Caring for High Risk Populations

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Caring for High Risk Populations

• Disease Management
• and
• Case Management

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Case study in CHF
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Case study in CHF
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Disease Management and the Population Health Model

• The population
• The problem (needs)
• The intervention
• The evaluation

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Disease Management

• A case study
• Addressing CAD risk factors

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The population

• Patients hospitalized for CABG or PTCA
• 5 Kaiser Permanente hospitals

DeBusk et al. Ann Intern Med 1994 120721-9
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The Problem

• Risk factors remain important after the procedure
• Nevertheless
• hypertension lipid management are inadequate
• patients continue to smoke
• exercise???!!!! Youve got to be kidding

DeBusk et al. Ann Intern Med 1994 120721-9
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The Intervention
What can we do?
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The Intervention Case Management

• In hospital
• nurses initiate education about smoking,
  exercise, and diet
• Post-discharge
• telephone and mail contact home visits prn
• telephone f-u for smokers
• food frequency questionnaires with feedback
• nurse-initiated lipid lowering therapy
• telephone f-u on exercise training plan

DeBusk et al. Ann Intern Med 1994 120721-9
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Evaluation

• Randomized trial the case management group had
• higher smoking cessation
• 70 vs 53
• lower LDL
• 2.77 mmol/L vs 3.41 mmol/L
• greater exercise capacity
• 9.3 METS vs 8.4

DeBusk et al. Ann Intern Med 1994 120721-9
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Why did DeBusk set up his program working with
nurses rather than doctors?
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Why dont we use telephone-based systems to care
for our patients more often?
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What is disease management?What is case
management?
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Disease Management

• Systematic, population-based approach to
• Identify persons at risk
• Clarify their needs
• Intervene with specific programs of care
• Measure clinical and other outcomes
• Focus is on improving outcomes for the specific
  disease condition
• Often facilitated by a case manager

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Systems to address common disease management
requirements
Identify Address unique patient needs
Better care for individual patients
Measurable improvements for populations
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Essential components for disease management

• Knowledge base about the prevention, diagnosis,
  and treatment of the disease
• Clinical information systems
• identify patients
• track measures/evaluate performance
• Resources for improvement

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Case Management

• Systematic, population-based approach to
• Identify persons at risk
• Intervene with various programs of care
• Measurement not always a key aspect
• Generic focus across spectrum of needs
• Patient issues coordinated by a case-manager

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Spectrum of Management Services
Disease Management - specific disease -
disease-specific outcomes - focused
assessments - guidelines specific to diagnosis
Case Management - diverse conditions -
multiple outcomes - generic assessments -
generic guidelines
Case managment
Disease Management
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Utilization of Case Managers

• Case Management
• Mental health
• Maternity care
• Disabled and Elderly
• Cost outliers in hospitals
• Disease Management
• Asthma, diabetes, CHF, preventive care

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Who does case management?

• Social workers
• Occupational therapists
• Nurses
• Pharmacists

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Financing Case/Disease Management

• Government programs
• AAA keeping high risk elderly out of NH
• Capitated insurers
• identifying high risk patients and keeping them
  out of the hospital
• Indemnity plans
• Utilization management of cost outliers - getting
  long-term patients out of the hospital faster

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Financing Case/Disease Management (cont.)

• Pharmacy benefits managers
• Track asthma meds
• identify patterns suggestive of
• non-compliance
• poor prescribing
• Intervene with
• patient education
• physician feedback

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Brain Teaser
Connect these 9 dots with 4 straight lines
without lifting your pencil off the paper.
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Think outside of the box
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Key principles

• Capitation allows out of the box thinking
• The more comprehensive the risk to the payer,
  the more comprehensive the case/disease management

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Return to the case study

• Youve been tasked with improving CHF care
• Mission
• Reduce expenditures while maintaining or
  improving care for CHF patients
• Model it on a program developed by Michael Rich
  in St. Louis

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Some needs of the population have already been
identified

• Needs of the population
• CHF is most common cause for Medicare
  hospitalization
• gt 30 readmissions in 3-6 months
• High mortality
• Evidence AHCPR and AHA guidelines
• education
• risk assessment and follow-up
• ACE-I

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But how should we identify the population?

• Everyone with CHF vs. highest risk?
• Methods of finding patients
• office, hospital, pharmacy???
• Data on risk?

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CHF Case/Disease Management

• Identifying a population
• hospitalized with CHF
• age gt 70 years
• one or more risk factors for readmission
• prior hx CHF
• gt 3 hospitalizations in 5 years
• CHF precipitated by AMI or uncontrolled HTN

Rich MW et al. NEJM 1995 3331190-5.
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Needs Why are patients rehospitalized

• What are the proximate causes?
• Patient factors
• Healthcare factors
• What are the root causes?
• System factors

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Intervention What are we going to do for this
population?

• Who will be involved?
• What will they do?
• Remember this is a capitated population
• think outside the box if you think it will work
• but money you save goes to profits

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CHF Case/Disease Management

• Intervening to address the needs
• Individualized dietary assessment and counseling
• Social service discharge planning
• Medication planning with geriatric cardiologist
• Nurse case manager
• intensive patient education
• home visit or telephone follow-up

Rich MW et al. NEJM 1995 3331190-5.
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Evaluation What will you measure to see if your
disease management program works?
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Rich evaluated by

• Randomized trial
• Track
• costs
• functional status
• mortality
• CHF readmissions
• all-cause readmissions

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CHF Case/Disease Management

• Evaluation - what did he find?
• 40 reduction in all cause readmissions
• 56 reduction in CHF readmissions
• Improved quality of life scores
• Overall cost of care decreased by 460
• Program abandoned when lead nurse changed jobs
  (he wasnt operating in a capitated environment)

Rich MW et al. NEJM 1995 3331190-5.
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So case/disease management is great?
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Obstacles to Disease Management

• Limited resources
• Inadequate information systems
• Lack of physician buy-in
• Disruption of continuity
• Perception of cookbook approach
• Difficulty changing current practices

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Disease Management Risks

• Fragmentation of care
• Woman with diabetes, CHF and hypertension
• Economic viability
• Strong HIV program in management care induces
  more HIV patients to join
• Unproven efficacy
• Few controlled trials. Can results of one
  program be inferred for another?

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What would be the role of the doctor in a CHF
disease management program?
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Post Test
Name three common conditions that might be
addressed by a disease management program. By a
case management program?
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Post Test
A formal method to identify high-risk patients
would be most important in which of the
following situations? A. Educating new
diabetics on glucose monitoring B.
Individualized case management for patients
with CHF
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Summary

• Case management addressing unique needs of
  individuals
• Disease management systems to address common
  needs for a population
• Identify high risk populations concentrate
  efforts on potential high cost patients
• Being at risk and having integrated systems
  allows innovative approaches