Chronic Disease and AgingThe 21st Century Healthcare Challenge

Howard Bergman, MD, FCFP, FRCPC

Chair, Department of Family Medicine

Professor of Family Medicine, Medicine and Oncology

The Dr. Joseph Kaufmann Chair of Geriatric MedicineMcGill University

17.3.12

Family MedicineMédecine de famille

The Shifting Face of Health Care

From acute to chronic disease

From institutions to networks of care; from a single site (hospital, nursing home) to many sites: home, assisted living, supportive housing, physician’s office, community clinics, ambulatory care centers, community hospitals, academic health centers, rehabilitation facilities, nursing homes, palliative care centers

From a single professional, generally a physician to many health care professionals: family doctors, specialists, nurses, physical therapists, nutritionists, social workers, psychologists, etc.

Expectations/knowledge/Involvement of patients and family

The Shifting Face of Health Care

↑ Complexity↑ Interdependency↑ UncertaintyIncreasing preoccupation with costs and

performance leading to increased government intervention/control/reform

Continuous change

MCSAC

Aging and Chronic DiseaseThe Challenge for the 21st Century

Dramatic increase in the number of old, in particular old/old

Increase in prevalence of chronic disease– 1 in 5 baby boomers will develop dementia– Cardiovascular: most important cause of hospital admission – Diabetes: increasing prevalence with age: 10% over 65– Cancer: increasing incidence and mortality with age

MCSAC

Growth will be greater at older ages …

100

125

150

175

200

225

250

2010 2015 2020 2025 2030 2035

0-19 20-64 65-74 75-84 85+

Index

MCSAC

Aging and Chronic DiseaseThe Challenge for the 21st Century

Complex relationship – Increase in chronic diseases due to aging as a result

of longer exposure to chronic disease risk factors in a vulnerable population

– Cumulative impact of chronic disease throughout the life course contributes to frailty and ultimately disability and dependency

A global challenge– ↑ chronic diseases +↑ life expectancy = Aging with ↑

disability

Heath care systems and the challenge of aging

Potential for promotion/prevention promoting healthy aging and in at least delaying onset of frailty and disability

↑ complex interventions (technology/surgery/medication) in increasingly older persons

Health care systems poorly adapted to the management of chronic disease, frailty and dependency; complexity of treating chronic diseases and frail older persons

Prevalence of Diabetes in Montreal

Prevalence of Heart Failurein Montreal

10

Those w/no chronic conditions

Those w/one chronic condition

Those w/multiple chronic conditions

People $$$

72%

21%

6%

36%

31%

33%

Source: Kaiser Permanente Northern California commercial membership, DxCG methodology, 2001.

http://www.natpact.nhs.uk/uploads/BobCrane.ppt#270

Aging and Chronic DiseaseThe Challenge for the 21st Century

• drivers of morbidity, mortality, utilization and costs • A challenge to quality of life of elderly and healthcare

system sustainability

MCSAC

Increasing prevalence of chronic disease

but.. are we getting it right

Optimizing Quality and Best Practice in Primary Care

Percent of people with diabetes receiving care according to guidelines

0%

20%

40%

60%

80%

100%

Year

Perc

en

t

What seniors receive?Jencks et al., JAMA, 2003; 289:305ACOVE, Ann Int Med, 2003; 139:740

• AMI – 50-75% receive B-blockers, 43-50% counseled for smoking

• CHF – 65-68% ACE on discharge

• Stroke – 57% of A-fib on anti-coagulants

• Diabetes – 48-70% have eye exam

• Falls – 3% of fallers have fall examination

• Depression – 26% of those with depressive symptoms treated or referred

• Medications – 18% of those prescribed new drug had documented education

• Cognition – 52% of new patients tested

16%(n=8)

30% (n=15)

42% (n=21)

12% (n=6)

0

20

40

60

80

100

Without frailtymarkers or IADL /

ADL disability

With frailtymarkers but

without IADL /ADL disability

IADL disabledwithout ADL

disability

ADL disabled

%

Retornaz F, Monette J, Monette M, Sourial N, Wan-Chow-Wah D, Puts M, Small D, Caplan S, Batist G, Bergman H.Usefulness of frailty markers in the assessment of the health and functional status in older cancer patient referred for

chemotherapy Journal of Gerontology:medical sciences. 2008

Health and functional status of cancer patients, aged 70 years and older referred for chemotherapy- preliminary findings

Life expectancy percentiles for men.

18

14.2

10.8

7.9

5.84.3

12.4

9.3

6.7

4.73.2

2.3

6.7

4.93.3

2.21.5 1

0

5

10

15

20

25

70 years 75 years 80 years 85 years 90 years 95 years

Lif

e e

xp

ec

tan

cy

, y

ea

rs

Top 25th percentile

Lowest 25th percentile

50th percentile

Walter LC et al. JAMA 2001, 285, 2750-2756

Healthy

vulnerable

With ADL disabilities

Embracing the heterogeneity and complexity

Healthy older persons– Primary medical care, Health

assessment/promotion/preventionEarly frail/low risk/chronic disease

– Primary medical care, Chronic disease management, detection of vulnerability, preventive home visits

Medium risk/mild-moderate disability– Primary medical care and home care, chronic disease

management. Specialized Geriatric care,↑ Disability and “complex” systems of

integrated careEnd of life care

Implementation in a coherent system: challenges to explore

Prevention and chronic disease management

Programs for health promotion/prevention Chronic disease management for clinical priorities

in older persons– Diabetes, CHF, hypertension, depression, cancer,

dementia– Potential role of frailty/vulnerability markers

Implementation in a coherent system:

challenges to explorePopulation Health ApproachPrimary Care Reform

– The Family Medicine Group(GMF): basis for integration– Example of proposed Quebec Alzheimer Plan

• Collaborative care model ; Partnership MD-Nurse-Patient-caregiver; Nurse navigator

• Community social care (AD support centre)• Intensive team based case management and multidisciplinary

community based services• Role of specialty care• End of life care

http://www.rqrv.com/en/document/alzheimer_report.pdf

http://www.rqrv.com/fr/document/rapport_alzheimer.pdf

 

Primary Care Medical Reform in Canada

GMF (Qc); Family Health Teams (Ont); Medical Home (College of family Physicians of Canada– May or may not be in the same building eg BC and

Alberta

Group practice; interdisciplinary practice; continuity of care with population and healthcare system responsibility; evolving remuneration; IT infrastructure: evolving integration of other healthcare professionals

Implementation of a service structure based on the chronic-care model and the collaborative-practice model, introduced gradually, starting in Family Medicine Groups (FMGs) and Network Clinics (NCs).

– The primary care physician and the nurse clinician responsible for continuity of patient services establish a partnership with each patient and his or her family for the process of assessment, diagnosis, treatment, monitoring, and follow-up.

• Approximately 10 to 15 patients with AD per MD = 100-150 per FMG with 10 MDs

– The nurse clinician plays the role of Alzheimer’s nurse care navigator.

20

Priority Action 2 Provide access to personalized, coordinated assessment and treatment services for

people with Alzheimer’s and their family/informal caregivers

Chronic Disease and Aging in the Acute Care Setting

↑ of chronic diseases– ↑ hospitalization

– ↑ hospitalization for Ambulatory Case-Sensitive (ACS) conditions

– ↑ hospitalization associated with avoidable and costly complication

> 65– 37% of admissions– 50% of hospital days– ↑ readmission

Siu et al: Health Affairs 2008

Change in profile ofhospitalized patients

Profile of patients on admission– demography/health promotion and prevention/medical

care– Treatment/intervention in ambulatory and primary

care

Increasingly complex medical and surgical interventions on older and older patients

The Challenge of the Aging Population Frailest elderly ~3% of population are the major client

group, use 30% of health-care resources Seniors use 1/3 of all hospital admissions & 1/2 of

inpatient days (2002/2003 Hospital morbidity database) Readmission rates 42% in patients >75 years Seniors have higher rates of return visits to emergency Disconnect between patient needs and hospital practices

= “hostile environment” Frail elderly experience further functional decline not

related to acute episode but to hospital practices (Inouye et al 2000)

Adverse effects are higher in frail elderly even when adjusted for age/co-morbidity

697,07334,713

42,298

176,992

1,8274,996

97,684

1,827

0%

20%

40%

60%

80%

100%

Population Inpatients Discharges Bed Days

Majority go home after hospitalization; Account for up to 80% of ALC days; 30%-40% have a mental health co-morbidity

High Resource Hospital Patients: 2/3 are Seniors

Health Region: Hospital Inpatient Data 06/07

36%

5%

1Defined as discharges not coded as emergency, direct or clinic; excludes stillborns, newborns and day surgery

Source: DAD database CIHI

11%

0%

20%

40%

60%

80%

100%

Population Inpatients Discharges Bed Days

ComplexInpatients

OtherInpatients

The loss of independent functioning during hospitalization has been associated with:

(Inouye et al 2000)

Prolonged lengths of hospital stay Increased readmissionA greater risk of institutionalizationHigher mortality rates

Myth: Elderly patients with chronic diseases are blocking the system– It’s only an outflow problem

Disconnect between patient needs and hospital environment

An appropriate approach …60 years ago

Structured to support continued action on single disease strategies and approaches; disjuncture and repetition of activities

Based on reducing LOS of uncomplicated acute admissionsPatients too complex to fit into standard critical pathways and

treatment modelsThe complex patients (“acute on chronic”; functional decline;

decreased reserve with age) get lost: – ↑ LOS;↑ LTC; ↑ Readmissions

Siu et al: Health Affairs 2008: The ironic case for the chronic disease model in the acute care setting

The Acute Care settingRe-thinking the approach in a coherent system of care

Engagement with primary medical and community care: a

collaborative care approach– Transition in and out of the hospital

– Specialty care supporting primary care• Not necessarily within the hospital

Engagement with LTC

– Smooth transitions

– Prevention of admissions

Counsell JAMA 20007; Callahan JAMA 2008;

Boult Journal Geronto Med sciences 2008; Béland, Bergman et al Journal Geronto Med sciences 2007

Naylor

Present system of care

Poor communication of best practices Innumerable programs and models

– The national disease strategies

The Acute Care settingRe-thinking the approach in a coherent system of care

From the traditional medical and surgical wards to the collaborative care wards

Clinical processes and organization of care within the hospital– Interdisciplinary team directed care based on best practices– Integrate holistic older person evaluation within the acute care process– Physical organization– Hospital environment– Patient and family engagement

Training including end of life care

The Acute Care settingRe-thinking the approach: the key elements

Aggregating the 3 components in a coherent system– Pre-hospital– Intra Hospital– Post-hospital

Inter disciplinary rather than disciplinary

Partnership: clinicians, managers, the community

Research: a key component

The Chronic Disease Modelquestions and issues

Can the Chronic Disease Model be implemented without primary medical reform– Family Medicine Groups in Quebec

How can the Chronic disease(S) model be integrated into primary care

Beyond the ModelsReflections on key elements Primary care

What seems to work/needs to be tested Primary med care: org

infrastructure/remuneration The multi disciplinary care

integrated into primary medical care

Evolution of relationships among professionals

Rapid access to intensive professional services (professional and social); access to a wide range of assisted/supportive housing

Population data/ responsibility

What does not seem to work Primary med care: organization

/infrastructure/remuneration not suited to complex continuing care

The programmatic, budgetary and geographic cleavage between primary medical and multidisciplinary care

Parallel play among professionals Sporadic responsibility There are no emergencies

Primary medical care

Primary multidisciplinary care

INTENSIVE TEAM BASED

CASE MANAGEMENT

Specialized Geriatric Program

hospitalER/wards

ACE/GAU BEDSER/WARD CONSULTATION

DAY HOSPITALREHAB

OUTPATIENT Transition beds

MD/nurse clinician geriatric consultation

team

DAY PROGRAMS

ASSISTED LIVING

COMMUNITY PROGRAMS

Canadian Initiative on Frailty and Aging / Initiative canadienne sur la fragilité et le vieillissementwww.frail-fragile.ca

Critical role of research in change

Understanding the health and functional status, on trajectory and costs of the population

Data to help understand why change is necessary and to make evidence based decisions

Understanding attitudes and expectations of both clinicians, patients and families

Clinical research and hospital and community based studies

Evaluative research Synthesising evidence

Conclusion A shared vision of the challenge

A complex challenge– data– The long haul– a multi disciplinary approach and a multi-dimensional

integrated strategy– Do not try and boil the ocean