Abstract
Individuals afflicted with multiple chronic conditions should be managed in real life settings and real time, while simultaneously reducing use of costly acute care services. New models of care delivery will enable patient participation in life-long care management programs and activities that target “wellness” while minimizing, delaying, or preventing clinical deterioration that requires hospitalization and/or visits to emergency care facilities. Successful care models will likely require new organizational and financial approaches that re-purpose health professional roles, responsibilities, and relationships. Remote monitoring and telehomecare technologies that employ advanced data management and analytic algorithms as well as dashboard displays of clinician- and services-relevant health information will support clinician decision-making at the point and time of care. Optimally, health professional financial incentives will be re-structured to support and sustain outcomes-driven long term chronic care that rewards efficiency and effectiveness. We present a work-in-progress model, RightHealthTM, including pilot project outcomes.
TopIntroduction
Timely access to healthcare in both urban and rural settings is a worldwide challenge because no nation committed to the health of its population can afford to replicate in every community all the resources required for each community’s healthcare needs. Tele-networking of patients, providers, and relevant health information may be the only way to make healthcare services and outcomes-driven decision-making available, responsive, and convenient for consumers, practical for providers, and economically viable for healthcare systems.
By definition, chronic conditions (CC) last a year or more, and limit activities of daily living and/or require on-going medical attention (Hwang, 2001). They include physical medical conditions, mental and cognitive disorders, developmental disabilities, and addiction disorders. The prevalence and burden of fifteen selected CC was summarized by the Centers for Medicare and Medicaid Services (CMS, 2013). Selected conditions (percentage of Medicare beneficiaries) included: Hypertension (58%), High Cholesterol (45%), Ischemic Heart Disease (31%), Arthritis (29%), Diabetes Mellitus (28%), Heart Failure (16%), Chronic Kidney Disease (15%), Depression (14%), Chronic Obstructive Pulmonary Disease (12%), Alzheimer’s Disease (11%), Atrial Fibrillation (8%), Cancer (8%), Osteoporosis (7%), Asthma (5%), and Stroke (4%). All are more prevalent in individuals 65 years of age or older, except depression and asthma.
Multiple chronic conditions (MCC):
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Increase with age:<65(52%) 65-74(63%) 75-84(78%) >85(83%)
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Increase hospitalizations in a year:0-1CC/MCC (4%/63% hospitalized; <1%/16% >3 hospitalizations):
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Increase use of post-acute care (at least one visit):0-1(1%) 2-3(7%) 4-5(19%) >6(49%)
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Increase home health visits:0-1(1%) 2-3(5%) 4-5(9%) >6(36%)
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Increase physician office visits (0/>13):0-1(34%/4%) 2-3(7%/15%) 4-5(7%/30%) >6(8%/46%)
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Increase emergency department visits (0/>13):0-1(86%/<3%) 2-3(75%/4%) 4-5(59%/8%) >6(30%/27%)
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Increase admissions with a re-admission within 30 days in people >65 years old:0-1(7%) 2-3(7%) 4-5(13%) >6(24%)
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Increased per capita Medicare 2010 spending:0-1($2,025) 2-3($5,698) 4-5($12,174) >6($32,658)
Key Terms in this Chapter
Electronic Medical Record: An EMR is a digital version of a paper medical chart in a medical office, a hospital, or a medical enterprise that contains the medical and treatment history of the patients managed in that setting. It allows patient care information and data to be stored, tracked, and retrieved over time.
Covered Home Health Services: Home health services prescribed by a physician who helps the home health care agency set up a care plan for patients who require part-time skilled nursing care or physical speech, or occupational therapy. Care must be provided by a Medicare-approved agency to patients confined to home because of injury, illness, or other medical condition, in order to maintain the condition slow its deterioration.
Chronic Condition/Disease: A chronic condition/disease lasts one year or more, limits activities of daily living, and/or requires on-going medical attention. It can be controlled, but not cured. While chronic diseases/conditions are often preventable, and most can be effectively managed, they are among the health care system’s most costly health problems.
Information Technology: anything related to computing technology, such as networking, hardware, software, the Internet, or the people that work with these technologies. In healthcare, it is the supporting infrastructure, software, and methodologies by which information is gathered, processed and analyzed in order to create new information for clinical decision support.
Telehomecare: The home delivery of healthcare services to patients using telecommunications technologies that capture patient clinical status measurements to enable and facilitate timely education, information dissemination, social, emotional and self-care support, as well care management by a healthcare professional at an external site or unscheduled home visits based on need. Messaging, voice, and/or video technologies may be employed.
Multiple Chronic Conditions: MCC is defined by the National Quality Forum’s Draft Report on Multiple chronic conditions Measurement Framework as “…two or more concurrent chronic conditions that collectively have an adverse effect on health status, function, or quality of life and that require complex healthcare management, decision-making, or coordination.” MCC afflict about 25% of the US population and about 50% of those 65 years of age and older.
Telehealth: The delivery of health-related services and information using telecommunications technologies. Telehealth includes education, medication management, health and wellness promotion, and health management, especially in chronic diseases where home monitoring of physiologic parameters can detect changes in patient status in order to facilitate timely correctional and/or preventative interventions.
Telemedicine: The use of telecommunication technology to move data in order to facilitate health- and healthcare-related education, care, diagnosis, mentoring, management and research over distance. As defined by the American Telemedicine Association: “…the use of medical information exchanged from one site to another via electronic communications to improve a patient’s clinical health status. Telemedicine includes a growing variety of applications and services using two-way video, email, smart phones, wireless tools and other forms of telecommunications technology.”
Remote Monitoring: Uses technology to enable real time evaluation of patient clinical status by patients themselves and their clinical providers, outside conventional clinical settings (home, work, school, travel). Ideally, it uses wireless technologies to function in mobile environments. It enables patient self-management and timely clinician interventional and/or preventative management.