Technology-Assisted Care Coordination for Chronic Disease Management in the Elderly

Stuti Dang, MD, MPHClinical Director, T-Care and TLC for Dementia

Miami VA GRECC & Medical CenterUniversity of Miami Miller School of Medicine

GRECC Audio Conference, May 26th, 2011

1

Objectives Understand definitions of care

coordination and home telehealth Discuss examples of technology assisted

care coordination for chronic diseases Review proposed reasons for technology-

assisted care coordination to work Recognize work ahead

2

Problems With Current System

Increasing number of complex older patients with chronic diseases

Disproportionate health care resources Fee for service payment structure Fragmentation and duplication Rapidly escalating health care costs Health care delivery system is under

stress with shrinking resources

3

Bodenheimer T, et al., N Engl J Med, 2009; 361:1521-1523.

Average Annual Per Capita Spending for Patients with Different Numbers of Chronic Conditions

4

Institute of MedicinePriorities for national action (2003):

Transforming Health Care Quality

-Increased demands-Poorly coordinated care-Inadequate implementation of information technology in health care

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Care Coordination Definition “Care coordination” is a client-centered,

assessment-based interdisciplinary approach to integrating health care and social support services in which an individual’s needs and preferences are assessed, a comprehensive care plan is developed, and services are managed and monitored by an identified care

coordinator following evidence-based standards of care.

Brown R, in a report commissioned by the National Coalition on Care Coordination, in 2009, at http://www.socialworkleadership.org/nsw/Brown_Full_Report.pdf

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Impact of Care Coordination Interventions

Nurse/SW directed, multidisciplinary interventions in high risk patients

Reduced hospital admissions Significantly reduced cost Improved quality of life for patients and

caregivers Improved satisfaction of care

Rich MW, et al., N Engl J Med, 1995;333(18):1213-4.Naylor MD, et al., JAMA, 1999;282(12):1129 – 36.

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Care Coordination Interventions Transitional care Self-management education: short

community-based programs to “activate” patients in disease self management

Coordinated care: patients with chronic conditions at high risk of hospitalization, provide care planning, monitoring of patients’ symptoms and self-care, working with the patient, PCP and caregivers

Coleman EA, et al.,Arch Intern Med. 2006 Sep 25;166(17):1822-8.Lorig KR et al. Eff Clin Pract. 2001 Nov-Dec;4(6):256-62. Peikes D, et al. JAMA. 2009 Feb 11;301(6):603-18.

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Medicare Coordinated Care Demonstration (MCCD) Only 3 of the 15 programs effective Six key components

Targeting In-person contact with patients Timely information on admissions Close interaction between care

coordinators and PCP: face-to-face and same care coordinator

Services provided Staffing: nurses, social workers

Peikes D, et al. JAMA. 2009 Feb 11;301(6):603-18. 9

Would Adding Technology Enhance the Model??……..

Technology assisted care coordination may provide an effective and efficient alternative to providing care coordination the traditional way

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Telemedicine Definition

“...the use of electronic information and communications technologies to provide and support health care when distance separates the participants...”

Field MJ, et al., Institute of Medicine: Telemedicine: A Guide to Assessing Telecommunications in Health Care, 1996.

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Telehealth Definition Telehealth (or Telemonitoring) is the use of

telecommunications and information technology to provide access to health assessment, diagnosis, intervention, consultation, supervision and information across distance.

Includes use for clinical and non-clinical services such as medical education, administration, and research.

Center for Medicare and Medicaid Services, 2010, at https://www.cms.gov/Telehealth/12

Care Coordination

The Veterans Health Administration defines care-coordination as the “wider application of care and case

management principles to the delivery of health-care services using health informatics, disease management, and telehealth technologies to facilitate access to care and improve the health of designated individuals and populations with the intent of providing the right care in the right place at the right time.”

http://vaww.telehealth.va.gov/telehealth/ccht/index.asp#info 13

Technology-Assisted Care Coordination Model for Chronic DiseaseBetter Health

Outcomes

Decreased Cost

Increased quality

CaregiversPharmacy

Care coordination

team

Specialists

Monitoring

Education

Support Technologies

Peer Leaders

Patients at homeHTN, DM, COPD, CHF,Asthma, depression,

PTSD

Feedback

Education

Support

Feedback

Primary Care Providers

Non VAProviders

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Blood Pressure Graph For a Patient

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Technology Assisted Care-Coordination

Some Examples

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Telephone-based Management

Telephone calls with RN follow-up Biweekly automated telephone calls Maximum benefit when A1c>8% (net effect

- 0.5 – 1.1%)

Mobile phone and SMS messaging Patients sent glucose result via phone,

received message from nurse Decrease in A1c by 1.1% over 12 weeks

Piette JD, et al., Diabetes Care, 2001;24(2):202-8.Kim HS, et al., Int J Nurs Stud, 2007;44(5):687-92.

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Web-based Management 104 Veterans with diabetes, HbA1c 9.0% Web-based care management: notebook

computer, glucose and blood pressure monitoring devices, and access to a care management website, messaging system

At 12 m, lower A1C, BP, HDL (P < 0.05) More improvement in persistent users and

with larger number of website data uploads

McMahon G, et al., Diabetes Care, 28:1624–1629, 2005 19

IDEATel - Informatics for Diabetes Education and Telemedicine

METHODS Telemedicine home unit with

videoconferencing and case management Randomized trial with a usual care group Five year follow up Medicare beneficiaries (n= 1665) Diabetes, >55 years, medically under-served

areas in NY (upstate and NYC)

Shea S, et al., JAMIA, 2006;13(1):40-51. 20

IDEATel Results Modest clinical effects

Small but significant changes A1c (0.29%), SBP (4.3 mm Hg), Lipids (3.8 mg/dl)

Reduced waist circumference and BMI Increased diet and exercise knowledge

No mortality benefit (Likely under-powered) Costs

$622 per person per month Mean Medicare payment in UC $9040

versus IDEATel $9669 per person per yrMoreno L, et al., Diabetes Care, 2009;32(7):1202-4.Palmas W, et al., J Am Med Inform Assoc, 2010;17(2):196-202.Izquierdo R, et al., Diabetes Therapeutics and Technology, 2010;12(3):213-20.

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The Diatel Study

Active Care Management + Home Telemonitoring (ACM+HT=73) Vs. Monthly Care Coordination Telephone Call (CC = 77)

Blood glucose, BP, and weight daily in ACM+HT ACM+HT had larger decrease in A1c at 3

months (1.7 vs. 0.7%) and 6 months (1.7 vs. 0.8%; P<0.001 for each)

Frequency of self monitored blood glucose did not correlate significantly with reduction in A1c

Stone RA, et al., Diabetes Care, 2010;33(3):478-84 22

Multicenter Randomized Trial on Home-based Telemanagement

460 patients with heart failure – 230 each HBT received a portable device to transfer a one-lead

trace to a nurse by telephone HBT group had

lower risk of readmission compared with the Usual Care group (RR = 0.56; 95% CI: 0.38–0.82; p = 0.01)

lower risk of heart failure-related readmission (RR = 0.49, 95% CI: 0.31–0.76; p = 0.0001)

No significant difference in cardiovascular mortality

Giordana A, et al., Int J Cardiology, 2009;131(2):192-9

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Telemonitoring to Improve Heart Failure Outcomes (Tele-HF)

1,653 recently hospitalized patients at 33 centers Telephone-based interactive voice-response system, daily

information on symptoms and weight No difference in all-cause mortality (11% both groups) or

hospital readmission for any reason (49.3% vs. 47.4%; P=0.45) at six months

14% did not use system; 55% used at 6 months Increase contact, formal education, medication

management, or peer support to enhance Caution about investment in unevaluated disease

management protocols and processes Chaudhry S, et al., NEJM, 2010;363(24):2301-9

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Effectiveness of Home Blood Pressure Monitoring on Hypertension Control

Three-arm randomized controlled trial for 12 m 778 pts, age 25–75, with Internet access Interventions—(1) BP monitoring and secure patient

website training (BPM-Web); (2) BPM-Web plus pharmacist care management via web

Results: BPM-Web: nonsignificant increase in % with controlled

BP compared to UC (36% vs 31%; P = .21) BPM-Web-Pharm: significant increase in % with

controlled BP (56%) vs. UC and BPM-Web (P <.001) No difference in PCP, ER or inpatient use Increased web and phone contact in BPM-Web-Pharm

Green B, et al., JAMA, 2008; 299(24): 2857–2867. 25

Telemonitoring for COPD – a Systematic Review

9 original studies with 858 patients Home telehealth

Reduced rates of hospitalizations Reduced emergency department visits Bed days of care varied Increased mortality based on 3 studies (Risk

Ratio 1.21; 95% CI 0.84-1.75) Improved quality of life Improved patient satisfaction

Polisena J, et al., J Telemed Telecare,2010;16:120-127.26

Other Chronic Diseases Interactive asthma education

Access to a website: Increased asthma knowledge, reduced symptom

days, fewer ER visits, lower steroid doses

Weight management using e-counseling Greater weight loss with website access and

e-counseling

Krishna S ,et al., Pediatrics 2003; 111: 503-510Tate DF,et al., JAMA 2003; 289: 1833-1836

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Improvement in Cardiovascular Risk Despite Clinical Inertia

Dang S, et al., Diabetes Therapeutics and Technology, 2010;12:995-1001. 28

Veterans Health Administration’sTelehealth Interventions

Care Coodination Home Telehealth (CCHT) with over 40,000 Veterans

diabetes mellitus (48.4%) hypertension (40.3%) congestive heart failure (24.8%) chronic obstructive lung disease (11.4%) depression (2.3%) and PTSD (1.1%).

Reductions in admissions (19.7%) and bed days of care (25.3%)

Darkins A, et al., Telemed J E Health, 2008 Dec;14(10):1118-26.Hill RD, et al., Am J Manag Care, 2010;16, e302-e310.http://www.carecoordination.va.gov/telehealth/ccht/index.asp

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Reduction in Utilization by Condition Monitored in the VHA

Condition # of Patients % Decrease

Diabetes 8954 20.4

Hypertension 7447 30.3

Chronic Heart Failure 4089 25.9

Chronic Obstructive Pulmonary Disease

1963 20.7

Post Traumatic Stress Disorder

129 45.1

Depression 337 56.4

Other Mental Health Condition 653 40.9

Single Condition 10885 24.8

Multiple Conditions 6140 26.0Darkins A, et al., Telemed J E Health, 2008 Dec;14(10):1118-26.Hill RD, et al., Am J Manag Care, 2010;16, e302-e310.http://www.carecoordination.va.gov/telehealth/ccht/index.asp

Key Contributions of VHA to Teleheath Care Coordination

Broadest spectrum of veteran patients Targeting the non institutional care (NIC) patients Standardized procedures for ensuring the security

of patient data Highlighted the role of the computerized patient

record as a fundamental prerequisite National training program focused on rapidly

training staff in care coordination Standardization of the clinical, educational,

technical, business, and organizational elements

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Why Might Technology-Assisted Care Coordination for Chronic Disease Management Work?

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Chronic Care Model ~ Care Coordination + Technology

Benefits stem from re-engineering care, not from addition of technology

Patients self-manage Just-in-time versus just-in-case care Proactive not reactive Continuous not episodic Integrate technology into care system Integrate available resources Redesign the system

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Interactive Behavior Change Technology (IBCT) Any hardware and software to promote and

sustain behavior change Assists patients and clinicians in monitoring Assists enhanced frequent communication b/w

patients and providers and caregivers Provides ongoing self-management education

and support Enables patients’ efforts to change behavior Feedback to providers enables changes in

treatment regimens and without office visits

Piette JD,et al., Diabetes Care, 2007;30(10):2425-32.

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Other Potential Benefits of Technology in Care Coordination Case management by exception Enhanced efficiency of care provision Cost effective approach to manage large

populations Centralized data management Potential cost savings Access to care Decrease travel time

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Technology-Assisted Care Coordination –Where does it stand? Establishing programs is feasible Can complement the ability to assess,

monitor, educate, and support patients Technology has limitations Some clinical benefits demonstrated Limitations in study design Questions regarding impact on health care

utilization, mortality, and cost Questions regarding design Technology is a tool

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Technology is a tool – Circle of Management

Reliable measure of the correct physiological variable(s)

Efficient transmission of information Information received by personnel

qualified to recommend an appropriate and effective intervention

Patient must correctly implement the intervention

Reassessment Desai A and Stevenson LW. NEJM, 2010; 363:2364-2367 38

Current and Perceived Challenges People: politics, relationships, provider, patients Cost: capitalization, operations, sustainability Difficult outside an integrated delivery model Reimbursement: unaligned incentives/payments Regulatory: licensure, credentialing, malpractice

liability and jurisdiction, protected health information Limitations of technology Systematic protocols, best practices, and standards Lack of adequate outcome dataKang ,et al., J Am Geriatr Soc, 2010; 58:1579–1586.Dang, et al., Telemedicine and e-Health, 2006; 12(1):14–23.

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Work Ahead… Evidence on cost, effectiveness, and best practices,

and guidelines Collaboration between clinicians, patients, academia,

industry, and health policy-makers Healthcare system reform

Integrated delivery models Payment reform and aligned incentives

Regulatory and licensure changes Interoperability of systems and devices

Robust, fail-safe systems and operating procedures Interoperability of systems and devices with the creation of

a single end user interface interoperable with multiple applications and providers

Kang, et al., J Am Geriatr Soc,2010; 58:1579–1586.http://www.ntia. doc.gov/reports/telemed/privacy.htm

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Interoperability of Systems and Devices

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Work Ahead…Issues for Ongoing Research Ideal design: technology, professional, patients, protocols

Ideal parameter(s) to monitor Episodic vs. continuous enrollment/eligibility For what purpose: prevention, disease management Frequency of monitoring Frequency of communication

How to assess technology’s contribution as distinct from other components of care

Impact on health care utilization, mortality, and cost

42Dang, S., et al., (2009). Telemedicine and e-Health. 15 (10),1-14.

Health Care Costs are Rising

Source: CBO43

The Health Care ImperativeThe Health Care Imperative

Improve Outcomes/Quality

Decrease Cost

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Patient Protection and Affordable Care Act – Public Law 111-148

Accountable Care Organizations Patient Centered Medical Home Partially Capitated Fully Capitated

Independence at Home Project

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“I don’t want to talk to the doctor, I want my symptoms to go straight through to your computer!”

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Special Thanks to: Office of Telehealth, VISN 8, and Sunshine Training Center

Adam Darkins, MD Pat Ryan, MSN Rita Kobb, MSN

Office of Geriatrics and Extended Care and GRECC Tom Edes, MD Ken Shay, DMD

Miami VAHS Bernie Roos, MD Adam Golden, MD, MBA Hermes Florez, MD, MPH, PhD Jorge Ruiz, MD Enrique Aguilar, MD Herman Cheung, PhD

Past and present care coordinators, fellows, and students

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Technology-Assisted Care Coordination: Design Questions Ideal intervention

Technology Professional Patients Protocols

Ideal parameter(s) to monitor Duration Frequency of monitoring Frequency of communication Relative contribution of technology vs. coordination

49Dang, S., et al., (2009). Telemedicine and e-Health. 15 (10),1-14.

It's Not About The Technology Most patients are comfortable and

adapt to technology Technology has its limitations

Patients’ willingness ability to use Providers willingness to be part of it

Health informatics and sufficiently robust

IT infrastructure can be implemented

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Issues Plaguing TeleCare CoordinationEvaluation Issues Lack of adequate outcome

dataFew systematic comparative studies that assess effect on quality, accessibility, or cost of health care Unmatched retrospective analyses

using a single-group study design regression to the mean

Quazi experimental design

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Essential Transformational Elements:Patient (Veteran) Centered Care

Delivering “health” in addition to “disease care”

Veteran as a partner in the team Empowered with education Focus on health promotion and disease

prevention Self-management skills

Efficient Access Visits Non face-to-face

Telephone Secure messaging Telemedicine Others?

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ACP Medical Home BuilderModules

Patient-Centered Care & Communication Access & Scheduling Organization of Practice Care Coordination & Transitions of Care Use of Technology Population Management Quality Improvement & Performance

Improvement

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Technology-Assisted Care:Research Questions Who benefits most? And from which

technologies? How long? In which setting? For what purpose,

e.g., prevention, disease management?

How to assess technology’s contribution as distinct from other components of care Chronic disease management (T-Care and TLC) Health promotion and disease prevention (MOVE) Patient safety and medication reconciliation for

community-based dependent elderly

U.S. Health Care Spending

In 2009, the U.S. spent

$2.53 TRILLION on Health Care

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Home Telemonitoring for Heart Failure: Systematic Review

Twenty-five original studies (3062 patients) A random effects model was used to compute

average treatment efficacy Reduced mortality (RR 0.66, 95% CI 0.54 to 0.81, P

< 0.0001) compared with usual care and CHF-related hospitalizations (RR 0.79, 95% CI 0.67 to 0.94, P = 0.008)

Several studies suggested lower the number of hospitalizations, improved quality of life and satisfaction

Polisena J, et al., J Telemed Telecare, 2010;16(2):68-76. 57

Patient Protection and Affordable Care Act –Public Law 111-148 Accountable Care Organizations Patient Centered Medical Home Partially Capitated Fully Capitated

Independence at Home Project

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Communication Links that could be Targeted by Interactive Behavior Change Technology

Piette JD, Diabetes Care, 2007;30(10):2425-32. 59

Care Coordinator Role Licensed health care professionals who

assess and monitor patients using home telehealth

Detect changes in chronic diseases and conditions

Identify and coordinate services across a continuum of care

Provide education and emotional support for frail patients with complex clinical needs

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Care Coordination Definition Veterans Health Administration definition:

“process of assessment and on–going monitoring of selected patients using telehealth to proactively enable prevention, investigation, and treatment that enhances the health of patients and prevents unnecessary and inappropriate use of resources. This process allows for the appropriate information to be communicated to providers and the healthcare system to assure the right care, at the right place, and at the right time. ”

http://vaww.telehealth.va.gov/telehealth/ccht/index.asp#info

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Types of Applications

Store and Forward Remote Monitoring Interactive Services

http://www.answers.com/topic/telemedicine#Types_of_telemedicine 62

Patient Centered Goals of Patient Centered Goals of Care CoordinationCare Coordination Medical, preventive and psychosocial needs Ensure appropriate and comprehensive care Make the patient a partner in his/her care Promote communication Guide through a maze of services Match need with funding and resources Maximum cost effective use of resources Maintain function and independence to

enable person to remain in the most independent environment

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REMOVE Care Coordination Definition

“the deliberate organization of patient care activities between two or more participants (including the patient) involved in a patient's care to facilitate the appropriate delivery of health care services. Organizing care involves the marshalling of personnel and other resources needed to carry out all required patient care activities, and is often managed by the exchange of information among partici-pants responsible for different aspects of care.

Closing the Quality Gap: A Critical Analysis of Quality Improvement Strategies. Agency for Healthcare Research and Quality (US); 2007

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Current and Perceived Challenges Physician skepticism of new healthcare models Coordination outside of an integrated delivery model Reimbursement - Payment reform and aligned

incentives Interoperability of systems and devices Developing the evidence Caution about increased use and investment in

unevaluated technologies Integrate into existing practice and process Identify best practices

Kang ,et al., J Am Geriatr Soc ,2010;58:1579–1586.

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Challenges Ahead…Technology Robust, fail-safe systems and operating

procedures for lay people Hardware and software with the creation of

a single end user interface interoperable with multiple applications and providers

Safe, reliable, and secure FDA approval

http://www.ntia. doc.gov/reports/telemed/privacy.htm Mahoney DM, et al. Telemed J E Health 2008;14:224–234.

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The Future…….

Dialogue between clinicians and patients and between academia, industry, and health policy-makers regulatory and licensure needs

Early real-world testing of technology and collection of cost effectiveness data

Guided by geriatrics providers, patients and caregivers

Kang, et al., J Am Geriatr Soc,2010; 58:1579–1586. 67

Care CoordinationCare Coordination

The Veterans Health Administration defines care-coordination as the “wider application of care and case

management principles to the delivery of health-care services using health informatics, disease management, and telehealth technologies to facilitate access to care and improve the health of designated individuals and populations with the intent of providing the right care in the right place at the right time.”

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But Needs Caution……. Nurse care management

- 246 patients, A1c 9.3%- Nurse care management using algorithms; follow-up over 18 months- No difference in A1c, BP, lipids- Intervention resulted in greater satisfaction with diabetes care

Gagnon AJ, et al., J Am Geriatr Soc, 1999;48(5):596-7.Boult C, et al. J Am Geriatr Soc, 2000;48(8):996-1001.

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IDEATEL – Change in A1c

Shea S, et al., JAMIA, 2009;16(4):446-56.71

Technology-Assisted Care:Some Recent Answers

Real Time Transmission of Data 1 year controlled parallel group trial Intervention group assigned to teleassistance system using real

time transmission of FSBG with immediate reply when needed + Telephone consultation

Control Group 328 T2D from 35 family practices in Spain At 12 months

Intervention group with in A1c (7.62 ±1.60 to 7.40 ±1.43; P=0.025) and significant in blood pressure, total and LDL cholesterol, and BMI

Control Group with in A1c (7.44 ±1.31 to 7.35 ±1.38; P=0.303) and only decrease in LDL cholesterol

Feasible in primary care setting

Rodriguez-Idigoras MI, et al., Diabetes Therapeutics and Technology, 2009;11(7):431-7.

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Care Coordination Definition Care Coordination Definition Veterans Health Administration definition: "the ongoing

monitoring and assessment of selected patients using telehealth technologies to proactively enable prevention, investigation, and treatment that enhances the health of patients and prevents unnecessary and inappropriate utilization of resources. Care Coordination uses best practices derived from scientific evidence to bring together health care resources from across the continuum of care in the most appropriate and effective manner to care for the patient“ Case management is the foundation of care coordination.

VHA Office of Care Coordination, 2003

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0

20

40

60

80

100

120

140

160

180

No Clinical Inertia Clinical Inertia

Baseline T-Care 2 Years

SBP mmHg p=0.09 p=0.03

Improvement in CardiovascularRisk Factors Despite Clinical Inertia

n = 46; Clinical Inertia is the lack of dose adjustment or initiation of a new medication for BP or lipid management when indicated according to practice guidelines. For BP medication: 10.8%; for lipid medication: 15.5%. Dang S, et al., Diabetes Therapeutics and Technology, 2010

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E-Health e-Health is broader than

either telemedicine or telehealth and can be described as an emerging field in the intersection of medical informatics, public health and business, that enables health services and information to be delivered or enhanced through the Internet and related technologies. (http://www.biohealthmatics.com/healthinformatics/ telemedicine/telemed.aspx )

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Reduction in Utilization by Condition Monitored

Condition # of Patients % Decrease

Diabetes 8954 20.4

Hypertension 7447 30.3

Chronic Heart Failure 4089 25.9

Chronic Obstructive Pulmonary Disease

1963 20.7

Post Traumatic Stress Disorder

129 45.1

Depression 337 56.4

Other Mental Health Condition 653 40.9

Single Condition 10885 24.8

Multiple Conditions 6140 26.076

Reimbursement

Provider - same Common Procedural Terminology (CPT) code, and add Healthcare Common Procedure Coding System (HCPCS) modifier code ‘‘GT’’

Patient site: Telehealth Originating Site Facility Fee -

CPT/HCPCS code Q3014 Appropriate clinical code for a separate face-to-

face visit to account for clinical activities Store and forward - CPT 99090

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Reimbursement – Medicare Limitations

‘‘Originating site’’ - non-Metropolitan or a rural health professional shortage area

Specific CPT codes - consultations, general office visits, psychiatry, psychotherapy, pharmacological management, end-stage renal disease services, and nutrition

Particular providers - physician, mid-level practitioner, nurse–midwife or clinical nurse specialist, psychologist, social worker, and registered dietitian or nutritionist

List of Medicare Telehealth Services. Vol Pub 100-04 Medicate Claims Processing: CMS Manual System; 2005

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Issues for Ongoing Research While much has been learned since the earliest care coordination efforts and the components of effective interventions can now be specified with a substantial probability of success, much remains to be learned. The key issues for which greater clarity is required are: • How to identify the optimal target population: using only data readily available to most clinics or programs, is there a simple way of identifying a mix of individuals who are at high enough risk to benefit from the intervention, but not so high risk that little can be done to help reduce their need for a hospitalization? While one of the successful MCCD programs risk-stratified very successfully, the assessment form used requires a substantial amount of data that can be obtained only by interviewing the patient. What targeting criteria provide the optimal tradeoff between identifying a group for which the likelihood of generating savings is high, while not limiting the target population so severely that the impact on total Medicare costs is small? • Episodic vs. continuous enrollment/eligibility for care coordination: while the transitional care and self-management interventions engage patients for a limited duration of about 1 to 3 months, the successful MCCD programs kept patients enrolled for the life of the program (up to 6 years). The advantage of continuous enrollment is that the relationship between care coordinator and patient remains intact, and the intervention can change as the patient’s needs change. On the other hand, continuous enrollment is expensive. Most programs that maintain continuous enrollment classify patients into specific risk tiers based on their assessed level of need for monitoring and coaching at any given time and move patients among tiers as their health and situation change. What is still undetermined is whether programs should be paid different rates for patients in different tiers or a single rate for all patients that on average will cover program costs. • How best to provide the transitional care intervention: should all care coordinators be trained in the transitional care intervention or is this intervention more effective if it is 6 provided by limited set of nurses who would specialize in transitional care? Do these nurses need to be advanced practice nurses, as in the most successful transitional care models? Could social workers be included in the pool of health professionals who can provide effective transitional care interventions, as is currently being tested in the Enhanced Discharge Planning Program at Rush University Medical Center? • How to provide care coordination as efficiently as possible: given the difficulty of generating large savings, this is a very important area for further investigation. A key issue is determining the optimal frequency and nature of ongoing contacts with participating patients and how this would vary with patients’ characteristics and length of time in the program. • What mix of nurse-oriented interventions and social service supports is most effective: as the baby boom generation ages into Medicare and life spans continue to grow, programs may need to adjust their service mix and staffing to meet the social support needs of frail individuals with chronic illnesses. The extent to which patients should be moved from care coordination programs to long term care-oriented programs versus extending the continuum of care to meet these needs is a key issue to address.

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Major Forces Driving Health Care into the Home

Aging of the U.S. population Epidemics of chronic diseases Technological advances Health care consumerism Rapidly escalating health care costs

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. The LifeMasters Demonstration program is a population-based program targeting people dually eligible for Medicare and Medicaid with particular diagnoses and is also at financial risk for program fees. Enrollment through January 2006 was 50,654 (36,182 of whom were in the treatment group). LifeMasters’ fees are lower because it is not providing prescription drug coverage. The Medicare Health Support Program (formerly called the Chronic Care Improvement Program) provides DM on a population scale to all eligible beneficiaries in a geographic area – again, bearing risk for financial performance. The nine providers began operating in 2004 and are expected to serve 180,000 beneficiaries.

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0

20

40

60

80

100

120

140

160

180

No Clinical Inertia Clinical Inertia

Baseline T-Care 2 Years

SBP mmHg p=0.09 p=0.03

Improvement in CardiovascularRisk Factors Despite Clinical Inertia

Clinical Inertia is the lack of dose adjustment or initiation of a new medication for BP or lipid management when indicated according to practice guidelines. For BP medication: 10.8%; for lipid medication: 15.5%.

TLC and Caregiver BurdenTLC and Caregiver Burden

0

5

10

15

20

25

30

35

40

Overall Black Hispanic White

Baseline TLC

Zarit Burden

Interview Score

p<0.05

n=113

n=60

*

*

Dang et al. J Telemed Telecare 2008;14:443-447.

TLC and Caregiver Depression

0

5

10

15

20

25

Overall Blacks Hispanics Whites

Baseline TLC 1 Year

CES-D Score

n=113

n=60

Dang et al. J Telemed Telecare 2008;14:443-447.