1. Caring for Older Persons with Multiple Chronic Conditions Chad Boult, MD, MPH, MBA Director, Improving Healthcare Systems, Patient-Centered Outcomes Research Institute Leyden Academy on Vitality and Ageing 9 April 2013

2. 79 year old widower Retired teacher, lives alone Income: small pension Daughter lives 10 km away, has three teenagers Five chronic conditions Three physicians Eight medications Hans Nijpels

3. In the past year, he 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 Mr. Hamond

4. Mr. Nijpels Confused by care, meds Gets discouraged Self-care is poor Mr. Nijpels’ daughter “Stressed out “ Reduced work to half-time Considering nursing homes

5. Chronic care is: Fragmented Discontinuous Difficult to access Inefficient Unsafe Expensive

6. The ¼ of older persons who have 4+ chronic conditions account for 80% of health care spending

7. perfectly “Every system is designed perfectly to produce the results it gets” Donald Berwick, MD

8. What’s Wrong Here? Chronically ill population Health care system designed to provide acute care

9. “We simply cannot afford to postpone health care reform any longer. We must attack the root causes of the inflation in health care.” Barack Obama June 2, 2009

10. What Can We Do?

11. Informed, Activated Patient Chronic Disease Self-Management, Caregiver Support, Action Plan Productive Interactions Prepared, Proactive Practice Team Monitoring Coaching Improved Outcomes Delivery System Design Decision Support Clinical Information Systems Self- Management Support Health System Community Resources and Policies Health Care Organization - T Bodenheimer et al JAMA, 2002

12. A Search for Success Literature review to identify recent innovations in chronic care that have shown promising results Rank the promising models’ potential for “diffusability”

13. Methods Literature search: Medline,1987-2011 Tabulation of evidence for promising models Classification of the strength of the evidence Consensus ratings of models’ diffusability

14. 2,714 titles identified 305 abstracts read 131 articles read 51 articles added from bibliographies 123 articles met inclusion criteria 2,409 excluded 174 excluded 59 excluded

15. 10 Successful Diffusable Models Model Improves health care quality or outcomes Improves health care efficiency Diffusability score (6-30) APN-physician team (for dementia pts) 1 cluster RCTNone19 IDT (for CHF) 1 meta-analysis 2 reviews 1 meta-analysis 2 reviews 25 Guided Care (for multi- morbid pts) 1 cluster RCT 1controlled trial 1 cluster RCT 1 controlled trial 23 Care mgmt (for CHF)3 RCTs 21 Pharmaceutical care4 RCTs2 RCTs19 Self-management training 1 meta-analysis 9 RCTs 4 RCTs24 Proactive rehabilitation4 RCTs2 RCTs19 Caregiver support/education 1 meta-analyses 1 RCT 2 meta - analyses 2 RCTs 19

16. Successful Diffusable Models Model Improves health care quality or outcomes Improves health care efficiency Diffusability score (6-30) Transitional care 1 meta-analysis 1 RCT 1 meta-analysis 2 RCTs 20 APN-physician dyads (for NH residents) 3 quasi- experimental studies 21

17. Summary Four types of successful, diffusable models: Primary care by interdisciplinary teams Adjuncts to traditional primary care Transitional care Dyadic care of residents of nursing homes “Successful Models of Comprehensive Care for Older Adults with Chronic Conditions” - IOM “Re-Tooling for an Aging America” report, 2008 - Boult et al. J Am Geriatr Soc, 2009

18. 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

19. 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

20. Who is Eligible? All Patients Age 65+ 25% High-Risk 75% Low-Risk Review previous year’s insurance data with PM software

21. Patient Selection 13,534 Patients of 14 teams/49 physicians 3,383 (25% highest-risk) 904 = Consenting Patients (Baseline Evaluation) Random Allocation 419 in seven Control teams 485 in seven Guided Care teams Boult C et al. J Gerontology, 2008

22. Baseline Characteristics Guided CareUsual Care Age77.278.1 Race (% white)51.148.9 Sex (% female)54.255.4 Education (12+)46.443.4 Living alone32.030.6 Chronic conditions4.3 Risk of utilizaton2.12.0 * ADL difficulty30.929.3

23. 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

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

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

26. 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

27. Comments by Guided Care Nurses “The best job I’ve ever had” “I love this role.”

28. 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

29. Effects on Costs of Care (per caseload, 55 patients) GC – UC Difference Average Expenditure Cost Difference Hospital days-76.1$1,519/day-115.6 SNF days-99.1$305/day-30.2 Home health episodes -20.1$1331/episode-26.8 Physician visits40.0$41/visit1.7 Gross savings----- -170.9 Cost of GCN95.9 NET SAVINGS----- -75.0 Leff et al. Am J Manag Care, 2009

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

31. 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

32. Take Home Points For patients with several chronic conditions, interdisciplinary primary care can improve care and reduce costs, especially in well- managed systems of care. Primary care physicians of the future may practice in new team-based models of care.

33. How could these lessons be used to improve chronic care in the Netherlands?