Kayla Brodkin MDDepartment of Gerontology and Geriatric

MedicinePuget Sound Veterans Administration Health

Care System

Questions to ponder…..

• What do I expect this course to be about?

• What skills do I hope to acquire during this rotation?

• How will the skills I learn from this course help me to become a more complete physician?

• What is chronic care-and why do I care?

What is Chronic Care and Why Do We Care Anyway?

• Demographic estimates 99M Americans live with chronic illness, most with >1 chronic illness, 88% of >65y have >1 chronic disease, 25% of which have >4

• Projections of increased complexity of care in future

• Aging and improved medical therapies contributing to increased prevalence, severity and complexity of chronic disease in US

• Chronic illness accts for 75% national health care costs

Chronic Disease: the transformed patient

• Requirements for continuous care management

• Continuity of care becomes cornerstone in management

• Self-management increasingly required• Patient education key to promoting

autonomy, responsibility and self-advocacy

• Caregiver support increasingly important

Acute v Chronic Medical Care

Acute CareEpisodicCurativeHierarchical (Doctor->patient)

Single care providerSingle site of care

Outcomes: evidence

Chronic CareContinuous/dynamicNon-curativeCo-managed (doctor<->patient)

Expanded care model (case-management/multidisciplinary team)

Expanded sites of care and mode f/u

(hospital/clinic/snf/AFH/Asst Living/home: telephone/email)

Evidence supports improvedmorbidity/mortality/

satisfaction/QOL/cost

Chronic Diseases

• HTN• DM• CHF• OA• COPD• Cancer• Mental Health Illness- depression/ dementia/

psychosis etc• Chronic Infectious Diseases: HIV/AIDS,

Hepatitis

Changing Demographics in America

Traditional Approach

Clinical Presentation ->DDX ->Testing->

Dx ->Therapeutics -> Add’l Testing ->Outcome

Traditional Approach

Clinical presentation ->DDX ->Testing->Dx->Therapeutics->Outcome

hx

Cough Infection CXR PNA ABX Resolution

Dyspnea Ht Failure CBC

COPD sputum

phys findings

Rhonchi

Wheeze

Fever

Chronic Care Approach

Community resources

Social Supports

Education Economic resources

Psychiatric Comorbity

Spirituality/personalvalues

Medical Comorbidity

FunctionQuality of life

Chronic Care Approach

Increased Complexity- medical/psychosocial

Interdependent variables

Patient expectations and values (autonomy)

Requires individualized approach

Multidisciplinary

Resource intense

Chronic Care Model (Wegner ’96)

• Model of primary care for chronic illness• Improve management and outcomes• Group Health Cooperative- novel

modalities for management diabetes• Requires rethinking of practice

– Involves entire community (include resources) and policies (public and private)

– Healthcare system (including payment str)– Provider organization

Chronic Care Model: The Evidence

• DM Improved measures of disease control (HgA1C)

• CHF Decreased hospitalizations/Cost of care

• Asthma Decreased hospitalization/cost

A Case: 90 yo hospitalized with ACS s/p stent placement whose hosp complicated by delirium and chf now ready for

discharge:

MealsOnWheelsAccess transportation

Niece/nephew (2)Live 20 mi from pt

Provide IADL supportWhen available

IntelligentAble to follow directions

Small pension SSI

(not medicaid eligible)

No Psychiatric dx

Lutheran backgroundSelf-reliance

CHF DM- (p. neuropathy)

Falls (walker)

PVDHearing

(diff with phone use)BPH (self cath)

Independent Living, (ADL)/ requires help

IADLS

Chronic Care Team• MD- managed medical aspect of care, medications, consulted

hospital resources (anticoagulation team, VNS) and arranged for medical follow-up

• Social Worker- developed strategy for discharge to bridge community resources (VNS, MOW), enlisted family support, arranged transportation (discharge, resume Access), facilitated lifeline

• Physical Therapist- assessed falls risk gait/station developed plan for strengthening LE and maintenance, arranged for

home safety evaluation, issued equipt for home use • Occupational Therapist- assessed ADLs, provided equipt for

home use (energy conservation)• Pharmacist- assessed meds for potential interactions, provided

mediset• Nurse- homecare visit to f/u sx, phlebotomy, fill medisets and

evaluate compliance, communicate with PCP and rest of care team

Issues for consideration

• Patient preferences• Functional status- newly acquired

weakness (decreased ability to transfer and toilet w/o help) permanent v transient

• Availability of social supports• Patients ability to manage own symptoms• Availability of additional resources• Safety of returning to previous living

situation

Case

• Pt preference to return home to independent living

• Weakness and ADL deficiency addressed by rehabilitation effort (10 d subacute stay TCU)

• Anticoagulation and cardiac meds monitored by home care nursing (VNS)– Mediset provided, home venipuncture, sx surveillance

• Enhanced involvement of family• Issuance of life-alert system for safety

Questions to ponder…..

• What do I expect this course to be about?

• What skills do I hope to acquire during this rotation?

• How will the skills I learn from this course help me to become a more complete physician?

• What is chronic care-and why do I care?

SUMMARY 1My definition of what chronic care is about…

• Chronic care is an approach to the ongoing care of a patient with incurable, perhaps life-limiting disease that integrates healthcare modalities to understand, support and facilitate an individual’s functional potential and quality of life that is attainable and consistent with realistic personal goals.

Summary 2

• Skills inclusive of:– Obtaining a functional history– Discussing ‘bad news’ with patients and their families – Participation as a member of a multidisciplinary team– Comprehension of community services and

alternative living situations for patients with chronic illness

• And provide– Opportunity to participate, listen and reflect

Summary 3My answer to why I care:

• Chronic illness is ubiquitous, ever increasing and realignment of healthcare resources to address the magnitude and impact of chronic illness on healthcare delivery and cost in particular and society in general is urgent