Programs Can Improve Your Patient Outcomes MAC, Inc. Living Well - PowerPoint PPT Presentation

Appendix E How Evidence-Based Self-Management Programs Can Improve Your Patient Outcomes MAC, Inc. Living Well Center of Excellence

Session Discussion Topics  Why refer clients/patients, especially older adults, to evidence-based self-management and behavior change programs?  What is the prevalence of chronic conditions, falls and/or depression among older adults?  How you can increase engagement/empowerment of older adults and improve their skills for managing their health.  How to link/refer individuals to community programs.

Why Prevention and Behavior Change Strategies Matter  Since January 1, 2011 every day for the next 19 years, 10,000 baby boomers turn 65. The aging of this huge cohort of Americans dramatically changes the composition of the country. 1  70% of physical and mental decline associated with aging is due to poor lifestyle behavior. 2  Older adults at any age can and do learn to make healthy behaviors and even modest lifestyle changes can produce big results when people are empowered and supported to cultivate health and longevity. 3

Why These Programs Are Important  1 in 3 people over 65 fall every year; falls are the leading cause of fatal and non-fatal injuries for older Americans.  Every 13 seconds, an older adult is treated in the emergency room for a fall; every 20 minutes, an older adult dies from a fall.  Almost 27% of older adults have mild depression and 2% suffer with clinical depression.  People with a chronic disease are more likely to suffer from depression.

Impact of Baby Boomers and the Elderly on the Health Care System  91% of people over 65 have one or more chronic conditions; 73% of 65+ have 2 or more chronic conditions.  Over 1.7 million Americans die of a chronic disease each year.  In 2009, the federal and state governments spent over $250 billion on health care benefits for 9 million low-income elderly or disabled people jointly enrolled in Medicare and Medicaid. 4 4 Dual-Eligible Beneficiaries of Medicare and Medicaid: Characteristics, Health Care Spending, and Evolving Policies, Congressional Budget Office, June 2013

Why These Programs Are Important  1 in 3 people over 65 fall every year and falls are the leading cause of fatal and non-fatal injuries for older Americans.  Every 13 seconds, an older adult is treated in the emergency room for a fall; every 20 minutes, an older adult dies from a fall.  Almost 27% of older adults have mild depression and 2% suffer with clinical depression.  People with a chronic disease are more likely to suffer 27 from depression.

MAC Inc. Living Well Center of Excellence: Delivering Evidence-Based Programs and Services Across the Continuum  Statewide License for Stanford University Chronic Disease Self- Management Education (CDSME) programs  Training and technical assistance for CDSME evidence-based programs  Centralized referral, certified workforce, community-based locations, quality assurance measures, HIPAA compliant  Statewide calendar, quarterly reporting to partners, feedback on patient activation, engagement and long-term goals

Maryland CDSME 1,859 Participants September 1 2015 – August 31 2016  Workshops : 302 Average participants per workshop: 10.3  Completers - attended 4 or more sessions: 1,424 (77%)  Race/Ethnicity : White/Caucasian 53% (870), Black or African American 43% (716), Asian 4% (60), Hispanic/Latino 3% (43)  Insurance Type: 63% Medicare (744), 63% Private Insurer (754) 15% Medicaid (176)  Living Arrangement: 37.9% Live alone (536), 62% Live with someone (877), 24.6% Unknown (460)

62% Reported Multiple Chronic Conditions (N= 1,308) Hypertension 989 Diabetes 932 Arthritis 591 Hypertension Depression/Mental Illness 309 Chronic Pain 305 Lung Disease 300 Lung Diabetes Heart Disease 252 Disease Cancer 230 Chronic Pain Osteoporosis 134 Depression Arthritis Stroke 104 None 432

Why These Programs Work  People with chronic conditions have similar concerns and problems.  People must deal not only with their disease, but also the impact these have on their lives and emotions.  People with chronic conditions are more likely to identify with and trust leaders who have had similar experiences.  Caregivers can be active participants

Self-Management Goals  Patients accept responsibility to manage or co- manage their own disease conditions.  Patients become active participants in a system of coordinated health care, intervention and communication  Patients gain confidence (self-efficacy) to perform tasks and focus on improved health status and appropriate health care utilization

Risk Assessment Questions Chronic Disease Assessment: 1) Do you have 2 or more chronic medical conditions?; 2) Are you taking more than 5 medications?; 3) Do you have difficulty managing your condition(s)? Falls Risk Assessment for patients over 65 : 1) Have you fallen in the past year?; 2) Do you feel unsteady when standing or walking?; 3) Do you worry about falling? Depression Screen : Over the past two weeks, how often have you been bothered by any of the following problems? 1) Little interest or pleasure in doing things; 2) Feeling down, depressed or hopeless Malnutrition : 1) Have you recently lost weight without trying?; 2) If yes, how much weight have you lost? (MST – Malnutrition Screening Tool)

Living Well Disease Management Programs Living Well Stanford University Self-Management Programs  Living Well with Chronic Conditions  Living Well with Diabetes  Living Well with Chronic Pain  Living Well: Cancer - Thriving and Surviving  Living Well: Spanish Diabetes Program  Living Well Home study chronic disease toolkit  Living Well with Hypertension (Recruitment session)

What goes on in Living Well?  Programs are open to individuals over 18 and caregivers  6-week workshop, 2.5 hours per session  Interactive peer-led groups of 10-16 people  Facilitated by 2 trained peer leaders, non-health professionals with chronic diseases or caregivers  Standardized materials and training for leaders  Highly scripted to maintain fidelity to original program  Free or low cost to participants  Participants become active in managing their care  DOES NOT replace existing programs or treatments

Living well workshop topics CDSMP  Nutrition  Appropriate exercise for strength, flexibility, and endurance  Communicating effectively with family, friends and health care providers  Appropriate use of medications  Techniques to deal with pain, fatigue, frustration  Decision Making  Action Planning and Goal Setting

Stanford Self-Management Programs National Study 2012 and the Triple Aim Base- 12- Triple Aim % Outcome Measure line Month Change Goal Mean Mean Communication with MD  IMPROVED Better Care 2.6 2.9 9% Medication Compliance  IMPROVED .25 .21 12% Health Literacy  IMPROVED 3.0 3.1 4% Better Self-assessed Health  IMPROVED 3.2 3.0 5% Outcomes PHQ Depression  REDUCED 6.6 5.1 21% Quality of Life  IMPROVED 6.5 7.0 6% Unhealthy Physical Days  REDUCED 8.7 7.2 15% Unhealthy Mental Days  REDUCED 6.7 5.6 12% Lower % w/ ED Visits in the Past 6 Months  ratio Health Care 18% 13% REDUCED .68 Costs An upward arrow indicates a higher value is desirable, a downward arrow that a lower value is desirable.

Financial Impact HOSPITALIZATIONS REDUCTION AT 6 MONTHS EMERGENCY ROOM VISITS ODDS REDUCED BY 32% NET COST SAVINGS PER $390 PER PERSON PERSON

Living well workshop topics Diabetes Self-Management (DSMP)  Key self-management strategies same as CDSMP (Decision Making, Problem Solving, Action Planning, Physical Activity)  What is Diabetes?  Monitoring  Formula for a Healthy Eating Plan  Preventing Low Blood Sugar  Preventing or Delaying Complications  Strategies for Sick Days  Foot Care

Living Well with Hypertension This interactive 2-1/2 hour session used as a recruitment strategy for Chronic Disease and Diabetes Self-Management Programs to help individuals learn to better manage hypertension Module activities/topics include:  What is High Blood Pressure  Problems with Salt/Sodium Intake  Home Monitoring Tips  Where’s the Salt  Knowing Your Numbers

Participant Action Plan and Blood Pressure Protocol

Hypertension Education/BP Screen Identified At Risk Individuals 250 Blood Pressure Screening (N = 196) 200 • 34% of individuals had hypertension • 21% were poorly controlled: counseled 150 to check with their health care provider 100 • 10% uncontrolled: referred to provider or community health worker 50 0 Participants Blood Pressure >140/>90 >160/>100 Screening

Change in BP at 7 weeks for 79 Workshop Participants 90 CDSMP/DSMP Workshops 80 70 • 58 had hypertension • 40 had diabetes 60 • 39 had week 1 and 7 BP 50 • 24 (62%) improved BP • 11 (28%) same BP 40 • 7 (18%) were healthy zone both times 30 • 5 (13%) had higher BP 20 10 0 Participants Week 1 and Week 7 Week 7 Improved Week 7 No Week 7 Worse BP BP BP improvement

CDSME Meets NCQA Expectations  Referral tracking and follow-up (standard 5)  Care plans (standard 4)  Self-management goals (standard 4)  Continuous Quality Improvement (standard 6)  Linkage to EHR/EMR