4 18-2013 chicago-chronic disease management

Axxess | 2013 1

C. SAM SMITHVice President – Business DevelopmentAxxess Technology SolutionsDallas, TX USA

DEBBIE CUNNINGHAMImplementation, Software Support Leader & TrainerAxxess Technology SolutionsDallas, TX USA

Chronic Disease Care

Management in Home Health Nursing & Agency

Operations

Axxess | 2013 2

TODAY’S LEARNING OBJECTIVES

The relevant chronic diseases

Statistics for the Nation, Illinois: impact on systems

Tools and Research – Strategic Information

Care Transitions

Technologies

Teaching Methods

Reflection, contemplation

Axxess | 2013 3

WHAT ARE THE MOST PREVALENT DISEASES?

High blood pressure

High cholesterol

Ischemic Heart Disease

Arthritis

Diabetes

Heart Failure

CKD

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WHAT ARE SOME OTHER PREVALENT DISEASES?

Depression

COPD

Alzheimer's

Atrial fibrillation

Cancer

Osteoporosis

Asthma

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• The number of people with chronic conditions is rapidly rising. For example, between 2000 and 2030, the number of Americans with one or more chronic conditions will increase 37 percent, an increase of 46 million people.• Some 28 percent of Americans have two or more chronic

conditions and they are responsible for two-thirds (67%)of health care spending.• In the Medicare program over two-thirds of the

expenditures are for beneficiaries with five or more chronic conditions.

THE STATISTICS ARE ALARMING

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CHRONIC DISEASE HAS A SIGNIFICANT IMPACT ON THE SYSTEM

• People with chronic conditions are use over 75 percent of hospital days, office visits, home health care and prescription drugs.• Because the health care system is not designed to meet the needs of

people with chronic conditions, their care is not coordinated, which leads to unnecessary service use.

• Individuals often receive conflicting advice from different providers, report difficulty accessing services and have difficulty paying out-of-pocket for health care.

• As a result, people with chronic conditions rely on others for financial support and personal assistance.

The impact of Chronic Diseases on the health care finance and delivery system

--------------From the Robert Wood Johnson Foundation

Axxess | 2013 7

CMS has launched a new web portal for the research involved in Chronic Disease Management—for you to utilizeCMS’s Medicare Chronic Conditions Dashboard may be accessed at

http://www.ccwdata.org/business-intelligence/chronic-conditions/index.htm   

CMS HAS LAUNCHED AN INFORMATIONAL PORTAL TO ADDRESS

THE SEVERITY OF THE ISSUE

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IMPACT OF CHRONIC DISEASE IN ILLINOIS

The 80-20 rule applies!

Roughly 80% of the money is spent on 20% of the population

Source: Centers for Medicare and Medicaid Services. Chronic Conditions among Medicare Beneficiaries, Chart book: 2012 Edition Baltimore, MD. 2012.

PERCENTAGE MEDICARE FFS BENEFICIARIES PER CHRONIC DISEASE

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CHICAGO IS A LEADER IN HOSPITAL READMISSIONS!

ChicagoBlue Island MunsterRegions: over 20% higher than national average

PER CAPITA SPENDING BY DEMOGRAPHIC GROUP FOR ILLINOIS

Dollars Spent per Chronic Conditions Dollars Spent per Gender

BENEFICIARIES WITH SELECTED CHRONIC CONDITIONS IN ILLINOIS

BENEFICIARIES WITH CHRONIC CONDITIONHYPERTENSION

Age Group all >65 in IllinoisTotal Population for Illinois

Category Illinois

Female 61%

Male 55%

<65 41%

65-74 53%

75-84 72%

85+ 72%

Dual 60%

Non-dual 58%

BENEFICIARIES WITH CHRONIC CONDITIONHYPERLIPIDEMIA

Illinois - Age group all >65 yrs. Total Population for Chronic condition

Category Illinois

Female 46%

Male 46%

<65 31%

65-74 47%

75-84 53%

85+ 43%

Dual 40%

Non-dual 47%

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• Solutions to the chronic care problem will come from broad-based reforms that involve:o Incorporating people with multiple chronic conditions in medical research; o Rethinking how the health care financing system values and pays for the care

received by people with chronic conditions; o Re-examining how we train health care providers; o Developing better connections between supportive and clinical care delivery

systems; o Incorporating quality metrics for people with multiple chronic conditions; and o Encouraging and supporting patient self-management and family caregiving.

--------------From the Robert Wood Johnson Foundation

SYSTEMIC SOLUTIONS TO CHRONIC CARE PROBLEMS

Click to add text

CARE PATHWAYS FOR CHRONIC DISEASES

• First -> what is the patient/caregiver’s understanding of the disease? • What do the patient/caregiver want to accomplish, how much

do they want to know?• Breakdown teaching goals to meet patient/caregiver’s

expectations. • Make sure teaching is easy to understand, remember and in

simple terms for the patient to repeat back and information to retain.

CARE PATHWAYS FOR CHRONIC DISEASES

• Make sure teaching is easy to understand, remember and in simple terms for the patient to repeat back and information to retain.

• Using templates to offer pathways for care, such as the templates modules contained in the Agencycore platform.

• Utilize paper format that is simple, easy to read and is information that is specific to the patients needs.

KEY TECHNOLOGIES THAT IMPACT HOME CARE

• Tele–Health/Tele-Monitoring > Phillips, Bosch, Cardiocom• Core operations system - Axxess at the ‘Agencycore’• Physician’s portal – Standing Order Management • Disruptive Technology: Zirmed’s ‘Clinical Link system’ > A

method for interchange of Continuum of Care documentations(CCD)

• Outcome-Based Technology Management • Maintaining the Metrics of outcomes for Chronic Patients: Aim: To

Reduce readmissions and reports to manage results

PRIORITY TEACHING FOR CHRONICALLY ILL PATIENTS

• Background for the disease • Diet • Medications• Activities• Equipment/supplies (have on hand or need)• Recognition of early signs & symptoms to handle/report• Request/include a MD treatment regimen if applicable• Standard orders

REFLECTIONS

• Allow patient/caregiver to absorb the diagnosis• Allow patient/caregiver to vent their feelings: anger;

frustration; denial; acceptance; depression; helplessness or even loneliness.• Involve as much family/friends the patient will allow• The end –Death & Dying- planning funeral with or

without family involvement, last wishes and deposing of assets and so on….

CONCLUSIONS

• Managing the Chronic Disease will be a challenge.

• Home Health will be the key• Reducing costs and keeping the patient at

home• More family involvement thus more

teaching/training• Other community resources to assist with

patient care • Web based teaching guides will assist the

clinicians • Web based software will be the key to

documentation• Other technologies will assist with

managing the conditions as well• All of us working together to make the

elderly comfortable, and enjoying their lives

Q & A

Thank you!

Sam Smithssmith@axxessconsult.com

Debbie Cunninghamdcunningham@axxessconsult.com