New Models of comprehensive care for patients with chronic

conditions: Guided Care Katherine Frey, MPH

March 20, 2009Supported by the John A. Hartford Foundation,

the Agency for Healthcare Research and Quality, the National Institute on Aging, and

the Jacob and Valeria Langeloth Foundation

Aging Trends in Spain

• Two Demographic Processes Declining Birth Rate Increasing Life Expectancy

• By 2015 the labor force will contract and the population over 65 will grow.

Sandell, Documento del Real Instituto, 2003

The population is aging.

Funding Health Care in Spain

• Taxes main source of finance• Health care expenditures 7.4% GDP (1997) and

growing• Mix of public (89%) and private (21%)

expenditures• Among people with private insurance (12%

population) Private expenditures primarily for outpatient and

specialist expenses Public expenditures primarily hospitalizations

• 48% hospital expenditures attributable to over 65Rodriguez et al, Health Policy, 2000

Complex care is:

FragmentedDiscontinuous

Difficult to accessInefficient

UnsafeExpensive

5+ Conditions

68%

01%

26%

310%

412%

13%

Source: Medicare 5% Sample, 2001

The ¼ of Beneficiaries Who Have 4+ Chronic Conditions Account for 80% of Medicare Spending

Failing System

Patient Perspective:• Poor quality of care• Low levels of patient satisfaction• High cost of care

Physician Perspective:• Low levels of satisfaction• Low levels of reimbursement

Usual Care

• Mr. Jackson Has 8 medical conditions Takes 8 medications 1 primary care physician 4 specialists

• Effect on Life Confused by his care Out of pocket costs are

high Quality of life is poor Wife is stressed out

Is our system working?

How can we improvechronic care?

What alternatives have been tested?How effective are they?

How can they be useful in the real world?

GEM (Geriatric Evaluation and

Management)• Home visit by social worker• Two inpatient examinations; one by an NP, one by a

geriatrician/nurse pair• Multidisciplinary Care Planning• Monthly care received at the GEM clinic; average 6

months treatment per study participant• Randomized trial

Decrease in loss of function, decreased rate of depression and caregiver burnout

Improved patient and physician satisfaction cost $1,350 per person treated

Boult JAGS 2001

Transitional Care for CHF

• Education about CHF by a nurse, using book specifically written for geriatric HF patients

• Dietary assessment and planning by dietician, with nurse follow-up

• Referral to social services• Medication adjudication by physician• Follow-up by study nurse post-discharge• Randomized clinical trial

Increased quality of life Reduced hospital admissions for CHF reduced costs

- Rich N Engl J Med 1995

Transitional Care for Multiple Chronic

Conditions• Advanced Practice Nurse (APN) visited patient

with 48 hrs admission and then at least every 48 hours during hospital course

• APN visits twice (at least) post-hospitalization, once within 48 hours, once within 7-10 days.

• Telephonic support, including weekly calls• Randomized trial

Fewer re-admissions Lower hospital charges

- Naylor JAMA 1999

Self-Management

• Evaluation of 6-week Chronic Disease Self-Management Course Subjects covered: cognitive symptom management;

nutrition, fatigue and sleep management; use of community resources; medication management; exercise; dealing with emotions; communicating with physicians; problem-solving; decision making

• Randomized clinical trial Improved function, general health, energy Reduced hospital days and costs

Lorig Med Care 1999

Health Enhancement Program

• Community-based exercise intervention, nutrition counseling, and home evaluation

• Randomized trial Reduced disability Reduced hospital days

Wallace JGMS 1998

Summary of Effects

 

Effect on:

GEM T. Care(CHF)

T. Care(multi)

SM HE

Health ↑ ↑ ↑ ↑ ↑

Hospital admits and Cost

↑ ↓ ↓ ↓ ↓

Guided Care Strategy: To Translate Knowledge to

Practice

Combine successful innovationsIntegrate them into primary careMake the model diffusable

The Guided Care Model

Specially trained RNs based in primary physicians’ offices

GCNs collaborate with physicians in caring for 50-60 high-risk older patients with chronic conditions and complex health care needs

Foundation of Guided Care

Motivational InterviewingSelf-Management

Guided Care Nurses’ Activities

Assess needs and preferencesCreate an evidence-based “care guide”Monitor patients proactivelySupport chronic disease self managementSupport caregiversCommunicate with providers in EDs, hospitals, specialty clinics,

rehab facilities, home care agencies, hospice programs, and social service agencies in the community

Smooth transitions between sites of careFacilitate access to community services

Boyd et al. Gerontologist 2007

Electronic Health Record

Creates: Evidence-based “Care Guides” RemindersProvides: Decision support: drug interactions Documentation of GCN-pt/cg encounters

Guided Care Nurse & Mr. Jackson

• Using a computerized data collection tool, assesses Mr. Jackson’s clinical needs and preferences

• With the physician and electronic decision support, creates an evidence-based comprehensive care plan and patient friendly Action Plan

• By telephone, monitors Mr. Jackson proactively• Around the care plan, coordinates efforts of providers in

primary care, EDs, hospitals, specialty clinics, rehab facilities, home care agencies, social services, and community agencies (with emphasis on facilitating transitions between sites of care)

• Through a self-management course and access to educational materials, informs and empowers Mr. Jackson (and his wife) to participate in his care

• By telephone, supports Mrs. Jackson in her role as a caregiver to Mr. Jackson.

Mr. Jackson is Hospitalized

• Exacerbation of CHF Cardiac catheterization reveals occlusion LAD

coronary artery CABG x 3 + mitral valve replacement

• New medications Change from hydrochlorothiazide to furosemide Oxycodone for pain management Warfarin

• New providers Cardiac rehabilitation Home care nurse

GCN Transitional Care Activities

• Visits him within 48 hours of admission and delivers Care Guide

• Prepares Mr. and Mrs. Jackson for his discharge, including explanation of new drugs

• Reviews the updated Action Plan within 48 hours of discharge

• Coordinates services with new providers• Updates primary care provider of all changes

Mr. Jackson’s Perspective• Two-hour interview with the nurse at home• Seven-session self-management course• Educational materials (verbal, written, Internet)• Telephone inquiries and reminders from nurse• Assistance in accessing the services of health care

providers and community agencies• Assistance in integrating all health-related services• Direct access to a nurse during normal business hours• Assistance making the transition from the hospital home

Physician’s Perspective

Assistance with most difficult patients Creating/implementing comprehensive plans Proactive follow-up Responding promptly to patients’/families’ calls Communicating with other providers Facilitating transitions from hospitals Minimal time requirement

Randomized Trial

High-risk older patients (n=904) of 49 community-based primary care physicians practicing in 14 teams

Physician/patient teams randomly assigned to receive Guided Care or “usual” care

Outcomes measured at 8, 20 and 32 months

Supported by the John A. Hartford Foundation, the Agency for Healthcare Research and Quality, the National Institute on Aging,

and the Jacob and Valeria Langeloth Foundation

Baseline CharacteristicsGuided Care Usual Care

Age 77.2 78.1

Race (% white) 51.1 48.9

Sex (% female) 54.2 55.4

Education (12+) 46.4 43.4

Living alone 32.0 30.6

Conditions 4.3 4.3

HCC score 2.1 2.0*

ADL difficulty 30.9 29.3

Cognition (SPMS) 9.1 9.0

Effects on Quality of Care

PACIC scales: GC UC aOR* 95% CI P

Goal setting 24.6 11.6 2.4 1.5-3.7 <0.001

Coordination 14.2 7.1 2.3 1.3-4.0 0.005

Decision support 42.7 33.1 1.5 1.1-2.1 0.014

Problem solving 33.4 24.7 1.4 1.0-1.9 0.096

Patient activation 26.6 23.0 1.1 0.7-1.5 0.763

Aggregate 17.4 8.5 2.0 1.2-3.4 0.006

Boult et al. J Gerontol Med Sci 2008

Effects on Physician Satisfaction

• Compared with Usual Care, Guided Care physicians were significantly more satisfied with their: Communication with their patients Caregiver education Ability to motivate patients Knowledge of patient medications

Annual Costs of Guided CareGuided Care Nurse

Salary $71,500

Benefits (@ 30%) 21,450

Travel (to pts’ homes, hospitals) 588

Communication services

Internet, cell phone 1,800

Equipment (amortized)

Computer 500

Cell phone 67

TOTAL $95,905

Annualized Use of Servicesper Caseload (55

Beneficiaries)

Leff et al. (in press)

Guided Care Usual Care

Hospital days 241 317

SNF days 170 270

Primary care visits 558 557

Specialist visits 473 434

Home health care episodes

50 70

Annualized Cost of Servicesper Caseload (55 Beneficiaries)

GC – UC Difference

Average Expenditure

Difference inExpenditures

Hospital days -76 $1,519/day -115,600

SNF days -99 $305/day -30,200

Primary care visits

-1.3 $41/visit -100

Specialist visits

39 $41/visit 1,600

Home health episodes

-20 $1331/episode -26,800

Gross savings ----- ----- -170,900

Net Savings ----- ----- -75,000

Future of Guided Care

• Diffusion Activities Online course for nurses Online course for physicians Guided Care Implementation Textbook Technical Assistance for practices seeking to adopt

Guided Care (www.medhomeinfo.org)

Conclusion

Guided Care is an innovative approach to efficiently managing

caseloads of older, complex patients living in the

community.

Patient, physician and nurse satisfaction is high.

Compared to usual care, Guided Care appears to improve the

quality and the efficiency of health care for patients with

chronic conditions.

References• Boult C et al. A randomized trial of outpatient geriatric evaluation and

management. JAGS, 2001;49:351-359.• Boult C et al. Early effects of "Guided Care" on the quality of health

care for multimorbid older persons: A cluster-randomized controlled trial. Journal of Gerontology: Medical Sciences 2008;63A(3):321-327.

• Boyd C et al. Guided Care for multimorbid older adults. The Gerontologist 2007;47(5):697-704.

• Leff B et al. Guided Care and the cost of complex health care (in press) • Lorig K et al. Evidence suggesting that a chronic disease self-

management program can improve health status while reducing hospitalization: A randomized trial. Medical Care 1999;37:5-14.

• Naylor M et al. Comprehensive discharge planning and home follow-up of hospitalized elders: A randomized clinical trial. NEJM 1999;281:613-620.

• Rich M et al. A multidisiplinary intervention to prevent the readmission of elderly patients with congestive heart failure. NEJM 1995;333:1190-1195.

• Wallace J et al. Implementation and effectiveness of a community-based health promotion program for older adults. Journal of Gerontology: Medical Sciences 1998;53:M301-306.

Thanks to:

• Dr. Charles Boult• Lisa Reider, MHS• Tracy Novak, MHS• The Guided Care Nurses• The Guided Care research Team• The Guided Care Patients• Johns Hopkins HealthCare and Kaiser

Permanente• The John A. Hartford Foundation, the Agency

for Healthcare Research and Quality, and the Joseph and Valeria Langeloth Foundation

www.guidedcare.org

Katherine Frey, MPHkfrey@jhsph.edu