2. JESSICA BORNE, ALYSIA CUMMINGS, AND CAROLYN WADSWORTH High Cost Patients

3. Background (National Institute for Health Care Management [NIHCM], 2012)

4. Background, cont’d (NIHCM, 2012)

5. Background, cont’d History of high cost patients  Spending has become slightly less concentrated in the top 1%  Accounted for 28% of healthcare spending in 1987 and 22% of spending in 2009  Contributed to the rise in obesity rates and secondary illnesses  A greater share of the population now requires moderately high medical expenditures (NIHCM, 2012; Stanton, 2006)

6. Background, cont’d Characteristics of high cost patients  Typically older and in poor health  Likely to rate their health as fair or poor  Risk of being a high cost patient directly related to the number of functional limitations and chronic conditions  IMS Institute for Healthcare Informatics  77% have at least one chronic disease  16% have battled cancer at least once  13% diagnosed with specialty condition or autoimmune disease High cost patients often receive poorly coordinated care (IMS Institute for Healthcare Informatics, 2012; NIHCM, 2012; Powers, Chaguturu, & Ferris, 2015)

7. Impact on Occupational Therapy (OT) Practice High cost patients and healthcare reform  Emphasis on health promotion and prevention with passage of the Patient Protection and Affordable Care Act of 2010 (ACA)  High-risk care management programs  Aimed to increase quality of care and decrease overall costs  Typically run by payers or third-party vendors in the past  Growing trend for these programs to now be based in medical practices (Anderko et al., 2012; Hong, Siegel, & Ferris, 2014; Powers et al., 2015)

8. Impact on OT Practice, cont’d The ACA and Accountable Care Organizations (ACO)  ACOs are integrated networks of providers working together  Improve individual and population level health outcomes  Coordinate care  Share accountability for the quality, cost, and outcomes of patients  Address rapidly rising healthcare costs and related inefficiencies  Reimbursement is benchmark-based related to outcomes  Savings achieved through prevention, improved self- management, reduced hospitalization, reduced length of stay, and/or successful discharge planning (AOTA, 2012)

9. Impact on OT Practice, cont’d The ACA and Patient-Centered Medical Homes (PCMH)  A priority of the ACA is to develop innovative models of health care delivery systems  Reduce fragmentation of care  Improve efficiency and outcomes  Reduce health care costs  PMCH is a primary care model  Patient-centered, coordinated, team-driven care  Each patient is assigned to a physician-directed practice and personal physician Held accountable for providing and coordinating entire spectrum of care (AOTA, 2012)

10. Impact on OT Practice, cont’d ACOs, PCMHs, and OT  ACO and PCMH principles align with traditional occupational therapy  Occupational therapists are trained to improve quality of life, function, and participation  Occupational therapists provide team-based, coordinated care that is patient-centered, family-focused, and holistic  Clearly articulate OT program of care, the cost of that care, OT’s role on the team, and the expected outcomes of care  Coordinated care across settings is an important aspect of OT involvement (AOTA, 2012)

11. The Role of OT Chronic Disease Management Health Promotion & Prevention Primary Health Care

12. The Role of OT: Chronic Disease Management Evaluation and treatment of occupational deficits Education of patients and family Modification of activities Energy conservation Health management Improve quality of life Maintain independence through self-management Provide community resources and supports (AOTA, 2015; Hand, Law, & McColl, 2011)

13. The Role of OT: Health Promotion & Prevention Examples of preventative strategies currently in practice:  Falls prevention programs, parenting skills training, promotion of healthy habits, injury prevention in the workplace, support groups, social, leisure, and life skills participation groups, ergonomic assessments, backpack awareness, and caregiver education Wellness and health promotion groups Is prevention an appropriate role for an occupational therapist in the acute setting?  Can help prevent hospital readmissions (AOTA, 2013; Matuska, Giles-Heinz, Flinn, Neighbor, Bass-Haugen, 2003; Roberts & Robinson, 2014)

14. The Role of OT: Primary Health Care AOTA Position Paper: Role of OT in Primary Care  AOTA “asserts that occupational therapy practitioners are well prepared to contribute to interprofessional care teams addressing the primary care needs of individuals across the lifespan, particularly those with, or at risk for, one or more chronic condition” (2014, p. S25) Who Better?  “Because occupational therapy professionals are broadly trained in human development (cognitive, physical, social, emotional), health promotion, disease process intervention, activity analysis and behavior modification, lifestyle interventions, and use of adaptive equipment, the profession could be fundamental to reducing fragmentation in health care” (Muir, 2012, p. 507)

15. The Role of OT: Primary Health Care, cont’d What do we need to do to promote OT’s role in primary health care?  Get familiar with the setting and terminology  Strengthen relationships with primary care providers  Advocate to be considered a team member in primary care  Examine OT literature and promote the role of OT in primary care (Metzler, Hartmann, & Lowenthal, 2012)

16. Conclusion High cost patients account for a disproportionate share of health care costs Chronic conditions and functional limitations increase a patient’s risk Healthcare reform emphasizes heath promotion and preventive care Healthcare reform principles align with OT Occupational therapists are well suited to manage patients with chronic care conditions AOTA is advocating for OT as a primary care provider

17. References American Occupational Therapy Association. (2012). Accountable care organizations and medical homes. Retrieved from https://www.aota.org/-/media/Corporate/Files/Advocacy/Health-Care- Reform/ACO/ACOs%20%20Medical%20Homes%20Fact%20Sheet%202012%20combined%20%20rev%2022012.pdf American Occupational Therapy Association. (2013). Occupational therapy in the promotion of health and well-being. American Journal of Occupational Therapy, 67(6 supplement), S47-S59 American Occupational Therapy Association. (2014). The role of occupational therapy in primary care. American Journal of Occupational Therapy, 68(Supplement 3), S25-S33. American Occupational Therapy Association. (2015). The role of occupational therapy in chronic disease management. Retrieved from https://www.aota.org/- /media/Corporate/Files/AboutOT/Professionals/WhatIsOT/HW/Facts/FactSheet_ChronicDiseaseManagement.pdf Anderko, L., Roffenbender, J. S., Goetzel, R. Z., Howard, J., Millard, F., Wildenhaus, K., &... Novelli, W. (2012). Promoting prevention through the Affordable Care Act: Workplace wellness. Preventing Chronic Disease, 9(E175). doi:10.5888/pcd9.120092

18. References Hand, C., Law, M., & McColl, M. A. (2011). Occupational therapy intervention for chronic diseases: A scoping review. American Journal of Occupational Therapy, 65(4), 428-436. Hong, C., Siegel, A., & Ferris, T. (2014). Caring for high-need high-cost patients: What makes for a successful care management program? Retrieved from http://www.commonwealthfund.org/~/media/files/publications/issue- brief/2014/aug/1764_hong_caring_for_high_need_high_cost_patients_ccm_ib.pdf IMS Institute for Healthcare Informatics. (2012). Essential health benefit packages explained: Understanding high-cost patients. Retrieved from http://www.imshealth.com/deployedfiles/ims/Global/Content/Insights/IMS%20Institute%20for%20Healthcare%20Informatics /Healthcare%20Spending/IHII_Spending_Report.pdf Matuska, K., Giles-Heinz, A., Flinn, N., Neighbor, M., & Bass-Haugen, J. (2003). Outcomes of a pilot occupational therapy wellness program for older adults. American Journal of Occupational Therapy, 57(2), 220-224. Metzler, C. A., Hartmann, K. D., Lowenthal, L. A. (2012). Defining primary care: Envisioning the roles of occupational therapy. American Journal of Occupational Therapy, 66(3), 266-270.

19. References Muir, S. (2012). Occupational therapy in primary health care: We should be there. American Journal of Occupational Therapy, 66(5), 506-510. National Institute for Health Care Management. (2012). The concentration of health care spending: NIHCM foundation data brief. Retrieved from http://www.nihcm.org/pdf/DataBrief3%20Final.pdf Powers, B. W., Chaguturu, S. K., & Ferris, T. G. (2015). Optimizing high-risk care management. Journal of American Medical Association, 313(8), 795-796. doi:10.1001/jama.2014.18171 Roberts, P. S., & Robinson, M. R. (2014). Occupational therapy’s role in preventing acute readmissions. American Journal of Occupational Therapy, 68(3), 254-259. Stanton, M. (2006). The high concentration of U.S. health care expenditures. Retrieved from http://archive.ahrq.gov/research/findings/factsheets/costs/expriach/expendria.pdf