Critical Dimensions for Transforming Primary Care Chad Boult, MD, MPH, MBA 7 th Annual SNP Leadership Forum October 27, 2011

Ms. Marian Chen 79 year old widow Retired teacher, lives alone Resources: SS, Medicaid and Medicare Daughter, lives 10 miles away with three teenagers Five chronic conditions Three physicians Eight medications

In 2011, Ms. Chen has had… 6 community referrals 2 home care agencies 5 months homecare 2 nursing homes 6 weeks sub- acute care 3 hospital admissions 19 outpatient visits 8 meds 22 scripts Mrs. Chen

Ms. Chen Confused by care, meds Discouraged Takes meds inconsistently Medicare paid $49,400; Medicaid paid $12,345 Daughter Stressed out Reduced work to half-time Considering a nursing home

For the chronically ill, the U.S. health care system is Fragmented Discontinuous Difficult to access Inefficient Unsafe Expensive “A nightmare to navigate” Institute of Medicine, Crossing the Quality Chasm, 2001

Medicare 5% Sample, 2001 The ¼ of Beneficiaries Who Have 4+ Chronic Conditions Account for 80% of Medicare Spending * * $516 billion in 2010

2011 ANNUAL REPORT OF THE BOARDS OF TRUSTEES OF THE FEDERAL HOSPITAL INSURANCE (Part A) AND FEDERAL SUPPLEMENTARY MEDICAL INSURANCE (Parts B and D) TRUST FUNDS “Income in 2010 was $486 billion. Total benefits paid were $516 billion. Part A trust fund will be exhausted in 2024, 5 years earlier than was shown in last year's report. ”

How can we transform primary care to improve the quality and efficiency of health care for people with chronic conditions?

Successful Models of Nurse Care Management Frequent face-to-face interactions Small caseloads for coordinators Medication management component Communication with multiple providers Patient education/activation component Transitional care Attention to psychosocial issues

Guided Care: Comprehensive Care for Persons with Chronic Conditions Specially trained RNs based in primary physicians’ offices GCNs collaborate with physicians in caring for high-risk older patients with chronic conditions and complex health care needs

Nurse/physician team Assesses needs and preferences Creates an evidence-based “care guide” and a patient-friendly “action plan” Monitors the patient proactively Supports chronic disease self-management Smoothes transitions between care sites Communicates with providers in EDs, hospitals, specialty clinics, rehab facilities, home care agencies, hospice programs, and social service agencies in the community Educates and supports caregivers Facilitates access to community services Boyd C et al. Gerontologist, 2007

AGGREGATE Activation Decision Support Problem Solving Coordination Goal Setting Effects on Quality of Care Quality rated in the highest category on PACIC PACIC Boyd et al. J Gen Intern Med, 2009

Effects on Physician Satisfaction Marsteller et al. Ann Fam Med, 2010 Change in Satisfaction

Effects on Caregiver Strain Wolff et al. J Gerontology Med Sci, 2009

Very satisfied Very dissatisfied Satisfaction Items 1= Familiarity with patients 2= Stability of patient relationships 3= Comm. w/ patients; availability of clinical info; continuity of care for patients 4= Efficiency of office visits; access to evidence based guidelines 5= Monitoring patients; communicating w/ caregivers; efficiency of primary care team 6= Coordinating care; referring to community resources; educating caregivers 7= Motivating patients for self management Satisfied Somewhat satisfied Somewhat dissatisfied Dissatisfied

Annual Costs of Guided Care Guided Care Nurse Salary$71,500 Benefits 30%)21,450 Travel (to pts’ homes, hospitals)588 Communication services Internet, cell phone1,800 Equipment (amortized over 3 years) Computer500 Cell phone67 TOTAL$95,905

Health Service Utilization, 1 st 20 Mos Boult et al. Arch Intern Med, 2011 *

Health Service Utilization, 1 st 20 Mos Boult et al. Arch Intern Med, % -49% -21% -47% -52% -17% 8% -7% 9%

Critical Dimensions for Sustainable Implementation Ensure a critical mass of patients Ensure a realistic business model Identify a local champion Tailor the model to local circumstances Specify new “top-of-license” roles for physicians, nurses, office staff Provide training Provide incentives to physicians, nurses Use QI to transform practice culture

Technical Assistance for Practices Guided Care: a New Nurse-Physician Partnership in Chronic Care (Springer Publishing Company) Online course for registered nurses Online course for physicians and practice leaders Orientation booklet for patients

Grant Support John A. Hartford Foundation Agency for Healthcare Research and Quality National Institute on Aging Jacob and Valeria Langeloth Foundation