ConceptsWorking collaboratively with patientsBehavior change theories and toolsAdult LearningEvidence-based guidelines as they relate to disease self-managementUse of telehealth and technology to support careTransitions of careHealth literacy
35 Showing an Improvement Data collection of outcomesData collection of process measuresTracking certificationTracking use of tools
36 Bringing All Concepts Together Multidisciplinary Case Conference PhysicianSTOTPTModel ChampionICCMTeam LeaderRN - NCMSWCPS-PCTelehealthPharmacist36
37 Training Curriculum Making the Case for Integrated Chronic Care Principles of Adult Education and Health LiteracyProblem Solving 101Evidenced-Based facilitation of Behavior ChangeTheory –Based TelehealthIntegrated Care TransitionsModel Implementation into Practice8 Hour class provides knowledge, practice and application of the vital skills for all clinical staff to become successful at implementing this model.
39 Vision : Develop Strategies to Achieve Clinical Information Systems Proactive follow-upPlanned visitVisit system changesLeadership supportProvider participationGuidelinesProvider educationExpert supportDeliverySystemDesignDecisionSupportHealth System OrganizationSelf-ManagementSupportClinical Information SystemsLinks to Community ResourcesTelemonitoringGuidelines embeddedDashboardPatient activationSelf-management assessmentSelf-management resourcesGuidelines to patientsSource: Pearson, M. et. al. Chronic Care Model Implementation Emphases, Rand Health Presentation to Academy Health Meeting, 200439
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 practiceWe 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.