1. Critical Dimensions for Transforming Primary Care Chad Boult, MD, MPH, MBA 7 th Annual SNP Leadership Forum October 27, 2011

2. Ms. Marian Chen 79 year old widow Retired teacher, lives alone Resources: SS, Medicaid and Medicare Daughter, lives 10 miles away with three teenagers Five chronic conditions Three physicians Eight medications

3. In 2011, Ms. Chen has had… 6 community referrals 2 home care agencies 5 months homecare 2 nursing homes 6 weeks sub- acute care 3 hospital admissions 19 outpatient visits 8 meds 22 scripts Mrs. Chen

4. Ms. Chen Confused by care, meds Discouraged Takes meds inconsistently Medicare paid $49,400; Medicaid paid $12,345 Daughter Stressed out Reduced work to half-time Considering a nursing home

5. For the chronically ill, the U.S. health care system is Fragmented Discontinuous Difficult to access Inefficient Unsafe Expensive “A nightmare to navigate” Institute of Medicine, Crossing the Quality Chasm, 2001

6. Medicare 5% Sample, 2001 The ¼ of Beneficiaries Who Have 4+ Chronic Conditions Account for 80% of Medicare Spending * * $516 billion in 2010

7. 2011 ANNUAL REPORT OF THE BOARDS OF TRUSTEES OF THE FEDERAL HOSPITAL INSURANCE (Part A) AND FEDERAL SUPPLEMENTARY MEDICAL INSURANCE (Parts B and D) TRUST FUNDS “Income in 2010 was $486 billion. Total benefits paid were $516 billion. Part A trust fund will be exhausted in 2024, 5 years earlier than was shown in last year's report. ”

8. How can we transform primary care to improve the quality and efficiency of health care for people with chronic conditions?

9. Successful Models of Nurse Care Management Frequent face-to-face interactions Small caseloads for coordinators Medication management component Communication with multiple providers Patient education/activation component Transitional care Attention to psychosocial issues

10. Guided Care: Comprehensive Care for Persons with Chronic Conditions Specially trained RNs based in primary physicians’ offices GCNs collaborate with physicians in caring for 50-60 high-risk older patients with chronic conditions and complex health care needs

11. Nurse/physician team Assesses needs and preferences Creates an evidence-based “care guide” and a patient-friendly “action plan” Monitors the patient proactively Supports chronic disease self-management Smoothes transitions between care sites Communicates with providers in EDs, hospitals, specialty clinics, rehab facilities, home care agencies, hospice programs, and social service agencies in the community Educates and supports caregivers Facilitates access to community services Boyd C et al. Gerontologist, 2007

12. AGGREGATE Activation Decision Support Problem Solving Coordination Goal Setting Effects on Quality of Care 2.1 1.3 1.5 1.8 Quality rated in the highest category on PACIC PACIC Boyd et al. J Gen Intern Med, 2009

13. Effects on Physician Satisfaction Marsteller et al. Ann Fam Med, 2010 Change in Satisfaction

14. Effects on Caregiver Strain Wolff et al. J Gerontology Med Sci, 2009

15. Very satisfied Very dissatisfied Satisfaction Items 1= Familiarity with patients 2= Stability of patient relationships 3= Comm. w/ patients; availability of clinical info; continuity of care for patients 4= Efficiency of office visits; access to evidence based guidelines 5= Monitoring patients; communicating w/ caregivers; efficiency of primary care team 6= Coordinating care; referring to community resources; educating caregivers 7= Motivating patients for self management Satisfied Somewhat satisfied Somewhat dissatisfied Dissatisfied

16. Annual Costs of Guided Care Guided Care Nurse Salary$71,500 Benefits (@ 30%)21,450 Travel (to pts’ homes, hospitals)588 Communication services Internet, cell phone1,800 Equipment (amortized over 3 years) Computer500 Cell phone67 TOTAL$95,905

17. Health Service Utilization, 1 st 20 Mos Boult et al. Arch Intern Med, 2011 *

18. Health Service Utilization, 1 st 20 Mos Boult et al. Arch Intern Med, 2011 -15% -49% -21% -47% -52% -17% 8% -7% 9%

19. Critical Dimensions for Sustainable Implementation Ensure a critical mass of patients Ensure a realistic business model Identify a local champion Tailor the model to local circumstances Specify new “top-of-license” roles for physicians, nurses, office staff Provide training Provide incentives to physicians, nurses Use QI to transform practice culture

20. Technical Assistance for Practices Guided Care: a New Nurse-Physician Partnership in Chronic Care (Springer Publishing Company) Online course for registered nurses Online course for physicians and practice leaders Orientation booklet for patients www.GuidedCare.org/adoption.asp

21. Grant Support John A. Hartford Foundation Agency for Healthcare Research and Quality National Institute on Aging Jacob and Valeria Langeloth Foundation