August 6, 2019

Kaiser Family Foundation: Medicare Spending and Use of Medical Services for Beneficiaries in Nursing Homes and Other Long-Term Care Facilities—A Potential for Achieving Medicare Savings and Improving the Quality of Care

We find that beneficiaries living in long-term care facilities account for a disproportionate share of Medicare spending, with relatively high rates of hospitalizations, emergency room visits, skilled nursing facility admissions and other Medicare-covered services. The relatively high Medicare spending is incurred not only by long-term care residents who die within […]
Read More
We find that beneficiaries living in long-term care facilities account for a disproportionate share of Medicare spending, with relatively high rates of hospitalizations, emergency room visits, skilled nursing facility admissions and other Medicare-covered services. The relatively high Medicare spending is incurred not only by long-term care residents who die within the year, or those who transition from another setting into a long-term care facility, but also by beneficiaries living in a facility throughout the calendar year. Studies indicate that 30 to 67 percent of hospitalizations among facility residents could be prevented with well-targeted interventions.3 Others have identified factors that contribute to preventable hospitalizations, including liability concerns, limited staff capacity, financial incentives, and physician preferences.4 This analysis illustrates how successful efforts to reduce the rate of preventable hospitalizations could yield savings to Medicare. Such efforts, if carefully implemented, could also help to improve the quality of patient care for Medicare’s oldest and most frail beneficiaries.
Read Less
http://www.kff.org/medicare/upload/Presentation-Slides-Jacobson.pdf

August 7, 2019

Guided Care: Care for the Whole Person, For Those Who Need It Most

Guided Care is a new solution to the growing challenge of caring for older adults with chronic conditions and complex health needs. A Guided Care Nurse, based in a primary care office, works with patients and their families to improve their quality of life and make more efficient use of […]
Read More
Guided Care is a new solution to the growing challenge of caring for older adults with chronic conditions and complex health needs. A Guided Care Nurse, based in a primary care office, works with patients and their families to improve their quality of life and make more efficient use of health services. The nurse assesses patient needs, monitors conditions, educates and empowers the patient, and works with community agencies to ensure that the patient’s healthcare goals are met. The Lipitz Center recently conducted a cluster-randomized controlled trial of Guided Care at eight community-based primary care practices in the Baltimore-Washington D.C. area that included over 900 patients, 300 caregivers, and 48 primary care physicians. Preliminary data indicate that Guided Care improves the quality of patients' care, reduces family caregiver strain, improves physicians' satisfaction with chronic care, and may reduce the use and cost of expensive services, especially in well-managed systems. Click here for a summary of preliminary data from the trial.
Read Less
http://www.guidedcare.org/

August 7, 2019

The effects of guided care on the perceived quality of health care for multi-morbid older persons: 18-month outcomes from a cluster-randomized controlled trial

J Gen Intern Med, 25;3:235-42 Authors: Boyd, C. M., Reider, L., Frey, K., Scharfstein, D., Leff, B. Wolff, J., Groves, C., Karm, L., Wegener, S., Marsteller, J., Boult, C. BACKGROUND: The quality of health care for older Americans with chronic conditions is suboptimal. OBJECTIVE: To evaluate the effects of “”Guided […]
Read More
J Gen Intern Med, 25;3:235-42 Authors: Boyd, C. M., Reider, L., Frey, K., Scharfstein, D., Leff, B. Wolff, J., Groves, C., Karm, L., Wegener, S., Marsteller, J., Boult, C. BACKGROUND: The quality of health care for older Americans with chronic conditions is suboptimal. OBJECTIVE: To evaluate the effects of ""Guided Care"" on patient-reported quality of chronic illness care. DESIGN: Cluster-randomized controlled trial of Guided Care in 14 primary care teams. PARTICIPANTS: Older patients of these teams were eligible to participate if, based on analysis of their recent insurance claims, they were at risk for incurring high health-care costs during the coming year. Small teams of physicians and their at-risk older patients were randomized to receive either Guided Care (GC) or usual care (UC). INTERVENTION: ""Guided Care"" is designed to enhance the quality of health care by integrating a registered nurse, trained in chronic care, into a primary care practice to work with 2-5 physicians in providing comprehensive chronic care to 50-60 multi-morbid older patients. MEASUREMENTS: Eighteen months after baseline, interviewers blinded to group assignment administered the Patient Assessment of Chronic Illness Care (PACIC) survey by telephone. Logistic and linear regression was used to evaluate the effect of the intervention on patient-reported quality of chronic illness care. RESULTS: Of the 13,534 older patients screened, 2,391 (17.7%) were eligible to participate in the study, of which 904 (37.8%) gave informed consent and were cluster-randomized. After 18 months, 95.3% and 92.2% of the GC and UC recipients who remained alive and eligible completed interviews. Compared to UC recipients, GC recipients had twice greater odds of rating their chronic care highly (aOR = 2.13, 95% CI = 1.30-3.50, p = 0.003). CONCLUSION: Guided Care improves self-reported quality of chronic health care for multi-morbid older persons.
Read Less
http://www.springerlink.com/content/1602g85371r24623/

August 7, 2019

Guided care: cost and utilization outcomes in a pilot study

Dis Manag, 11;1:28-36 Authors: Sylvia, M. L., Griswold, M., Dunbar, L., Boyd, C. M., Park, M., Boult, C., Guided Care (GC) is an enhancement to primary care that incorporates the operative principles of disease management and chronic care innovations. In a 6-month quasi-experimental study, we compared the cost and utilization […]
Read More
Dis Manag, 11;1:28-36 Authors: Sylvia, M. L., Griswold, M., Dunbar, L., Boyd, C. M., Park, M., Boult, C., Guided Care (GC) is an enhancement to primary care that incorporates the operative principles of disease management and chronic care innovations. In a 6-month quasi-experimental study, we compared the cost and utilization patterns of patients assigned to GC and Usual Care (UC). The setting was a community-based general internal medicine practice. The participants were patients of 4 general internists. They were older, chronically ill, community-dwelling patients, members of a capitated health plan, and identified as high risk. Using the Adjusted Clinical Groups Predictive Model (ACG-PM), we identified those at highest risk of future health care utilization. We selected the 75 highest-risk older patients of 2 internists at a primary care practice to receive GC and the 75 highest-risk older patients of 2 other internists in the same practice to receive UC. Insurance data were used to describe the groups' demographics, chronic conditions, insurance expenditures, and utilization. Among our results, at baseline, the GC (all targeted patients) and UC groups were similar in demographics and prevalence of chronic conditions, but the GC group had a higher mean ACG-PM risk score (0.34 vs. 0.20, p < 0.0001). During the following 6 months, the GC group had lower unadjusted mean insurance expenditures, hospital admissions, hospital days, and emergency department visits (p > 0.05). There were larger differences in insurance expenditures between the GC and UC groups at lower risk levels (at ACG-PM = 0.10, mean difference = $4340; at ACG-PM = 0.6, mean difference = $1304). Thirty-one of the 75 patients assigned to receive GC actually enrolled in the intervention. These results suggest that GC may reduce insurance expenditures for high-risk older adults. If these results are confirmed in larger, randomized studies, GC may help to increase the efficiency of health care for the aging American population.
Read Less
http://www.liebertonline.com/doi/abs/10.1089/dis.2008.111723?prevSearch=allfield%253A%2528Guided%2BCare%2529&searchHistoryKey

August 7, 2019

Early effects of “Guided Care” on the quality of health care for multimorbid older persons: a cluster-randomized controlled trial

J Gerontol A Biol Sci Med Sci, 63;3:321-7 Authors: Boult, C., Reider, L., Frey, K., Leff, B., Boyd, C. M., Wolff, J. L., Wegener, S., Marsteller, J., Karm, L., Scharfstein, D., BACKGROUND: The quality of health care for older Americans with multiple chronic conditions is suboptimal. We designed “”Guided Care”” […]
Read More
J Gerontol A Biol Sci Med Sci, 63;3:321-7 Authors: Boult, C., Reider, L., Frey, K., Leff, B., Boyd, C. M., Wolff, J. L., Wegener, S., Marsteller, J., Karm, L., Scharfstein, D., BACKGROUND: The quality of health care for older Americans with multiple chronic conditions is suboptimal. We designed ""Guided Care"" (GC) to enhance quality of care by integrating a registered nurse, intensively trained in chronic care, into primary care practices to work with physicians in providing comprehensive chronic care to 50-60 multimorbid older patients. METHODS: We hypothesized that GC would improve the quality of health care for this population. In 2006, we began a cluster-randomized controlled trial of GC at eight practices (n = 49 physicians). Older patients of these practices were eligible to participate if they were at risk for using health services heavily during the coming year. Teams of two to five physicians and their at-risk older patients were randomized to either GC or usual care (UC). Six months after baseline, participants rated the quality of their health care by answering validated closed-ended questions from telephone interviewers who were masked to group assignment. RESULTS: Of the 13,534 older patients screened, 2391 (17.7%) were eligible to participate in the study, of which 904 (37.8%) gave informed consent and were cluster-randomized. After 6 months, 93.8% and 93.2% of the GC and UC participants who remained alive and eligible completed telephone interviews. GC participants were more likely than UC participants to rate their care highly (adjusted odds ratio = 2.0, 95% confidence interval, 1.2-3.4, p =.006), and primary care physicians were more likely to be satisfied with their interactions with chronically ill older patients and their families (p <.05). CONCLUSIONS: GC improves important aspects of the quality of health care for multimorbid older persons. Additional data will become available as this trial continues.
Read Less
http://biomedgerontology.oxfordjournals.org/content/63/3/321.abstract

August 7, 2019

Successful models of comprehensive care for older adults with chronic conditions: evidence for the Institute of Medicine’s “retooling for an aging America” report

J Am Geriatr Soc, 57;12:2328-37 Authors: Boult, C., Green, A. F., Boult, L. B., Pacala, J. T., Snyder, C., Leff, B., The quality of chronic care in America is low, and the cost is high. To help inform efforts to overhaul the ailing U.S. healthcare system, including those related to […]
Read More
J Am Geriatr Soc, 57;12:2328-37 Authors: Boult, C., Green, A. F., Boult, L. B., Pacala, J. T., Snyder, C., Leff, B., The quality of chronic care in America is low, and the cost is high. To help inform efforts to overhaul the ailing U.S. healthcare system, including those related to the ""medical home,"" models of comprehensive health care that have shown the potential to improve the quality, efficiency, or health-related outcomes of care for chronically ill older persons were identified. Using multiple indexing terms, the MEDLINE database was searched for articles published in English between January 1, 1987, and May 30, 2008, that reported statistically significant positive outcomes from high-quality research on models of comprehensive health care for older persons with chronic conditions. Each selected study addressed a model of comprehensive health care; was a meta-analysis, systematic review, or trial with an equivalent concurrent control group; included an adequate number of representative, chronically ill participants aged 65 and older; used valid measures; used reliable methods of data collection; analyzed data rigorously; and reported significantly positive effects on the quality, efficiency, or health-related outcomes of care. Of 2,714 identified articles, 123 (4.5%) met these criteria. Fifteen models have improved at least one outcome: interdisciplinary primary care (1), models that supplement primary care (8), transitional care (1), models of acute care in patients' homes (2), nurse-physician teams for residents of nursing homes (1), and models of comprehensive care in hospitals (2). Policy makers and healthcare leaders should consider including these 15 models of health care in plans to reform the U.S. healthcare system. The Centers for Medicare and Medicaid Services would need new statutory flexibility to pay for care by the nurses, social workers, pharmacists, and physicians who staff these promising models.
Read Less
http://onlinelibrary.wiley.com/doi/10.1111/j.1532-5415.2009.02571.x/abstract

August 7, 2019

Comprehensive primary care for older patients with multiple chronic conditions: “Nobody rushes you through”

JAMA, 304;17:1936–43 Authors: Boult, C., Wieland, G. D. Older patients with multiple chronic health conditions and complex health care needs often receive care that is fragmented, incomplete, inefficient, and ineffective. This article describes the case of an older woman whose case cannot be managed effectively through the customary approach of […]
Read More
JAMA, 304;17:1936–43 Authors: Boult, C., Wieland, G. D. Older patients with multiple chronic health conditions and complex health care needs often receive care that is fragmented, incomplete, inefficient, and ineffective. This article describes the case of an older woman whose case cannot be managed effectively through the customary approach of simply diagnosing and treating her individual diseases. Based on expert consensus about the available evidence, this article identifies 4 proactive, continuous processes that can substantially improve the primary care of community-dwelling older patients who have multiple chronic conditions: comprehensive assessment, evidence-based care planning and monitoring, promotion of patients' and (family caregivers') active engagement in care, and coordination of professionals in care of the patient--all tailored to the patient's goals and preferences. Three models of chronic care that include these processes and that appear to improve some aspects of the effectiveness and the efficiency of complex primary care--the Geriatric Resources for Assessment and Care of Elders (GRACE) model, Guided Care, and the Program of All-inclusive Care for the Elderly (PACE)--are described briefly, and steps toward their implementation are discussed.
Read Less
http://jama.ama-assn.org/content/304/17/1936.abstract

August 7, 2019

The Promise of Care Coordination: Models that Decrease Hospitalizations and Improve Outcomes for Medicare Beneficiaries with Chronic Illnesses

Brown R. The National Coalition On Care Coordination.The Promise of Care Coordination: Models that Decrease Hospitalizations and Improve Outcomes for Medicare Beneficiaries with Chronic Illnesses. http://www.nyam.org/social-work-leadership-institute/docs/N3C-Promise-of-Care-Coordination.pdf. March 2009. Accessed April 26, 2013. A synthesis of the literature on best practices in care management and transitions of care models as well […]
Read More
Brown R. The National Coalition On Care Coordination.The Promise of Care Coordination: Models that Decrease Hospitalizations and Improve Outcomes for Medicare Beneficiaries with Chronic Illnesses. http://www.nyam.org/social-work-leadership-institute/docs/N3C-Promise-of-Care-Coordination.pdf. March 2009. Accessed April 26, 2013. A synthesis of the literature on best practices in care management and transitions of care models as well as outcomes.
Read Less
http://www.nyam.org/social-work-leadership-institute/docs/N3C-Promise-of-Care-Coordination.pdf

August 7, 2019

NTOCC: Cultural Competence—Essential Ingredient for Successful Transitions of Care

Health care professionals increasingly recognize the crucial role that culture plays in the health care of a client or patient and the need to deliver services in a culturally competent manner. Cultural competence is essential to successful, client-/patient-centered transitions of care. This tool provides information about culture and cultural competence, […]
Read More
Health care professionals increasingly recognize the crucial role that culture plays in the health care of a client or patient and the need to deliver services in a culturally competent manner. Cultural competence is essential to successful, client-/patient-centered transitions of care. This tool provides information about culture and cultural competence, as well as strategies and resources to enhance professionals’ capacity to deliver culturally competent services during transitions of care.
Read Less
http://www.ntocc.org/Portals/0/PDF/Resources/CulturalCompetence.pdf

August 7, 2019

Care management of patients with complex health care needs: Research Synthesis Report No. 19

Brown R, Peikes D, Peterson G. Care management of patients with complex health care needs: Research Synthesis Report No. 19. http://www.rwjf.org/content/dam/farm/reports/issue_briefs/2009/rwjf49853/subassets/rwjf49853_1. December 2009. Accessed April 17, 2013. This synthesis looks at the evidence and explores the potential for care management to improve quality of care and reduce costs for people […]
Read More
Brown R, Peikes D, Peterson G. Care management of patients with complex health care needs: Research Synthesis Report No. 19. http://www.rwjf.org/content/dam/farm/reports/issue_briefs/2009/rwjf49853/subassets/rwjf49853_1. December 2009. Accessed April 17, 2013. This synthesis looks at the evidence and explores the potential for care management to improve quality of care and reduce costs for people with complex health care needs. This synthesis addresses the following questions: 1. What is care management? 2. How are patients identified for care management programs? 3. Do research-based care management programs enhance quality and reduce costs for patients with complex health care needs? 4. What are the characteristics of successful care management programs? 5. How have research-based care management programs been adapted to real-world treatment settings? 6. How do payment policies influence the creation and success of care management programs?
Read Less
https://www.rwjf.org/content/dam/farm/reports/issue_briefs/2009/rwjf49853/subassets/rwjf49853_1