Care of the Chronically Ill and the Older PersonsELECTIVE 2BSN 14BJuly 20, 2011Risk factors associated in Chronic Illness in elderlyModifiable/non-modifiableRisk factors: ModifiableLifestyleSmokingPoor nutritionPhysical inactivityFailure to use preventive and screening servicesCoping styles, stress
Risk factors: Non-modifiableAgePre-existing conditionsLong term medicationHereditary Patterns of Illness in ElderlyMultiple chronic conditionsUndiagnosed diseasesAccommodated to disease and impairmentLimits toleration (multiplicity of dis)Functionally limitedDependent on others
Comprehensive Geriatric AssessmentComprehensive Geriatric AssessmentA multidimensional, interdisciplinary diagnostic process to determine the:MedicalPsychologicalFunctional capabilities of a frail elderly person Comprehensive Geriatric AssessmentPurposeDevelop a coordinated and integrated plan for treatment and long-term follow-upAchieve quality and functional status of life
Comprehensive Geriatric AssessmentPurposeDetermine prognosis and outcome of care Employment of interdisciplinary teams Utilize standardized instruments to evaluate aspects of patient functioning, impairments, and social supportsGoals and Objectives (CGA)To refer those at risk for other more thorough workup
To improve process of care:Improve diagnostic accuracyImprove medical treatmentArrange for long-term case managementGoals and Objectives (CGA)To improve outcomes of care:Improve functional statusBetter quality of life
To contain costs of care:Reduce use of unnecessary formal servicesProlong tenure in the home/communityCOMPONENTS OF COMPREHENSIVE ASSESSMENTComponentElementsMedical assessmentProblem listComorbid conditions and disease severityMedication reviewNutritional statusAssessment of functioningBasic activities of daily livingInstrumental activities of daily livingActivity/exercise statusGait and balancePsychological assessmentMental status (cognitive) testingMood/depression testingSocial assessmentInformal support needs and assetsCare resource eligibility/financial assessmentEnvironmental assessmentHome safetyTransportation and telehealthCHRONIC ILLNESS IN ELDERLYWellness is the Goal at All Ages
SpiritualFaithMeaning in lifeEmotionalFriendshipConnections to othersSense of well beingBelonging to a family and communityPhysicalNutritionExerciseMentalActivities and hobbiesProblem-solvingContinuing educationFinancialSecurityIndependenceFlexibility1515Age and IllnessAging does not cause disease nor does disease cause agingDizziness, confusion, forgetfulness and incontinence are not normal aging, but usually signs of a disease processEven if someone has a disease, symptoms may be corrected or relieved16Being an older adult,Does not mean being ill!16An older person may develop lung disease from having smoked heavily not because he is older
Chronic Illness and Chronic CareEstimated 99M Americans live with chronic illnessMost with >1 chronic illness88% of >65yo have >1 chronic disease25% of which have >4Chronic illness accts for 75% national health care costs18Not just long-term conditionsCo-morbidityComplexityFrailty
And for the next steps..19Unlike Acute Illness.Short-termEither die or get wellInfluenzaPneumoniaGI infections
20Chronic IllnessPersists for a long time and is either incurable and/or results in pathological changes that limit normal functioning. Virtually everyone will eventually develop some type of chronic condition.
21Differences between acute and chronic conditions Acute diseaseChronic IllnessOnsetAbruptGenerally gradual and insidiousDurationLimitedLengthy and indefiniteCauseUsually singleUsually multiple and changes over timeDiagnosis & prognosisUsually accurateOften uncertainInterventionUsually effectiveOften indecisive; adverse effects commonOutcomeCure possibleNo cureUncertaintyMinimalPervasiveKnowledgeProf.s - knowledgeable Patients - inexperiencedProf.s and patients have comple-mentary knowledge and experienceChronic DiseasesHTNDMCHFOACOPDCancerMental Health Illness- depression/ dementia/ psychosis etcChronic Infectious Diseases: HIV/AIDS, Hepatitis24Complexities of Chronic IllnessCognitive impairmentObesityDiabetesImpaired mobilityCardiovascular diseasesDepressionBiggest Worries About Having A Chronic Illness (Age 50 +)Losing independenceBeing burden to family or friendsAffording medical careBut what are patients really concerned about?
Source: Partnership for Solutions, Medicare data and Harris polls of Medicare recipients. (from Jerry Anderson)
The Increasing Burden of Chronic IllnessAdditional Medical Problems *45%Functional Limitations **50%> 2 Symptoms ***35%Poor Health Habits30%For example: Patients with diabetes have * Arthritis (34%), obesity (28%), hypertension (23%),cardiovascular (20%), lung (17%) ** Physical (31%), pain (28%), emotional (16%), daily activities (16%)*** Eating/weight (39%), joint pain (32%), sleep (25%), dizzy/fatigue (23%), foot (21%), backache (20%)Or you might choose to think about the care of a patients with chronic diseases, such as diabetes.However, dont fall into a trap. A disease management program aimed only at improving a hemoglobin A1C will miss the mark. These patients often have multiple diagnoses, functional limits and symptoms.Source: John Wasson, data from howsyourhealth.com
The Impact of Chronic Illness The IndividualInitial ImpactShockDenialLoss and griefAnxiety and depression20-25% experience psychological symptomsIf these reactions last too long, they can have an negative effect on the illnessThe Impact of Chronic Illness The IndividualMust adjust to:Symptoms of the diseaseStress of TreatmentFeelings of vulnerabilityLoss of ControlThreat to self-esteemFinancial ConcernsChanges in family structure
The Impact of Chronic Illness - The FamilyMust adjust to:Increased stressChange in the nature of the relationshipChange in family structure/rolesLost income Different issues for different relationshipsAdult children of ill parentsSpouse of ill personParents of ill children
29Issues and trends in Chronic CarePovertyIlliteracyCentralization & Fragmentation of CarePhysician shortages concurrent with restrictions in use of nurse practitionersThe Disease-Model of CarePrevention a minor expenditure in health care budget..Glimmers of HopeThe Cancer, Kidney, Diabetes, & Heart & Stroke Associations working togetherMoves to develop true community clinicsConcerted efforts to produce model of care that makes the best use of resources & improves access to relevant & effective careGovernment has identified priorities & improved collaboration
Informed,ActivatedPatientProductiveInteractionsPrepared,ProactivePractice TeamDeliverySystemDesignDecisionSupport ClinicalInformationSystemsSelf-Management SupportHealth SystemResources and PoliciesCommunity Health Care OrganizationChronic Care ModelImproved OutcomesOur premise is that good outcomes at the bottom of the model (clinical, satisfaction, cost and function) result from productive interactions. To have productive interactions, the system needs to have developed four areas at the level of the practice (shown in the middle): self-management support (how we help patients live with their conditions), delivery system design (whos on the health care team and in what ways we interact with patients), decision support (what is the best care and how do we make it happen every time) and clinical information systems (how do we capture and use critical information for clinical care). These four aspects of care reside in a health care system, and some aspects of the greater organization influence clinical care. The health system itself exists in a larger community. Resources and policies in the community also influence the kind of care that can be delivered. It is not accidental that self-management support is on the edge between the health system and the community. Some programs that support patients exist in the community. It is also not accidental that it is on the same side of the model as the patient. It is the most visible part of care to the patient, followed by the delivery system design. They know what kind of appointments they get, and who they see. They may be unaware of the guidelines that describe best care (but we should work to change that) and they may be totally unaware of how we keep information to provide that care. Well talk about each in detail in the following slides.Wagner EH, Davis C, Schaefer J, Von Korff M, Austin B. A survey of leading chronic disease management programs: Are they consistent with the literature? Managed Care Quarterly. 1999;7(3):56-66. Bodenheimer T, Wagner EH, Grumbach K. Improving primary care for patients with chronic illness: the chronic care model, Part 2. JAMA 2002 Oct 16; 288(15):1909-14. Wagner EH, Austin BT, Davis C, Hindmarsh M, Schaefer J, Bonomi A., Improving chronic illness care: translating evidence into action. Health Aff (Millwood). 2001 Nov-Dec;20(6):64-78.
Model Development 1993 --Initial experience at GHCLiterature reviewRWJF Chronic Illness Meeting -- SeattleReview and revision by advisory committee of 40 members (32 active participants)Interviews with 72 nominated best practices, site visits to selected group Model applied with diabetes, depression, asthma, CHF, CVD, arthritis, and geriatricsThe chronic care model grew in the following way. It began with attempts to improve care for diabetes at Group Health Cooperative, which has approximately 20,000 patients with diabetes. The improvements were based on a careful reading of the literature. In 1996, GHC was funded to bring together international experts in chronic illness care and charged them with finding the commonalities in the ways they provided good care. This seemed like a useful strategy to continue, and RWJF funded a planning grant which had a