10,000 MEYER ET AL. ווווןווי 12 FIG. 1. Intervened group: clínic visits. siderably greater improvements on all mea sures. Performance improvement Performance improvement data was evaluated on the intervened group. All eight clinical demonstration sites participated in the data collection. Measures identified were immunization rates for influenza (flu) and pneumococcal pneumonia, compliance with antihypertensive medication, and appropriate, timely communication between the primary care provider and the care coordinator. Data for the TABLE 5. INTERVENED AND COMPARISON five complex medical/chronic disease projects is included here. The immunization measures were in line with VHA performance standards. Other measures were developed by CCCS staff based on identified problem areas. VHA immunizations target goals were 78% for both influenza and pneumococcal measures. Eightythree percent of the CCCS veterans had a mococcal vaccine. Medication compliance, current flu shot, and 90% had a current pneuwhich was chosen as a measure because it is often an issue with the chronically ill population, was 93%. The target goal was also 78%. Primary care providers responded positively to the role of the care coordinator, with an 85% outcome measure for appropriate and timely communication. Eighty-five percent was also the target goal for this measure. VIRTUALLY HEALTHY The chronic disease dialogues used by the inhome messaging device not only provided daily, repetitive education on self-management principles, but also monitored a variety of symptom parameters including blood sugar, weight, blood pressure, and chest pain. Leider and Krizan postulated that, for a disease management model to be effective, it must employ three basic strategies: improving patient compliance and self-management behaviors, strong physician leadership, and rigorous monitoring of patients so that clinical outcomes can be improved. The CCCS model embodied these strategies, and staff members were able to effectively operationalize them in practice. Technologies were chosen that supported patient compliance and provided educational opportunities to enhance self-management. Special emphasis was put on keeping the technology simple and user friendly to allow for the broadest use regardless of the patient's technological expertise. The CCCS leaders strongly relied upon the collaboration of physician providers with care coordinators. Physician champions were sought to provide leadership at local project sites and to work directly with CCCS leaders to promote acceptance of the care coordinator role. Care coordinators themselves were chosen for their judgment skills and their effectiveness in managing patient needs across the healthcare continuum. CONCLUSION Based on the first-year findings, it is evident that the CCCS model has benefited many frail elderly, medically complex patients. It has helped them to maintain their independence, improved their functional status and deterred from costly hospitalizations and institutionalizations. It is strongly believed that the key to this success has been the carefully constructed role of the care coordinator, with clinical expertise to properly assess patient needs. This role in tandem with the right tools and the technology most adaptable to the needs of the patient and clinician have provided the means for early detection of patients at risk for further deterio ration. Through the use of technology, efficiencies in process and practice, previously not pos sible, are achieved. This approach has given the patients a safer and more secure environment in their most preferred setting, the home. The first step in the process of inventing a proactive healthcare model that facilitates patient-oriented and cost-effective delivery of services is improving health and information access. The primary concept of integrating technology into care coordination has gone beyond that first step. The model has successfully evolved into an effective approach for managing patients with multiple chronic diseases. The CCCS is in the initial phase of identifying best practices for the strategic model. The intent is to draw upon the lessons learned and develop standards that can serve as the basic foundation for any population management program. The early successes have warranted expansion of the program to other populations. In 2001, two new demonstration programs were added. There will be a second request for proposals in 2002 to explore the effect of the concepts on other populations and new technologies not yet tested in this environment. In addition, VISN 8 is exploring accreditation opportunities in disease management to further validate and strengthen both the clinical and business applications of the concepts. The aging in place model has been the most notable success of this program. It is readily apparent that more veterans are stable, satisfied and able to manage their chronic health problems in their home environment. ACKNOWLEDGMENTS We would like to thank the following individuals: (1) Project staff from the following clinical demonstration medical program sites: Lake City, Gainesville, Ft. Myers, Miami, and San Juan. (2) Douglas D. Bradham, Dr.P.H., Associate Professor, Division of Healthcare Outcomes Research, Department of Epidemiology and Preventive Medicine, School of Medicine, University of Maryland. (3) Neale R. Chumbler, Ph.D., Associate Professor, Department of Health Policy and Epidemiology, University of Florida. Policy makers have a once-in-a-generation chance to remake the U.S. health care system to meet the needs of an aging population while saving billions of dollars in Medicare spending and keeping the program solvent. The Medicare Modernization Act of 2003 includes provisions that begin to transform the program's approach to chronic conditions, which are the biggest drivers of health care spending. Properly implemented, chronic care improvement programs can improve the health and quality of life of Medicare beneficiaries with chronic illness particularly high-risk patients such as 8 million Medicare beneficiaries with five or more chronic conditions who account for over two-thirds of the program's $302 billion in 2004 spending." Many of these patients are hospitalized at a huge cost and suffer because their conditions are allowed to deteriorate to the point where they reach a crisis. Chronic care improvement programs orient doctors and hospitals to working proactively with patients to maintain their health and keep them out of the hospital. For example, the Department of Veterans Affairs has instituted a model of chronic care that integrates care coordination services with daily in-home monitoring and clinical information tools, and has reported a 60 percent reduction in hospital admissions.2 If Medicare could achieve similar results with similar patients, the program could save over $30 billion a year. The federal government would also fuel technological innovation for chronic care improvement that would serve a growing need globally. The Need for Chronic Care Improvement The nation's most costly chronic conditions include coronary artery disease, heart failure, chronic obstructive pulmonary disease, mental-health disorders, diabetes mellitus, hypertension, and asthma. Chronic illness 1 Dr. Gerard Anderson, Partnership for Solutions, "Medicare and Medicaid Are Programs for People with Chronic Illness... But Do Not Know It," presentation to General Accounting Office, February 5, 2004; Partnership for Solutions, Chronic Conditions: Making the Case for Ongoing Care, December 2002; Medicare spending data from U.S. Department of Health and Human Services. M. Meyer, R. Kobb, P. Ryan, "Virtually Healthy: Chronic Disease Management in the Home," Disease Management, 2002;5(2):87-94. disease Medicare The prevalence of chronic illness will only increase amid the aging of the population and rising levels of obesity, which can lead to diabetes and heart disease. Many chronic conditions such as heart failure and chronic obstructive pulmonary disproportionately affect beneficiaries age 65 and older, whose numbers are projected to double by 2030. At the same time, public health officials are becoming increasingly concerned about the rising numbers of obese and overweight Americans. The federal Centers for Disease Control recently released figures indicating that poor diet and physical inactivity in 2000 caused 16.6 percent of all deaths, up from 14 percent in 1990. Obesity is poised to pass smoking as the leading preventable cause of death." "Obesity has got to be job No. 1 for us in terms of chronic diseases," Dr. Julie Gerberding, CDC's director, told the Associated Press. ©2004 All Rights Reserved Source: estimates based on 2001 hospital discharge and cost data from the Agency for Health Quality Research, Healthcare Cost and Utilization Project' (a) Number of afflicted does not total due to co-morbid conditions. (b) May not total due to rounding. patients, for instance, are at risk of peripheral vascular disease that can lead to amputations and disability. The concept of chronic care improvement begins with the recognition that patients with chronic conditions can lead healthier, happier lives under a model of care based on coordinated and proactive daily monitoring, education, guidance, and management by health care providers. Diet, exercise, and medication adherence are well known factors that influence how chronic conditions progress. A key, often overlooked factor is whether doctors and patients identify and effectively deal with problems early, before they result in emergency room visits or hospital admissions, with the associated pain and expense. Proactive monitoring and management can also prevent a patient with one chronic disease from contracting additional conditions. The result: Saving lives and saving money. ©2004 All Rights Reserved |