Washington Washington Association of Area Association of Area Agencies on AgingAgencies on Aging

Staff Development Staff Development ConferenceConference

June 12, 2008June 12, 2008

Intensive Chronic Case Intensive Chronic Case Management Project Sites Management Project Sites

(09/06)(09/06)

Olympic Area Agency on AgingOlympic Area Agency on Aging Northwest Regional CouncilNorthwest Regional Council Pierce County Aging and Long Term Pierce County Aging and Long Term

CareCare SE Washington Aging and Long Term SE Washington Aging and Long Term

CareCare Aging and Long Term Care of Eastern Aging and Long Term Care of Eastern

WashingtonWashington

A quick look at the dataA quick look at the data

The number of Americans with chronic The number of Americans with chronic conditions is expected to increase from conditions is expected to increase from 125 million in 2000 to 157 million by 2020.125 million in 2000 to 157 million by 2020.

The number of people with multiple The number of people with multiple chronic conditions will rise from 60 million chronic conditions will rise from 60 million to 81 million.to 81 million.

Care for people with chronic conditions Care for people with chronic conditions accounts for 77 percent of Medicaid accounts for 77 percent of Medicaid spending for beneficiaries living in the spending for beneficiaries living in the community.community.

(Mollica and Gillespie, 2003)(Mollica and Gillespie, 2003)

Per capita health Per capita health expendituresexpenditures

The average per capita medical The average per capita medical expenditure is significantly higher for expenditure is significantly higher for individuals with one or more chronic individuals with one or more chronic conditions than for those with no chronic conditions than for those with no chronic conditionsconditions

Among the Medicaid population the costs Among the Medicaid population the costs are more than double and for people over are more than double and for people over age 65 and older who are dually eligible age 65 and older who are dually eligible the costs are more than five times higher.the costs are more than five times higher.

(Mollica and Gillespie, 2003)(Mollica and Gillespie, 2003)

The Governor’s Memo The Governor’s Memo (01/06)(01/06)

Five percent of Medicaid Five percent of Medicaid clients account for 50 clients account for 50 percent of the costs.percent of the costs.

They are consumers of They are consumers of LTCLTC

Are diagnosed with Are diagnosed with depression and chronic depression and chronic pain.pain.

Current health care Current health care system is focused on system is focused on acute care and misses acute care and misses working with clients with working with clients with chronic conditions from chronic conditions from developing complications.developing complications.

Who are the most Who are the most vulnerable? vulnerable?

5 % have the most claim activity5 % have the most claim activity 60% female and 40% male60% female and 40% male Most are 25 to 64 years oldMost are 25 to 64 years old Health services cross all agenciesHealth services cross all agencies Common health risks;Common health risks;

Cardiovascular, muscular and cancersCardiovascular, muscular and cancers 60% are on narcotics and antidepressants60% are on narcotics and antidepressants Their co-morbid conditions make all Their co-morbid conditions make all

interventions challenging.interventions challenging. High risk factors include mental illness and High risk factors include mental illness and

chemical dependency.chemical dependency. WA state dataWA state data

Definition of a chronic Definition of a chronic conditioncondition

A chronic condition is one that is A chronic condition is one that is expected to last more than one yearexpected to last more than one year Limits a persons activitiesLimits a persons activities May require ongoing medical care May require ongoing medical care

Arthritis, asthma, congestive heart failure, Arthritis, asthma, congestive heart failure, diabetes, eye disease, hypertension, cancer diabetes, eye disease, hypertension, cancer and cardiovascular disease, mental illness, and cardiovascular disease, mental illness, and obesity.and obesity.

(Partnerships for Solutions, 2004)(Partnerships for Solutions, 2004)

And so what about care And so what about care coordination…coordination…

Care coordination for people with chronic Care coordination for people with chronic conditions who participate in Home and conditions who participate in Home and Community Based Services has been Community Based Services has been narrowly focused on supportive services.narrowly focused on supportive services.

At the same time, a medical model of care At the same time, a medical model of care coordination has begun to emerge in the coordination has begun to emerge in the Fee For Service health care system.Fee For Service health care system.

Yet… a gap exists between supportive and Yet… a gap exists between supportive and medical services and needs to be medical services and needs to be addressed.addressed.

(Mollica and Gillespie, 2003)(Mollica and Gillespie, 2003) (Partnerships for Solutions, 2004)(Partnerships for Solutions, 2004)

Definition of “chronic care Definition of “chronic care management?”management?”

““Chronic care management" means programs that Chronic care management" means programs that provide care management and coordination activities provide care management and coordination activities for medical assistance clients determined to be at risk for medical assistance clients determined to be at risk for high medical costs. for high medical costs.

"Chronic care management" provides evidence-based "Chronic care management" provides evidence-based assessment and interventions, coordination of health assessment and interventions, coordination of health care and other supportive services, education and care and other supportive services, education and training that assists program participants in improving training that assists program participants in improving self-management skills to improve health outcomes, self-management skills to improve health outcomes, reduces medical costs, improve functional and self-care reduces medical costs, improve functional and self-care abilities, and slows progression of disease or disability. abilities, and slows progression of disease or disability.

Chronic care management recognizes and provides Chronic care management recognizes and provides interventions for the medical, social, economic, mental interventions for the medical, social, economic, mental health and environmental factors impacting health and health and environmental factors impacting health and health care choices. health care choices.

Six Goals of Chronic Care Six Goals of Chronic Care ManagementManagement

Goal # 1 Goal # 1

1.1. Improve or enhance case Improve or enhance case management interventions to allow management interventions to allow the client to partner with health the client to partner with health and social service providers to and social service providers to manage their care and services.manage their care and services.

Goal # 2Goal # 2

Implement evidence-based Implement evidence-based preventive care measures that delay preventive care measures that delay the decline or promote the abilities the decline or promote the abilities of the client to be able to achieve the of the client to be able to achieve the highest level of health. highest level of health.

Goal # 3 Goal # 3

Develop or adopt protocols that Develop or adopt protocols that enhance the client’s options to enhance the client’s options to manage their care and services to manage their care and services to achieve individual goals.achieve individual goals.

Goal # 4Goal # 4

Identify individual health goals the Identify individual health goals the client would like to achieve. The client would like to achieve. The goals are expected to include goals are expected to include principles of the IOM Chasm Report. principles of the IOM Chasm Report. These goals are established cross These goals are established cross DSHS agency when possible.DSHS agency when possible.

Goal # 5Goal # 5

Combine medical and personal care Combine medical and personal care services to improve cost and service services to improve cost and service utilization;utilization; Create a medical home for the client.Create a medical home for the client. Apply predictive modeling results for Apply predictive modeling results for

long term care planning with the client long term care planning with the client and their community.and their community.

Goal # 6 Goal # 6

Improve cost effectiveness and Improve cost effectiveness and utilization to achieve individual utilization to achieve individual client outcomes;client outcomes;

Nurse case managers to have access Nurse case managers to have access to medical cost and provider to medical cost and provider utilization for each client in their utilization for each client in their respective projects and work with respective projects and work with the client and their providers to the client and their providers to address these health care issues.address these health care issues.

Program DescriptionProgram Description The focus of the ICCM projects is:The focus of the ICCM projects is:

Integration of acute and long term care Integration of acute and long term care services through coordination;services through coordination;

Consideration of adoption of evidence-based Consideration of adoption of evidence-based practices that promote health outcomes;practices that promote health outcomes;

Targeted to populations with high-cost and Targeted to populations with high-cost and high-risk chronic conditions;high-risk chronic conditions;

Recognition and interventions for the Recognition and interventions for the medical, social, economic, mental health, medical, social, economic, mental health, chemical dependencies, and environmental chemical dependencies, and environmental factors impacting health and health care factors impacting health and health care choices.choices.

Risk DeterminantsRisk Determinants

High medical cost and risk client High medical cost and risk client determinantsdeterminants Predictive modeling softwarePredictive modeling software

Past twelve months medical claims, gender and Past twelve months medical claims, gender and age determine future medical costs and risk.age determine future medical costs and risk.

Diabetes, cardiovascular disease, mental health Diabetes, cardiovascular disease, mental health and substance abuse.and substance abuse.

Pharmacy, inpatient care, and emergency room Pharmacy, inpatient care, and emergency room utilization.utilization.

Care opportunitiesCare opportunities Risk ScoreRisk Score

IMPACT PRO © Risk Profile IMPACT PRO © Risk Profile

Impact Pro© Care Impact Pro© Care OpportunitiesOpportunities

High Risk DeterminantsHigh Risk Determinants

CARE risk criteriaCARE risk criteria Client lives aloneClient lives alone High risk moods/behaviorsHigh risk moods/behaviors Self health rating is fair or poorSelf health rating is fair or poor Overall self-sufficiency declined in last Overall self-sufficiency declined in last

90 days90 days Greater than six medicationsGreater than six medications

Evidence Based PracticeEvidence Based Practice

An intervention that has been An intervention that has been tested and proven to be tested and proven to be effective.effective.

The intervention must be applied The intervention must be applied as tested with fidelity to the as tested with fidelity to the intervention.intervention.

Why do we want to use Why do we want to use Evidence Based Practices?Evidence Based Practices? Studies have supported that outcomes are Studies have supported that outcomes are

substantially improved when health care is based substantially improved when health care is based on evidence from well designed studies versus on evidence from well designed studies versus tradition or clinical expertise alone. tradition or clinical expertise alone.

Examples from ICCM include:Examples from ICCM include: Diabetes managementDiabetes management Pain managementPain management Fall assessment and prevention planningFall assessment and prevention planning Medication managementMedication management Skin Observation ProtocolSkin Observation Protocol

EBP ResourcesEBP Resources CDC Community Preventive ServicesCDC Community Preventive Services

www.thecommunityguide.orgwww.thecommunityguide.org CDC’s Healthy Aging Program CDC’s Healthy Aging Program

www.cdc.gov.agingwww.cdc.gov.aging AHRQ Evidence Based Practice CentersAHRQ Evidence Based Practice Centers

www.effectivehealthcre.ahrq.govwww.effectivehealthcre.ahrq.gov US Preventive Services Task ForceUS Preventive Services Task Force

http://preventiveservices.ahrq.govhttp://preventiveservices.ahrq.gov National Guidelines ClearinghouseNational Guidelines Clearinghouse

http://www.guideline.govhttp://www.guideline.gov

Patient Activation Patient Activation Measure ©Measure ©

The process of working with the client The process of working with the client to determine their:to determine their: Perceived level of confidence Perceived level of confidence for for

changechange Readiness for changeReadiness for change Priority of needs Priority of needs based on risk and based on risk and

individualized service planningindividualized service planning

Assessing for ActivationAssessing for Activation

A person’s level of activation can help A person’s level of activation can help the client, caregivers, and nurse case the client, caregivers, and nurse case manager to assess for:manager to assess for: The client’s readiness and skills for change, The client’s readiness and skills for change,

emotional support needs and beliefsemotional support needs and beliefs With activation, the client can:With activation, the client can:

Build knowledge and confidence, Build knowledge and confidence, Take action, andTake action, and Maintain behaviorsMaintain behaviors

Activation for Chronic Activation for Chronic ConditionsConditions

Determine how they feel about their ability Determine how they feel about their ability to manage their health – For example how to manage their health – For example how do these statements apply to your client? do these statements apply to your client? (Copyright 2003, Insignia Health)(Copyright 2003, Insignia Health)

When all is said and done, I When all is said and done, I am the person who is am the person who is responsible for taking care responsible for taking care of my health problems. of my health problems.

DisagreDisagree e

StronglyStrongly

DisagreeDisagree AgreeAgree Agree Agree StronglyStrongly

N/AN/A

Taking an active role in my Taking an active role in my own health care is the most own health care is the most important thing that affects important thing that affects my health. my health.

DisagreDisagree e

StronglyStrongly

DisagreeDisagree AgreeAgree Agree Agree StronglyStrongly

N/AN/A

I am confident I can help I am confident I can help prevent or reduce the prevent or reduce the problems associated with problems associated with my health condition my health condition

DisagreDisagree e

StronglyStrongly

DisagreeDisagree AgreeAgree Agree Agree StronglyStrongly

N/AN/A

I know what each of my I know what each of my prescribed medications doprescribed medications do

DisagreDisagree e

StronglyStrongly

DisagreeDisagree AgreeAgree Agree Agree StronglyStrongly

N/AN/A

What Assessing For What Assessing For Activation Can Tell YouActivation Can Tell You

Whether a client:Whether a client: Is or isn’t ready to make changesIs or isn’t ready to make changes Is thinking about changing or is ready to Is thinking about changing or is ready to

change but doesn't have a planchange but doesn't have a plan Is ready to change and has some steps in Is ready to change and has some steps in

placeplace Is currently making a changeIs currently making a change Has made some changes and is staying Has made some changes and is staying

on trackon track

Examples of Discussion Examples of Discussion PointsPoints

When all is said and done, I am When all is said and done, I am the person who is responsible for the person who is responsible for managing my health.managing my health.

Tell me what you were thinking Tell me what you were thinking about when you answered that about when you answered that you disagree/strongly disagree you disagree/strongly disagree that you are the person who is that you are the person who is responsible for managing your responsible for managing your health?health?

Taking an active role in my own Taking an active role in my own health care is the most important health care is the most important factor in determining my health factor in determining my health and ability to function.and ability to function.

Tell me what you were thinking Tell me what you were thinking when you answered when you answered disagree/strongly disagree that disagree/strongly disagree that taking an active role in your own taking an active role in your own health care is the most important health care is the most important factor in determining your health factor in determining your health and ability to function.and ability to function.

(Copyright 2007 Insignia Health)(Copyright 2007 Insignia Health)

Coaching for ActivationCoaching for Activation Encourage client confidence - that Encourage client confidence - that

their actions can make an impact on their actions can make an impact on their health and independence their health and independence

Discuss and offer options that allow Discuss and offer options that allow the client to increase their ability to the client to increase their ability to manage their own care to improve manage their own care to improve quality of life and/or health outcomesquality of life and/or health outcomes

Ask the client what ideas they have to Ask the client what ideas they have to better manage their health care.better manage their health care.

Habit is habit. It is not to be flung

out of the window by anyone, but coaxed

downstairs a step at a time.

- Mark Twain

ICCM SummaryICCM Summary

The client is in charge of the care plan;The client is in charge of the care plan; There is value in bridging systems of care;There is value in bridging systems of care; Behavioral changes take time;Behavioral changes take time; A client’s perception of need and A client’s perception of need and

readiness for change will determine the readiness for change will determine the speed of the change;speed of the change;

This approach includes; physical, mental, This approach includes; physical, mental, emotional, psycho-social and emotional, psycho-social and environmental needs.environmental needs.

ClosingClosing and Questions and Questions

Contact InformationContact Information Candace GoehringCandace Goehring

360-725-2562360-725-2562 goehrcs@dshs.wa.govgoehrcs@dshs.wa.gov Kay CoulterKay Coulter

253-798-7236253-798-7236 kcoulte@co.pierce.wa.uskcoulte@co.pierce.wa.us Kathy MedfordKathy Medford

509-965-0105509-965-0105 medfokf@dshs.wa.gov medfokf@dshs.wa.gov Jessie StopsenJessie Stopsen

360-538-2456360-538-2456 stopsja@dshs.wa.gov stopsja@dshs.wa.gov