© Transamerica Center for Health Studies, 2013© Transamerica Center for Health Studies, 2013

Healthy AgingNCLR Health Summit

September 2015

Our MissionThe Transamerica Center for Health Studies (TCHS) is focused on empowering consumers and employers so that they can achieve the best value and protection from their health coverage, as well as the best outcomes in their personal health and wellness.

Our Content • Affordable Care Act (ACA)

Overview provides information about the health care new law and how it affects individuals and employers, summarizes options available in each of the 50 states, and a glossary of terms.

• The Annual TCHS Survey: Benchmark on Health Care Coverage Perceptions and Readiness is a comprehensive examination of both employers and consumers as they face a shifting health care coverage landscape.

• Small Businesses can learn about new options for providing employees health benefits and possible tax benefits.

• Health and Wellness educational content about how to stay healthy.

Our Site www.TransamericaCenterforHealthStudies.org

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Transamerica Center for Health Studies®

• In 2004, National Geographic and the world’s best longevity researchers sought to identify pockets around the world where people live measurably longer and better. In these “Blue Zones” they found that people reach age 100 at rates 10 times greater than in the United States.

Five Blue Zones• Ikaria, Greece – 20% less cancer, half the rate of heart disease, and almost

no dementia• Loma Linda, California – outlive average Americans by almost a decade• Sardinia, Italy – more male centenarians than anywhere on earth.• Okinawa, Japan – longest lived women on earth.• Nicoya, Costa Rica – more than twice as likely as Americans to reach a

healthy 90 years.

• Teams of scientists then went to each location to identify lifestyle characteristics that might explain longevity, producing the 9 Blue Zones Lessons.

• Three locations in the United States have signed on to the Blue Zones Project in building communities through these lessons to improve quality of life and longevity: Albert Lea, Minnesota; Beach Cities in South Bay, California; and the State of Iowa.

Blue Zones for Longevity Around the World

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• Move Naturally - The world’s longest-lived people don’t pump iron or run marathons. Instead, their environments nudge them into moving without thinking about it.

• Purpose - Why do you wake up in the morning? Knowing your sense of purpose is worth up to seven years of extra life expectancy.

• Down Shift - Stress leads to chronic inflammation, associated with every major age-related disease. The world’s longest-lived people have routines to shed that stress.

• 80% Rule - “Hara hachi bu”: the Okinawans say this mantra before meals as a reminder to stop eating when their stomachs are 80 percent full.

• Plant Slant - The cornerstone of most centenarian diets? Beans. They typically eat meat—mostly pork—only five times per month.

• Wine @ 5 - Moderate drinkers outlive non-drinkers, especially if they share those drinks with friends.

• Belong - Attending faith-based services four times per month – no matter the denomination – adds up to 14 years of life expectancy.

• Loved Ones First - Centenarians put their families first. They keep aging parents and grandparents nearby, commit to a life partner and invest in their children.

• Right Tribe - The world’s longest lived people chose or were born into social circles that support healthy behaviors.

Main Characteristics of Blue Zones for Longevity

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National Standards to Improve Health and Prevent Disease - Effectiveness/Appropriateness/Cost

• Alcohol • Asthma• Cancer• Cardiovascular Disease• Diabetes• Emergency Preparedness• Health Equity• Mental Health• Motor Vehicle Injury• Nutrition• Obesity• Oral Health• Physical Activity• Social Environment• Tobacco• Violence• Falls

CDC Guide to Community Preventive Services

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• Combining traditional health care practices with Western medicine – often because of lower cost.

• Home remedies and/or seeking care from family members or community members that delay treatment.

• Some prescription medications that are available without a prescription in Mexico are purchased and self-administered in lieu of care from a health provider.

• A lack of insurance results in fewer visits to primary care physicians and more visits to the emergency room.

• Low paid jobs which rarely offer health coverage benefit pose health risks for workers and their families.

• Manual labor jobs expose workers to injuries that require health care.

Barriers for Health Care Access for Older Latinos Study:• Personal Beliefs• Language Proficiency• Economic Status• Perceptions of illness, consequences of aging, and utility of medicine* Often lead to delays in seeking needed health care

Barriers to Care in the Latino Community

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RAND gave a high priority ranking – for effectiveness and cost-effectiveness – to primary prevention programs in five programmatic areas:•Health Risk Appraisals (HRAs) and follow-up tailored intervention programs. A systematic approach to collecting information from individuals to identify their risk factors and offer follow-up tailored interventions. These programs are often effective at lowering blood pressure, helping with smoking cessation, and aiding weight loss.•Obesity prevention and treatment. Exercise programs and diet counseling can lower morbidity and mortality among the elderly.•Fall prevention. Encouraging physical activity, offering balance training, introducing environmental modification, performing a medication review, and treating alcohol abuse are effective components of a multi-factorial fall risk assessment and management intervention.•Immunizations. Providing a blanket prescription for immunizations to a population in a specified setting, such as a nursing home, having separate vaccination clinics, or scheduled preventive care visits where immunizations can be administered are the most effective interventions. •General preventive care services. Providing full reimbursement or low financial barriers to recommended clinical preventive and behavior modification services lead to improved health and lower medical costs.

Primary Prevention Interventions

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Among the programs that seek to detect disease early, RAND found high ranked programs related to:

•Screenings. Providing full or low barrier reimbursement for screenings such as for blood pressure, cholesterol, vision, hearing, and depression are recommended. Providing doctors with specific patient visit protocols that include automated computer generated or hard copy reminders about screenings can lead to higher compliance--i.e., more physicians are likely to offer these services--and lower costs from treatment of disease.

•Smoking cessation. Counseling coupled with pharmacotherapy is an effective strategy in helping individuals to stop smoking.

•Blood Pressure, Blood Sugar and Lipid Monitoring. Regular monitoring of blood pressure, blood sugar and lipids can help doctors detect cardiovascular disease in its early stages, thereby allowing for more effective and less expensive treatment.

Secondary Prevention Interventions

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A high ranking of disease management and treatment programs were given in two areas.

• Diabetes. Disease management programs for diabetes patients targeted at providers encourage them to more carefully monitor patients’ blood glucose, lipids, retinopathy, urine protein, and foot lesions. These programs lead to better blood glucose control and therefore better outcomes.

• Cardiovascular disease. Antihypertensive medications and statins have been found to be very effective in treating cardiovascular disease.

Tertiary Prevention Interventions

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Community Health Workers, or Promotoras, expand access and facilitation for health care:• Outreach• Cultural Linkages• Health Education• Screening• Detection• Patient-Provider Communication• Continuity of Care• Consumer Protection

Strengthen and Expand Community Health Workers• Information Sharing and Technical Assistance• Program and Training Support• Basic Research and Program Evaluation• Continuing Education and Career Advancement

Common and Successful Model: Promotoras

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WISEWOMAN (Well-Integrated Screening and Evaluation for Women Across the Nation) • Serves low-income, under-insured or uninsured women aged 40-64• Promotes lifestyle changes in women at risk for heart disease, stroke and

other chronic diseases

SPARC (Sickness Prevention Achieved through Regional Collaboration)• Regional focus (New England and Atlanta)• Builds partnerships between community-based organizations and health

care providers to increase the delivery of multiple vaccinations and screenings

Johns Hopkins Family Heart Study• Studied African-Americans aged 30-59 with a sibling who had been

hospitalized for coronary heart disease• Provides physical exams, medical histories, prescription drugs, rick

reduction seminars, diet and exercise programs, and smoking cessation

Three CDC-highlighted Intervention Strategies

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Programs for Promoting Healthy Lifestyles• Primary Care-Based:• Virginia Ambulatory Care Outcomes Research Network (ACORN) – website providing

patients information and resources tailored to patients’ health risks based on their HRA.

• Leaders for Effective Activity Planning (LEAP), Colorado Research Network – promotes behavior change among physician office staff in order to transmit their effective strategies for behavior change and health improvement.

• Minnesota Clinicians Motivating Health Improvement (MINIT) – provides self-help materials, web technology, and trained motivational counselors to encourage behavior change among patients.

• Stand-alone or Health Plan-based:• Active for Life (AFL) – university-based system to engage local community

organizations in telephone counseling and small group classes to promote physical activity for those 50+.

• Aetna Health Care Simple Steps – employer-based website includes an online HRA and tailored behavior change programs.

• Health Partners – health management programs with telephone-based counseling and website/print materials focused on modifiable health risks.

• Blue Shield of California – offers telephone counseling and educational materials to lower the risk of adverse events for cardiovascular patients.

CMS New Opportunities for Healthy Aging in Medicare

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• Six week small group workshop for those with chronic conditions• Once a week, 2 ½ hour sessions • In community settings such as senior centers, churches, libraries and

hospitals• Facilitated by two trained leaders, one or both non-health professionals who

have chronic conditions• Provides skills to coordinate and manage their health and wellbeing

Subjects covered:• Techniques to deal with frustration, fatigue, pain, and isolation• Appropriate exercise for maintaining and improving strength, flexibility, and

endurance• Appropriate use of medications• Communicating effectively with family, friends, and health professionals• Nutrition• Decision making• How to evaluate new treatments

Stanford Chronic Disease Self-Management Program

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Evidence-based?• Implemented previously• Evaluated by researchers• Found to make positive differences in the lives of

participants

Toolkit shaped by experiences with community organizations that serve seniors by the Community Research Center for Senior Health in Waco, TX.• Step by Step Guide• Identify Need• Find a Suitable Evidence-based Program• Implement a Suitable Evidence-based Program

Evidence-based Programming for Seniors Toolkit

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Currently, more than 11 million individuals need long-term care (LTC) to assist them with daily activities. Medicaid finances 40% of national LTC spending, and out-of-pocket expenditures and private LTC insurance make up most of the rest.

Long term care services in less restrictive environments are Home and Community-Based Services and may include care coordination, personal care assistance, meals, transportation, and medication assistance, among others.

• Informal Services• Formal Personal Care Services• Skilled Home Care• Home-based Primary Care• Hospital at Home• Adult Daycare• Adult Day Health• Adult Foster Care• Group Living with Support• Assisted Living

The next tier of Long-term care is provided through an institutional setting – Nursing Homes – in state-licensed 24 hour room and board, supervision, and nursing care. Almost 1.4 million individuals currently live in nursing homes.

Continuum of Home and Community-Based Services (HCBS)

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Medicaid Expenditures for Seniors (65+) and the Disabled

• HCBS: Home and Community-Based Services

Include:• LTSS: Long-Term

Services and Supports

• PACE: Program of All-Inclusive Care for the Elderly

http://www.medicaid.gov/medicaid-chip-program-information/by-topics/long-term-services-and-supports/downloads/ltss-expenditures-2012.pdf

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https://www.genworth.com/corporate/about-genworth/industry-expertise/cost-of-care.html

Comparing Long Term Care Costs Across the U.S.

• Researchers used data from 1992 to 2009 to estimate how many years an individual turning 65 in various years could expect to live with or without a disability.

• Defined Disability to refer to anyone unable to handle any activity of daily living (ADL), such as getting from a bed to a wheelchair, or any instrumental activity of daily living (IADL), such as going shopping.

• Overall, life expectancy at age 65 increased from 17.5 years to 18.8 years (to 83.8 years)• The number of disabled life years fell half a year, to 8 years (of the 18.8 years), while the

number of disability-free years increased to 10.8 years

Four Key Findings• The disability rate for Medicare enrollees who are more than 36 months away from death

fell to less than 40 percent, from about 50 percent; and the disability rate for enrollees who had 24 to 36 months to live fell to about 70 percent, from 75 percent. About 80 percent of enrollees in the last 12 months of life had disabilities.

• Alzheimer’s and Parkinson’s diseases are minor factors in late-life disability, but heart disease, stroke, diabetes, and eye diseases are significant contributors to disability.

• Heart disease and stroke accounted for about 4 percent of disability in the elderly, a significant improvement in mortality brought on by statins and warfarin during the research period.

• Improvements in arthritis care reduced the disability rate for seniors over the study period.

Disabilities at the End of Life

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• In 2009, the top 5% of Medicare’s highest cost beneficiaries represented 38% of the total annual Fee For Service (FFS) costs.

Key Medical Contributors to High Medicare Spending (6 to 16 percent increase in risk)• High home health utilization (41+ visits) in the prior year• High Medicare spending (top 20%) in the prior year• Diabetes with complications• Neurological or mental health conditions• Cardiovascular conditions• High hospital outpatient (34+ visits) in the prior year• Kidney disease

Key non-Medical Contributors to High Medicare Spending (2 to 8 percent increase in risk)• Self-reported fair or poor health status• Moderate functional impairment with daily activities• Age 85 or older• Living in a residential setting in the prior year• Living in a nursing home in the prior year

Costs of High-Risk Older Populations

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• The 15% of Medicare beneficiaries who have both chronic illness and functional limitations account for about one-third of Medicare’s total spending. Spending for those with chronic conditions and functional limitations averaged about $15,800 per person (in 2006), compared to $7,900 for those with 3 or more chronic conditions but no functional limitations.

• There are 2-3 million older adults with high grade functional impairment.

• This population will double in about 15 years.

Problem of Duals• Sickest, least educated, and most expensive Medicare and Medicaid

beneficiaries.• The 8 million duals represent 46% of Medicaid and 25% of Medicare

expenditures.• Complex social and medical needs.• Current siloed programs and imbalance between Medicare and Medicaid

coverage (often state by state) create inefficiencies forcing patients into institutional settings.

Care Coordination for High-Risk Older Populations

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Breakdown of Costs for Medicare Enrollees

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Key Elements of Promising Models• Comprehensive primary medical care• Assessment of patients’ long term service needs, including caregiver assessment• Coordination of long term care as well as medical care (same person or team)• Ongoing collaboration between care coordinators and primary care physicians• Ongoing relationship between care coordinators and patients (and family)• Support for patients during transitions between care settings• “Person-centered” care with emphasis on patient preferences and collaboration

Care coordination within primary care practice• Guided Care – Registered nurse coordinates care, including patient and caregiver

assessment; caregiver education and support; and referrals to services.• Geriatric Resources for Assessment and Care of Elders (GRACE) – Nurse practitioner

and social worker deliver care with support from geriatrics team, including patient and caregiver assessment; and assistance linking to support team services.

• Massachusetts General Hospital – Registered nurse coordinates care with interdisciplinary team, including patient and caregiver assessment; and assistance linking to interdisciplinary team services.

• Commonwealth Care Alliance (CCA) – Nurse practitioner coordinates care and leads interdisciplinary team, including assessment; and integrated delivery of continuum of services.

Models of Care Coordination for High-Risk Older Populations

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Care coordination outside of primary care practice• Health Quality Partners (HQP) – Registered nurse/care manager coordinates care

and preventive health group activities, including assessment; long term care planning; and assistance in arranging services.

• Community Care of North Carolina – Registered nurse or social worker coordinates care for aged/blind/disabled patients, managing referrals to services.

Care coordination following hospitalization• Care Transitions Intervention – Monthly group visits of patients with a primary care

physician, nurse, and pharmacist, emphasize self-management of chronic conditions with home/phone support from primary care team.(UofC Health Care Policy and Research)

• Project RED – Nurse Discharge Advocates provide a personalized discharge plan to patients for their transition home, with pharmacist follow up on plan and medications.

• Transitional Care Model – Transitional care nurse starts with assessment, provide personalized discharge plan and home follow-up including 7 day a week phone access for approximately two months after discharge.

• Project BOOST – Interdisciplinary team conducts assessment and prepares discharge plan, follow up within 72 hours of discharge on self care and continuing with year-long mentoring program aimed at reducing hospital readmissions.

Models of Care Coordination for High-Risk Older Populations

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