1. Washington Association of Area Agencies on Aging Staff Development Conference June 12, 2008

2. Intensive Chronic Case Management Project Sites (09/06) Olympic Area Agency on Aging Olympic Area Agency on Aging Northwest Regional Council Northwest Regional Council Pierce County Aging and Long Term Care Pierce County Aging and Long Term Care SE Washington Aging and Long Term Care SE Washington Aging and Long Term Care Aging and Long Term Care of Eastern Washington Aging and Long Term Care of Eastern Washington

3. A quick look at the data The number of Americans with chronic conditions is expected to increase from 125 million in 2000 to 157 million by 2020. The number of Americans with chronic conditions is expected to increase from 125 million in 2000 to 157 million by 2020. The number of people with multiple chronic conditions will rise from 60 million to 81 million. The number of people with multiple chronic conditions will rise from 60 million to 81 million. Care for people with chronic conditions accounts for 77 percent of Medicaid spending for beneficiaries living in the community. Care for people with chronic conditions accounts for 77 percent of Medicaid spending for beneficiaries living in the community. (Mollica and Gillespie, 2003) (Mollica and Gillespie, 2003)

4. Per capita health expenditures The average per capita medical expenditure is significantly higher for individuals with one or more chronic conditions than for those with no chronic conditions The average per capita medical expenditure is significantly higher for individuals with one or more chronic conditions than for those with no chronic conditions Among the Medicaid population the costs are more than double and for people over age 65 and older who are dually eligible the costs are more than five times higher. Among the Medicaid population the costs are more than double and for people over age 65 and older who are dually eligible the costs are more than five times higher. (Mollica and Gillespie, 2003) (Mollica and Gillespie, 2003)

5. The Governor’s Memo (01/06) Five percent of Medicaid clients account for 50 percent of the costs. Five percent of Medicaid clients account for 50 percent of the costs. They are consumers of LTC They are consumers of LTC Are diagnosed with depression and chronic pain. Are diagnosed with depression and chronic pain. Current health care system is focused on acute care and misses working with clients with chronic conditions from developing complications. Current health care system is focused on acute care and misses working with clients with chronic conditions from developing complications.

6. Who are the most vulnerable? 5 % have the most claim activity 5 % have the most claim activity 60% female and 40% male 60% female and 40% male Most are 25 to 64 years old Most are 25 to 64 years old Health services cross all agencies Health services cross all agencies Common health risks; Common health risks; Cardiovascular, muscular and cancers Cardiovascular, muscular and cancers 60% are on narcotics and antidepressants 60% are on narcotics and antidepressants Their co-morbid conditions make all interventions challenging. Their co-morbid conditions make all interventions challenging. High risk factors include mental illness and chemical dependency. High risk factors include mental illness and chemical dependency. WA state data WA state data

7. Definition of a chronic condition A chronic condition is one that is expected to last more than one year A chronic condition is one that is expected to last more than one year Limits a persons activities Limits a persons activities May require ongoing medical care May require ongoing medical care Arthritis, asthma, congestive heart failure, diabetes, eye disease, hypertension, cancer and cardiovascular disease, mental illness, and obesity. Arthritis, asthma, congestive heart failure, diabetes, eye disease, hypertension, cancer and cardiovascular disease, mental illness, and obesity. (Partnerships for Solutions, 2004) (Partnerships for Solutions, 2004)

8. And so what about care coordination… Care coordination for people with chronic conditions who participate in Home and Community Based Services has been narrowly focused on supportive services. Care coordination for people with chronic conditions who participate in Home and Community Based Services has been narrowly focused on supportive services. At the same time, a medical model of care coordination has begun to emerge in the Fee For Service health care system. At the same time, a medical model of care coordination has begun to emerge in the Fee For Service health care system. Yet… a gap exists between supportive and medical services and needs to be addressed. Yet… a gap exists between supportive and medical services and needs to be addressed. (Mollica and Gillespie, 2003) (Mollica and Gillespie, 2003) (Partnerships for Solutions, 2004) (Partnerships for Solutions, 2004)

9. Definition of “chronic care management?” “Chronic care management" means programs that provide care management and coordination activities for medical assistance clients determined to be at risk for high medical costs. “Chronic care management" means programs that provide care management and coordination activities for medical assistance clients determined to be at risk for high medical costs. "Chronic care management" provides evidence-based assessment and interventions, coordination of health care and other supportive services, education and training that assists program participants in improving self-management skills to improve health outcomes, reduces medical costs, improve functional and self-care abilities, and slows progression of disease or disability. "Chronic care management" provides evidence-based assessment and interventions, coordination of health care and other supportive services, education and training that assists program participants in improving self-management skills to improve health outcomes, reduces medical costs, improve functional and self-care abilities, and slows progression of disease or disability. Chronic care management recognizes and provides interventions for the medical, social, economic, mental health and environmental factors impacting health and health care choices. Chronic care management recognizes and provides interventions for the medical, social, economic, mental health and environmental factors impacting health and health care choices.

10. Six Goals of Chronic Care Management

11. Goal # 1 1. Improve or enhance case management interventions to allow the client to partner with health and social service providers to manage their care and services.

12. Goal # 2 Implement evidence-based preventive care measures that delay the decline or promote the abilities of the client to be able to achieve the highest level of health. Implement evidence-based preventive care measures that delay the decline or promote the abilities of the client to be able to achieve the highest level of health.

13. Goal # 3 Develop or adopt protocols that enhance the client’s options to manage their care and services to achieve individual goals. Develop or adopt protocols that enhance the client’s options to manage their care and services to achieve individual goals.

14. Goal # 4 Identify individual health goals the client would like to achieve. The goals are expected to include principles of the IOM Chasm Report. These goals are established cross DSHS agency when possible. Identify individual health goals the client would like to achieve. The goals are expected to include principles of the IOM Chasm Report. These goals are established cross DSHS agency when possible.

15. Goal # 5 Combine medical and personal care services to improve cost and service utilization; Combine medical and personal care services to improve cost and service utilization; Create a medical home for the client. Create a medical home for the client. Apply predictive modeling results for long term care planning with the client and their community. Apply predictive modeling results for long term care planning with the client and their community.

16. Goal # 6 Improve cost effectiveness and utilization to achieve individual client outcomes; Improve cost effectiveness and utilization to achieve individual client outcomes; Nurse case managers to have access to medical cost and provider utilization for each client in their respective projects and work with the client and their providers to address these health care issues. Nurse case managers to have access to medical cost and provider utilization for each client in their respective projects and work with the client and their providers to address these health care issues.

17. Program Description The focus of the ICCM projects is: The focus of the ICCM projects is: Integration of acute and long term care services through coordination; Integration of acute and long term care services through coordination; Consideration of adoption of evidence-based practices that promote health outcomes; Consideration of adoption of evidence-based practices that promote health outcomes; Targeted to populations with high-cost and high-risk chronic conditions; Targeted to populations with high-cost and high-risk chronic conditions; Recognition and interventions for the medical, social, economic, mental health, chemical dependencies, and environmental factors impacting health and health care choices. Recognition and interventions for the medical, social, economic, mental health, chemical dependencies, and environmental factors impacting health and health care choices.

18. Risk Determinants High medical cost and risk client determinants High medical cost and risk client determinants Predictive modeling software Predictive modeling software Past twelve months medical claims, gender and age determine future medical costs and risk. Past twelve months medical claims, gender and age determine future medical costs and risk. Diabetes, cardiovascular disease, mental health and substance abuse. Diabetes, cardiovascular disease, mental health and substance abuse. Pharmacy, inpatient care, and emergency room utilization. Pharmacy, inpatient care, and emergency room utilization. Care opportunities Care opportunities Risk Score Risk Score

19. IMPACT PRO © Risk Profile

20. Impact Pro© Care Opportunities

21. High Risk Determinants CARE risk criteria CARE risk criteria Client lives alone Client lives alone High risk moods/behaviors High risk moods/behaviors Self health rating is fair or poor Self health rating is fair or poor Overall self-sufficiency declined in last 90 days Overall self-sufficiency declined in last 90 days Greater than six medications Greater than six medications

22. Evidence Based Practice An intervention that has been tested and proven to be effective. An intervention that has been tested and proven to be effective. The intervention must be applied as tested with fidelity to the intervention. The intervention must be applied as tested with fidelity to the intervention.

23. Why do we want to use Evidence Based Practices? Studies have supported that outcomes are substantially improved when health care is based on evidence from well designed studies versus tradition or clinical expertise alone. Studies have supported that outcomes are substantially improved when health care is based on evidence from well designed studies versus tradition or clinical expertise alone. Examples from ICCM include: Examples from ICCM include: Diabetes management Diabetes management Pain management Pain management Fall assessment and prevention planning Fall assessment and prevention planning Medication management Medication management Skin Observation Protocol Skin Observation Protocol

24. EBP Resources CDC Community Preventive Services CDC Community Preventive Services www.thecommunityguide.org www.thecommunityguide.org www.thecommunityguide.org CDC’s Healthy Aging Program CDC’s Healthy Aging Program www.cdc.gov.aging www.cdc.gov.aging www.cdc.gov.aging AHRQ Evidence Based Practice Centers AHRQ Evidence Based Practice Centers www.effectivehealthcre.ahrq.gov www.effectivehealthcre.ahrq.gov www.effectivehealthcre.ahrq.gov US Preventive Services Task Force US Preventive Services Task Force http://preventiveservices.ahrq.gov http://preventiveservices.ahrq.gov http://preventiveservices.ahrq.gov National Guidelines Clearinghouse National Guidelines Clearinghouse http://www.guideline.gov http://www.guideline.gov http://www.guideline.gov

25. Patient Activation Measure © The process of working with the client to determine their: The process of working with the client to determine their: Perceived level of confidence for change Perceived level of confidence for change Readiness for change Readiness for change Priority of needs based on risk and individualized service planning Priority of needs based on risk and individualized service planning

26. Assessing for Activation A person’s level of activation can help the client, caregivers, and nurse case manager to assess for: A person’s level of activation can help the client, caregivers, and nurse case manager to assess for: The client’s readiness and skills for change, emotional support needs and beliefs The client’s readiness and skills for change, emotional support needs and beliefs With activation, the client can: With activation, the client can: Build knowledge and confidence, Build knowledge and confidence, Take action, and Take action, and Maintain behaviors Maintain behaviors

27. Activation for Chronic Conditions Determine how they feel about their ability to manage their health – For example how do these statements apply to your client? (Copyright 2003, Insignia Health) Determine how they feel about their ability to manage their health – For example how do these statements apply to your client? (Copyright 2003, Insignia Health) When all is said and done, I am the person who is responsible for taking care of my health problems. Disagree Strongly DisagreeAgree Agree Strongly N/A Taking an active role in my own health care is the most important thing that affects my health. Disagree Strongly DisagreeAgree Agree Strongly N/A I am confident I can help prevent or reduce the problems associated with my health condition Disagree Strongly DisagreeAgree Agree Strongly N/A I know what each of my prescribed medications do Disagree Strongly DisagreeAgree Agree Strongly N/A

28. What Assessing For Activation Can Tell You Whether a client: Whether a client: Is or isn’t ready to make changes Is or isn’t ready to make changes Is thinking about changing or is ready to change but doesn't have a plan Is thinking about changing or is ready to change but doesn't have a plan Is ready to change and has some steps in place Is ready to change and has some steps in place Is currently making a change Is currently making a change Has made some changes and is staying on track Has made some changes and is staying on track

29. Examples of Discussion Points When all is said and done, I am the person who is responsible for managing my health. Tell me what you were thinking about when you answered that you disagree/strongly disagree that you are the person who is responsible for managing your health? Taking an active role in my own health care is the most important factor in determining my health and ability to function. Tell me what you were thinking when you answered disagree/strongly disagree that taking an active role in your own health care is the most important factor in determining your health and ability to function. (Copyright 2007 Insignia Health)

30. Coaching for Activation Encourage client confidence - that their actions can make an impact on their health and independence Encourage client confidence - that their actions can make an impact on their health and independence Discuss and offer options that allow the client to increase their ability to manage their own care to improve quality of life and/or health outcomes Discuss and offer options that allow the client to increase their ability to manage their own care to improve quality of life and/or health outcomes Ask the client what ideas they have to better manage their health care. Ask the client what ideas they have to better manage their health care.

31. 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

32. ICCM 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 readiness for change will determine the speed of the change; A client’s perception of need and readiness for change will determine the speed of the change; This approach includes; physical, mental, emotional, psycho-social and environmental needs. This approach includes; physical, mental, emotional, psycho-social and environmental needs.

33. Closing and Questions Contact Information Contact Information Candace Goehring Candace Goehring 360-725-2562goehrcs@dshs.wa.gov 360-725-2562goehrcs@dshs.wa.govgoehrcs@dshs.wa.gov Kay Coulter Kay Coulter 253-798-7236kcoulte@co.pierce.wa.us 253-798-7236kcoulte@co.pierce.wa.uskcoulte@co.pierce.wa.us Kathy Medford Kathy Medford 509-965-0105 medfokf@dshs.wa.gov 509-965-0105 medfokf@dshs.wa.govmedfokf@dshs.wa.gov Jessie Stopsen Jessie Stopsen 360-538-2456 stopsja@dshs.wa.gov 360-538-2456 stopsja@dshs.wa.govstopsja@dshs.wa.gov