Improving the lives of older Americans

Critical Issues in Aging

Addressing the Chronic Care Challenge Through Collaborative

Care

March 27, 2008

Addressing the Chronic Care Challenge Through Collaborative Care

2008 NCOA-ASA Annual Meeting

Robin Mockenhaupt, RWJF

March 27, 2008

Agenda

•Chronic Care in the US

•What will it take to improve care for chronic illness?

•Role of the Aging Network

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

The “Take Home” Messages

The Aging Network has a significant opportunity NOW to improve chronic care outcomes

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 don’t 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.

Chronic Condition Prevalence

Hypertension 51.5%

Arthritis 49.3%

Heart Disease 21.2%

Cancer 20.8%

Diabetes 16.5%

Sinusitis 13.9%

Ulcer 12.1%

Stroke 9.1%

Asthma 8.5%

Hay Fever 6.7%

Chronic Bronchitis 5.8%

Emphysema 5.1%

Kidney Disease 3.7%

Liver Disease 1.3%

Prevalence of Select Chronic Conditions, 2003

US Adults Ages 65 and Over

Prevalence estimates from the NHIS

Number of Chronic Conditions per Medicare Beneficiary

Number of Conditions

Percent of Beneficiaries

Percent of Expenditures

0 18 1

1 19 4

2 21 11

3 18 18

4 12 21

5 7 18

6 3 13

7+ 2 14

63%63% 95%95%

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

Informed,Activated

Patient

ProductiveInteractions

Prepared,Proactive

Practice Team

DeliverySystemDesign

DecisionSupport

ClinicalInformation

SystemsSelf-

Management Support

Health System

Resources and Policies

Community

Health Care Organization

Chronic Care ModelChronic Care Model

Improved Outcomes

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.

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.

What will it take to improve care for chronic illness?

End the complacency*

• US 30th in life expectancy (Cuba is 29th)

• 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

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

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

What will it take to improve care for Chronic Illness?

Someone needs to take and thenassure leadership…

•Political leaders?

•Providers? Plans? Payers? Patients?

•Why not the Aging Network?

The “Take Home” Messages

The Aging Network should be leaders in integrating chronic care services and systems between health care and the community

Aging Network

Aging Network

Aging Network

Aging Network

The “Take Home” Messages

Effective and timely action will improve outcomes and reduce costs for those we serve…

…What can you do?

The Role of the Aging Network The Role of the Aging Network in in

Addressing the Chronic Care Addressing the Chronic Care Challenge Challenge

John WrenJohn WrenDeputy Assistant Secretary for Policy & ManagementDeputy Assistant Secretary for Policy & Management

U.S. Administration on AgingU.S. Administration on AgingMarch 27, 2008March 27, 2008

Aging Services NetworkAging Services Network

U.S. Administration on AgingCentral Office and Regional Offices

U.S. Administration on AgingCentral Office and Regional Offices

Area Agencies on Aging (655)

Area Agencies on Aging (655)

Local Service Providers (29,000)

Local Service Providers (29,000)

State Units on Aging (56)State Units on Aging (56)

CONSUMERSOlder People & Family Caregivers

(10,000,000)

CONSUMERSOlder People & Family Caregivers

(10,000,000)

Strategies for Modernizing the Aging Strategies for Modernizing the Aging Network’s Role in Health & LTCNetwork’s Role in Health & LTC

• Help seniors take more control of their healthHelp seniors take more control of their health--- Evidence-Based Prevention Program--- Evidence-Based Prevention Program

• Make it easier for consumers to learn about & Make it easier for consumers to learn about & access care optionsaccess care options--- Aging & Disability “one stop shop” Resource Centers--- Aging & Disability “one stop shop” Resource Centers

• Provide more choices for high-risk individualsProvide more choices for high-risk individuals--- Nursing Home Diversion Programs--- Nursing Home Diversion Programs

Key Elements of AoA’s Key Elements of AoA’s Prevention StrategyPrevention Strategy

• Evidence-Based ModelsEvidence-Based Models

• PartnershipsPartnerships

• Funding and Technical Assistance Funding and Technical Assistance

AoA Evidence-Based Prevention InitiativeAoA Evidence-Based Prevention Initiative • 2003 2003

-- Community Projects in 12 Sites-- Community Projects in 12 Sites-- National Technical Assistance Center-- 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-- 24 State Projects

• 2007 2007 -- Hispanic Health Disparity Initiative - 8 cities-- Hispanic Health Disparity Initiative - 8 cities

Metropolitan Area Projects of HHS Hispanic Elders Health Initiative

Evidence Based Disease Prevention ProjectsEvidence Based Disease Prevention Projects

MA

AK

Hawaii

MT

ID

WA

CO

WY

NV

CA

NMAZ

MN

KS

TX

IA

WI

IL

KY

TN

OH

MI

ALMS

AR

LA

GA

FL

SC

WV VA

NC

MD

DE

PA NJ

RI

OR

UT

SD

ND

MO

OK

NE

NY

ME VT

NH

CT

Guam

NorthernMarianas

IN

State Projects Funded by Atlantic Philanthropies

Private Foundation PartnersPrivate Foundation Partners• ArchstoneArchstone• Atlantic PhilanthropiesAtlantic Philanthropies• Baptist Health Foundation of San Baptist Health Foundation of San

AntonioAntonio• 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 Comprehensive Health Education

FoundationFoundation• 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 Healthcare & Nursing Education

FoundationFoundation

• 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. Luke’s Health FoundationSt. Luke’s Health Foundation• TXU EnergyTXU Energy• Unihealth FoundationUnihealth Foundation• United WayUnited Way• Weinberg FoundationWeinberg Foundation• Wellness FoundationWellness Foundation• William Bingham 2William Bingham 2ndnd Betterment Fund Betterment Fund

AoA Evidence-Based Prevention InitiativeAoA Evidence-Based Prevention Initiative

• 2008 Activities - 2008 Activities -

-- Cost studies on 3 programs-- Cost studies on 3 programs

-- Partnerships with QIOs-- Partnerships with QIOs

-- Linking Participants to Medicare Claims Data-- Linking Participants to Medicare Claims Data

-- Assessing Feasibility of Medicare Reimbursement -- Assessing Feasibility of Medicare Reimbursement for Stanford Diabetes Self-Management Program for Stanford Diabetes Self-Management Program

Contact InformationContact Information

John WrenJohn Wren

Deputy Assistant Secretary for Policy & Deputy Assistant Secretary for Policy & ManagementManagement

U.S. Administration on AgingU.S. Administration on Aging

(202) 357-3460(202) 357-3460

John.Wren@aoa.hhs.govJohn.Wren@aoa.hhs.gov

Addressing the Chronic Care Challenge Through Collaborative Care

The Medical Perspective

Rob Schreiber, M.D.

Physician-in-ChiefHebrew SeniorLife

Harvard Medical SchoolBoston, MA

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,"

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?

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

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?

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

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

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

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.

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., 2004http://www.nap.edu/catalog/11085.html

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

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)?

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 provider’s services

• P4P $ now attached to medical care practice

• Posting of outcomes of providers by payers

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

“Vision without action is merely a dream. Action without vision just

passes the time. Vision with action can change the world."

-- Joel Barker

Improving the lives of older Americans

How the Aging Network Can Help Meet the Chronic Care

Challenge

James FirmanNCOA President & CEO

March 27, 2008

© 2007. Copyright NCOA

$0

$50

$100

$150

$200

$250

$300

$350

Medicare MedicaidAged

AoA CDC CD

US Federal Spending in Billions, 2006

© 2007. Copyright NCOA

Developing and Strengthening the Community Portion of the Chronic Care Model

COMMUNITY ORGANIZATIONSOutreach to &

engagement of high risk

populations

Advocate for policies that

improve health

HEALTHCARE ORGANIZATIONS

Self Management

Support

DecisionSupport

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

linkageservices

= Where Aging Network can help

Offer proven, effective

programming

Increase access to benefits and services

AGING NETWORK

© 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

“Utilities”problem

Lack of incentives for fee-for-service health care providers to reduce overall utilization/expenditures

© 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

© 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.