New Models of comprehensive care for patients with chronic conditions: Guided Care Katherine Frey, MPH March 20, 2009 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

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 65 Rodriguez et al, Health Policy, 2000

Complex care is: Fragmented Discontinuous Difficult to access Inefficient Unsafe Expensive

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 improve chronic 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: GEMT. Care (CHF) T. Care (multi) SMHE Health ↑↑↑↑↑ Hospital admits and Cost ↑↓↓↓↓

Guided Care Strategy: To Translate Knowledge to Practice Combine successful innovations Integrate them into primary care Make the model diffusable

The Guided Care Model 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

Foundation of Guided Care Motivational Interviewing Self-Management

Guided Care Nurses ’ Activities Assess needs and preferences Create an evidence-based “care guide” Monitor patients proactively Support chronic disease self management Support caregivers Communicate 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 care Facilitate access to community services Boyd et al. Gerontologist 2007

Electronic Health Record Creates: Evidence-based “Care Guides” Reminders Provides: 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 Characteristics Guided CareUsual Care Age Race (% white) Sex (% female) Education (12+) Living alone Conditions4.3 HCC score * ADL difficulty Cognition (SPMS)

Effects on Quality of Care PACIC scales: GCUCaOR*95% CIP Goal setting <0.001 Coordination Decision support Problem solving Patient activation Aggregate 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 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) Computer500 Cell phone67 TOTAL$95,905

Annualized Use of Services per Caseload (55 Beneficiaries) Leff et al. (in press) Guided CareUsual Care Hospital days SNF days Primary care visits Specialist visits Home health care episodes 5070

Annualized Cost of Services per Caseload (55 Beneficiaries) GC – UC Difference Average Expenditure Difference in Expenditures 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/visit1,600 Home health episodes -20$1331/episode-26,800 Gross savings ,900 Net Savings ,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 (

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: 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): Boyd C et al. Guided Care for multimorbid older adults. The Gerontologist 2007;47(5): 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: Rich M et al. A multidisiplinary intervention to prevent the readmission of elderly patients with congestive heart failure. NEJM 1995;333: Wallace J et al. Implementation and effectiveness of a community-based health promotion program for older adults. Journal of Gerontology: Medical Sciences 1998;53:M

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

Katherine Frey, MPH