1. Improving the lives of older Americans Critical Issues in Aging Addressing the Chronic Care Challenge Through Collaborative Care March 27, 2008

2. Addressing the Chronic Care Challenge Through Collaborative Care 2008 NCOA-ASA Annual Meeting Robin Mockenhaupt, RWJF March 27, 2008

3. Agenda Chronic Care in the US What will it take to improve care for chronic illness? Role of the Aging Network

4. The Take Home Messages The Aging Network has a significant opportunity NOW to improve chronic care outcomes The Aging Network should be leaders in integrating chronic care services and systems between health care and the community Effective and timely action will improve outcomes and reduce costs for those we serve

5. The Take Home Messages The Aging Network has a significant opportunity NOW to improve chronic care outcomes

6. Chronic Care in the US More than 125 million Americans suffer from one or more chronic illnesses and 40 million limited by them. Despite annual spending of nearly $1 trillion and significant advances in care, one-half or more of patients still dont receive appropriate care. Gaps in quality care lead to thousands of avoidable deaths each year. Best practices could avoid an estimated 41 million sick days and more than $11 billion annually in lost productivity. Patients and families increasingly recognize the defects in their care.

7. Chronic ConditionPrevalence Hypertension51.5% Arthritis49.3% Heart Disease21.2% Cancer20.8% Diabetes16.5% Sinusitis13.9% Ulcer12.1% Stroke9.1% Asthma8.5% Hay Fever6.7% Chronic Bronchitis5.8% Emphysema5.1% Kidney Disease3.7% Liver Disease1.3% Prevalence of Select Chronic Conditions, 2003 US Adults Ages 65 and Over Prevalence estimates from the NHIS

8. Number of Chronic Conditions per Medicare Beneficiary Number of Conditions Percent of Beneficiaries Percent of Expenditures 0181 1194 22111 318 41221 5718 6313 7+214 63% 95%

9. Changing Outcomes = Fundamental Change Effective practice changes are similar across conditions influencing physician behavior, better use of non-physician team members, enhancements to information systems, planned encounters modern self-management support care management for high risk patients prepared and engaged community resources

10. Informed, Activated Patient Productive Interactions Prepared, Proactive Practice Team Delivery System Design Decision Support Clinical Information Systems Self- Management Support Health System Resources and Policies Community Health Care Organization Chronic Care Model Improved Outcomes

11. Self-Management Support Emphasize the patient's central role. Use effective self-management support strategies that include assessment, goal-setting, action planning, problem-solving, and follow-up. Organize resources to provide support.

12. Community Resources and Policies Encourage patients to participate in effective programs. Form partnerships with community organizations to support or develop programs. Advocate for policies to improve care.

13. What will it take to improve care for chronic illness? End the complacency* US 30 th in life expectancy (Cuba is 29 th ) Rank among the lowest of Western countries in other health indicators 40–50% more expensive than other countries Nearly 1 in 6 have no health insurance; 25% higher mortality rate Significant racial, ethnic and income disparities *Ed Wagner, MD, AGS, 2007

14. What will it take to improve Care for Chronic Illness? We know that the current care systems cannot do the job Need to change care systems Major stakeholders need to be involved and committed to improvement Payers, plans, providers, patients Regional Quality Improvement Shared data and performance management

15. What will it take to improve care for chronic illness? Engaging consumers Report cards and public info Consumer education Improving health care delivery and systems IT tools QI strategies Consensus guidelines Care management Aligning benefits/financing Incentives, measures and rewards

16. What will it take to improve care for Chronic Illness? Someone needs to take and then assure leadership… Political leaders? Providers? Plans? Payers? Patients? Why not the Aging Network?

17. The Take Home Messages The Aging Network should be leaders in integrating chronic care services and systems between health care and the community

18. Aging Network

19. The Take Home Messages Effective and timely action will improve outcomes and reduce costs for those we serve… …What can you do?

20. The Role of the Aging Network in Addressing the Chronic Care Challenge John Wren Deputy Assistant Secretary for Policy & Management U.S. Administration on Aging March 27, 2008

21. Aging Services Network U.S. Administration on Aging Central Office and Regional Offices Area Agencies on Aging (655) Local Service Providers (29,000) State Units on Aging (56) CONSUMERS Older People & Family Caregivers (10,000,000)

22. Strategies for Modernizing the Aging Networks Role in Health & LTC Help seniors take more control of their healthHelp seniors take more control of their health --- Evidence-Based Prevention Program Make it easier for consumers to learn about & access care optionsMake it easier for consumers to learn about & access care options --- Aging & Disability one stop shop Resource Centers Provide more choices for high-risk individualsProvide more choices for high-risk individuals --- Nursing Home Diversion Programs

23. Key Elements of AoAs Prevention Strategy Evidence-Based ModelsEvidence-Based Models PartnershipsPartnerships Funding and Technical AssistanceFunding and Technical Assistance

24. AoA Evidence-Based Prevention Initiative 20032003 -- Community Projects in 12 Sites -- National Technical Assistance Center 2004 on-going2004 on-going -- Workshops & National Learning Networks for States -- Workshops & National Learning Networks for States 20062006 -- 24 State Projects 20072007 -- Hispanic Health Disparity Initiative - 8 cities

25. Metropolitan Area Projects of HHS Hispanic Elders Health Initiative Evidence Based Disease Prevention Projects MA State Projects Funded by Atlantic Philanthropies

26. Private Foundation Partners ArchstoneArchstone Atlantic PhilanthropiesAtlantic Philanthropies Baptist Health Foundation of San AntonioBaptist Health Foundation of San Antonio Barbara Henley FoundationBarbara Henley Foundation Brown FoundationBrown Foundation California Community FoundationCalifornia Community Foundation California EndowmentCalifornia Endowment California Healthcare FoundationCalifornia Healthcare Foundation Colorado Health FoundationColorado Health Foundation Comprehensive Health Education FoundationComprehensive Health Education Foundation Davis Family FoundationDavis Family Foundation Donaghue Medical Research FoundationDonaghue Medical Research Foundation Elwood FoundationElwood Foundation Frees FoundationFrees Foundation Grand Rapids Community FoundationGrand Rapids Community Foundation Health Foundation of South FloridaHealth Foundation of South Florida Healthcare & Nursing Education FoundationHealthcare & Nursing Education Foundation Horizon FoundationHorizon Foundation Houston Endowment, Inc.Houston Endowment, Inc. Isla Carroll Turner Friendship TrustIsla Carroll Turner Friendship Trust John A. HartfordJohn A. Hartford Kaiser Foundation Health PlanKaiser Foundation Health Plan Kronkosky FoundationKronkosky Foundation Merck Institute for Aging & HealthMerck Institute for Aging & Health Northwest Health FoundationNorthwest Health Foundation PacificSource Charitable FoundationPacificSource Charitable Foundation Piper TrustPiper Trust Robert Wood JohnsonRobert Wood Johnson Rockwell FundRockwell Fund St. Lukes Health FoundationSt. Lukes Health Foundation TXU EnergyTXU Energy Unihealth FoundationUnihealth Foundation United WayUnited Way Weinberg FoundationWeinberg Foundation Wellness FoundationWellness Foundation William Bingham 2 nd Betterment FundWilliam Bingham 2 nd Betterment Fund

27. AoA Evidence-Based Prevention Initiative 2008 Activities -2008 Activities - -- Cost studies on 3 programs -- Partnerships with QIOs -- Linking Participants to Medicare Claims Data -- Assessing Feasibility of Medicare Reimbursement for Stanford Diabetes Self-Management Program

28. Contact Information John Wren Deputy Assistant Secretary for Policy & Management U.S. Administration on Aging (202) 357-3460 John.Wren@aoa.hhs.gov

29. Addressing the Chronic Care Challenge Through Collaborative Care The Medical Perspective Rob Schreiber, M.D. Physician-in-Chief Hebrew SeniorLife Harvard Medical School Boston, MA

30. The Wake Up Call: Medicare Expenditures David Walker General Comptroller of the US In 2040, if nothing changes, the federal government's not gonna be able to do much more than pay interest on the mounting debt and some entitlement benefits. It won't have money left for anything else – national defense, homeland security, education, you name it,"

31. The New Environment for Community Based Organizations Is your organization going to be relevant? Do you provide value to the social and health system? – How do you demonstrate and measure it? Leadership and vision is needed Is their organizational readiness to implement change?

32. The Expanded Chronic Care Model, (Barr, Robinson, Marin-Link, Underhill, Dotts, Ravensdale, & Salivaras, 2003).

33. The Challenge CBOS have significant difficulty working with the medical care system Silo mentality still is the norm Leveraging your reputation and connections not effective here How do CBOS and the Health Care system build consensus to serve a population as envisioned by the Expanded Chronic Care Model?

34. Seek to Understand the Health Care Provider Measurement and scientific method is the rule Evidence-based decision making is the standard of care for health care providers Outcomes are critically important to demonstrate value and effectiveness Evidenced-based approaches and initiatives have been lacking in the vast majority of CBO

35. Barriers Connecting with Health Care Providers Clinicians are very busy and are hard to engage Clinician behavior is regarded as relatively hard to influence and practice styles vary Changing clinician behavior requires understanding how physicians prescribe, refer and communicate Take Home Point: Start EB programs before there is support from providers

36. How Do Senior Care Agencies Integrate into the System? Develop coalitions focusing on healthy aging initiatives-invite medical care providers Build programs and they will come –AoA Evidence-based disease prevention programs –Use of existing funds for community education, outreach, marketing funneled into funding these programs Do not depend on up-front support of medical community Advocate for the role of the Aging Network with legislators

37. Best Practices in Physical Activity http://www.healthyagingprograms.org/content.asp?sectionid=73 &ElementID=98 Cress, M.E., Buchner, D.M., Prohaska, T., Rimmer, J., Brown, M., Macera, C., DiPietro, L., Chodzko-Zajko, W. (2004). ACSM Best Practices Statement Physical activity programs and behavior counseling in older adult population. Medicine and Science in Sports and Exercise, 36,11, 19917-2003.

38. Essential Features of Self- Management Programs Self-management is defined as the tasks that individuals must undertake to live well with one or more chronic conditions. These tasks include having the confidence to deal with medical management, role management, and emotional management of their conditions. Adams et al., 2004 http://www.nap.edu/catalog/11085.html

39. Need to Engage Physicians and the Medical Care System Need to clarify your vision and strategy Develop an understanding of what is needed by medical care community to help them succeed Need to find physician champion(s)-opinion leader Develop programs that are well-established, accessible and on going Feedback to the providers of medical care the outcomes that occur

40. CBOS Engaging Physicians with Evidenced-Based Programs Marketing programs smartly –Keep it simple –Available and accessible Be Prepared to Answer – What is the evidence? –Will it really work for my patients?? –What is in it for me (WIIIFM)?

41. Talking Points to the Medical Community and Physicians National initiative AoA, CDC, AHRQ, CMS State governments agencies are leading this change Improve quality of care and satisfaction Increase demand for providers services P4P $ now attached to medical care practice Posting of outcomes of providers by payers

42. The Role of the Engaged Aging Network Mentor other provider organizations Work collaboratively to promote Health Aging Initiatives and Disease Prevention Leveraging your connections with other medical providers, hospitals Work with your State Legislators Continue to innovate

43. Vision without action is merely a dream. Action without vision just passes the time. Vision with action can change the world." -- Joel Barker

44. Improving the lives of older Americans How the Aging Network Can Help Meet the Chronic Care Challenge James Firman NCOA President & CEO March 27, 2008

45. © 2007. Copyright NCOA US Federal Spending in Billions, 2006

46. © 2007. Copyright NCOA Developing and Strengthening the Community Portion of the Chronic Care Model COMMUNITY ORGANIZATIONS Outreach to & engagement of high risk populations Advocate for policies that improve health HEALTHCARE ORGANIZATIONS Self Management Support Decision Support Delivery System Design Clinical Information Systems Informed Activated Patient Activated Community Prepared Proactive Practice Team Prepared Proactive Community Partners Productive Interactions & Relationships Improved Health and Functional Outcomes Provide gap- filling and linkage services = Where Aging Network can help Offer proven, effective programming Increase access to benefits and services AGING NETWORK

47. © 2007. Copyright NCOA Barriers to greater participation of the aging network in chronic care Lack of business case about the value of community-based EBP and other community-based services A disorganized, non-network of aging services The need for greater business acumen Utilitiesproblem Lack of incentives for fee-for-service health care providers to reduce overall utilization/expenditures

48. © 2007. Copyright NCOA What the Aging Network Needs to do to Make Markets Work for Community-based Chronic Care Get out of the services business and into the outcomes business Prove that programs achieve improvements in health status and pay for themselves (at least on marginal cost basis) Make it easier and safer for regional and national payers to contract with local aging service providers. Centralize more of the contracting and other business functions Organize itself to achieve scale across payers and across markets

49. © 2007. Copyright NCOA What Would Long-term Success Look Like? Significant improvements in health outcomes for millions of older adults Demonstrated increase in number/degree of informed, activated patients/consumers Demonstrable net savings to Medicare, Medicaid and Managed Care Organizations At least $1 billion of Medicare funds flow annually to community-based organizations in the aging network for chronic care services Contracted network(s) are robust, growing social enterprise(s) Public policy changes support a greater role for the aging network.