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OCR for page 27
- ~
Chronic Care: Reducing the Toll of
Chronic Conditions on
Individuals and Communities
SUMMARY DESCRIPTION
Demonstration projects in this category are intended to improve the quality of care for individu-
als with one or multiple chronic conditions in a particular geographic area. The projects are expected
to result in changes at two levels: (~) redesign of the delivery system to provide care that is ongoing,
is coordinated across multiple providers (both acute and Tong-term care providers and social
services), and supports patient self-management; and (2) implementation of community-wide educa-
tional and other initiatives designed to improve population health. Changes in both areas will involve
extensive use of 2ISt-century information and communications technology (ICT).
The committee suggests that demonstrations initially focus on Medicare beneficiaries, with the
objective of expanding to all payers and even the uninsured over time. These demonstrations would
be community-based (although some may be state-wide or even multistate efforts). Regardless of the
geographic area, state collaboration would be important because many Medicare beneficiaries are
also eligible for Medicaid. The Department of Health and Human Services (DHHS) would issue a
Request for Proposals (REP), and a limited number of demonstration sites (10-12) would be selected
from the applicants Applicants might be a consortium of providers (e.g., medical groups, hospitals),
a health plan, an academic health center, a professional or trade association, or other establishecl
health care organization. Each selected applicant would receive a 1-year planning grant to accom-
plish two objectives: establishment of a public-private partnership and development of a 3-year
implementation plan. The public-private partnership should encompass all major stakeholders,
including consumer groups, health care professionals, health care and social service organizations,
the public health community, state government, and others.
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~ Chronic Care
The demonstration projects would be
4 years in duration (including the 1-year plan-
ning period). Measurable improvements in care
delivery should be achieved within 2 years.
Over the long haul, the objective is to achieve a
lessening of chronic illness burden in a commu-
nity. These demonstrations are intended to be
budget neutral over the long term (exclusive of
up-front federal capital investments in ICT).
BACKGROUND
A chronic condition is defined as "a condi-
tion that requires ongoing medical care, limits
what one can do, and is likely to last longer than
one year" (Partnership for Solutions, 2002a,
p. 1~. An estimated 120 million Americans have
one or more chronic conditions; more than half
of these people have multiple such conditions.
People with chronic conditions account for the
majority
Chronic illness affects all age groups and also
leads to reduced worker productivity and lost
of overall health care spending.
time from school for children (National Acad-
emy on an Aging Society, 20004. Some chroni-
cally ill patients have inadequate or no health
insurance, and these individuals receive less
care and have higher out-of-pocket expenditures
than they should (Partnership for Solutions,
2002b).
Some patients with chronic conditions
experience disability and functional limitations
(e.g., hearing loss, visual impairment, loss of
mobility), including cognitive impairment and
other geriatric syndromes that severely under-
mine quality of life and pose a threat to inde-
pendence. The 5 million Medicare beneficiaries
who are under age 65 and disabled fall into this
category, as does an increasing proportion of
over-65 Medicare beneficiaries, sometimes
referred to as the "frail elderly" (Gluck and
Hanson, 2001) (see Table 2-1~.
These individuals require ongoing treatment
of a specific diseased), but this treatment is not
sufficient. C are fu] management of geriatric
TABLE 2-1 Prevalence of Chronic Conditions, Disability, and Functional Limitations
Age 65-74 75-84 85+
None ofthe Three Problems I 17% 10% 4%
Chronic Conditions Only
Disability Only
Functional Limitations Only
Any Two of the Three Problems
5 1%
37o/o
17%
2.1% 2.1% 3%
0.4% *
22%
32%
32%
AH Three Problems
8% 1 9% 44%
SOURCE: Partnership for Solutions, Johns Hopkins University analysis of 1996 Medical Expenditure Panel
Survey, unpublished data; also in American Association of Retired Persons (2002~.
~ ~~ _ ~ . , ~ ~ ~ ~ ~ ~ ~ ~ . . ~ . . . . .
I
no
NOTE: This table makes use of the following definitions to estimate the prevalence of three types of health
problems chronic conditions, disability and functional limitations. Chronic condition has lasted or is
expected to last 12 months or longer and either (1) involves ongoing medical care or (2) places limitations on
age-appropriate task performance, basic self-care, independent living skills, or social interactions. Functional
limitation- the need for help or supervision with any activities of daily living or instrumental activities of daily
living. Disability includes any one of the following characteristics: (1) the use of assistive technology; (2)
difficulty walking, climbing stairs, grasping objects, reaching overhead, lifting, bending or topping, or standing
for long periods of time; (3) any limitation in work, housework, or school; (4) social/recreational limitations;
(5) cognitive limitations, such as confusion or memory loss, or decision-making problems that lead to interfer-
ence with daily activities or require supervision to ensure one's safety; (6) vision problems; and (7) dearness or
difficulty in hearing.
. ~ . . ~ ~ . .
OCR for page 29
Chronic Care
syndromes (e.g., cognitive decline, lack of resil-
ience, undernutntion, loss of mobility) and
attention to the patient's social and environ-
mental circumstances are needed to preserve
maximum levels of independence and slow the
progression of disability (Buchner and Wagner,
1992; Welch et al., 1996~.
For many with chronic conditions, navigat-
ing the complex health care system can be
difficult, sometimes even distressingly so. The
chronically ill typically require care from multi-
ple clinicians (both primary care providers and
specialists) and across multiple sites (e.g.,
hospital, nursing home, in the community with
or without home care), and this care is generally
not well coordinated. Moreover, in the current
highly decentralized, paper-driven health care
system, clinical information (e.g., diagnoses,
test results, medications, specialty consults) is
frequently unavailable when needed.
The chronically ill experience many prob-
lems with access to care and avoidable compli-
cations of care. In a recent survey of chronically
ill individuals, about three of four respondents
reported difficulty with obtaining medical care;
specifically, many experienced difficulty getting
care freon a primary care physician (72 percent)
or a medical specialist (79 percent), as well as
obtaining prescription drugs (74 percent)
(Partnership for Solutions, 2002c). Nearly 20
percent of Americans report problems commu-
nicating with their clinicians (Collins et al.,
2002~. The lack of coordinated care results in
chronically ill people receiving inconsistent and
contradictory information and experiencing
many avoidable complications (Partnership for
Solutions, 2002a, 2002c). All of these problems
are likely exacerbated for those chronically ill
who are disabled, frail, and/or have cognitive
impairments.
devoted to direct medical care services, mainly
for the treatment of people with chronic
diseases (McGinnis et al., 2002~. Very few
resources are devoted to reducing the unhealthy
behaviors that currently contribute to about 40
percent of deaths in the United States
(McGinnis et al., 2002), including poor dietary
habits, lack of physical activity, smoking, and
excessive alcohol consumption.
The health care delivery system must take
greater responsibility for promoting healthy life-
styTes. The personal health care system has a
role to play in educating individual patients and
providing supportive interventions (e.g., coun-
seling, nicotine patches), but the personal health
care system reaches only those who seek health
services, many of whom have already suffered
serious and irreparable damage as a result of
poor health behaviors. Broader-based interven-
tions are needed to reach the entire population
of a community before harm has occurred.
It is unrealistic and inefficient to expect
providers acting individually to address all
population concerns. They do not have the
financial resources, incentives, or expertise to
do so. Some health plans have attempted to
focus greater attention on the prevention of
chronic diseases for their members, but many
people are not enrolled in comprehensive health
plans. In many communities, moreover, the
frequent turnover of enrollees attenuates incen-
tives to focus on interventions that can produce
substantial long-term benefits in terms of
improved health status. Collaborative commu-
nity-wide efforts are needed, as are specific
interventions to align provider financial incen-
tives in ways that reward the provision of high-
quaTity care.
Improving care for people with chronic
conditions must be a high priority, but improved
care alone is not enough. The health care system
must focus far more attention and resources on
community-wide interventions aimed at
preventing or at least slowing the onset and
progression of these conditions. About 95 per-
cent of health care expenditures is currently
GOALS
The primary objective of the demonstration
projects in this category is to improve the
quality of care provided to the chronically ill
and to reduce the burden of disease and disabil-
ity in a community. Specific goals include the
following:
[~1~
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f Chronic Care
1. The right care at the right time in the right
setting
State-of-the-art, science-based care for
the patient's condition or conditions
Elimination of underuse (i.e., the failure
to provide services from which the
patient would likely have benefited) and
overuse (i.e., the provision of services
that expose patients to more harm than
good)
Emphasis on primary, secondary, and
tertiary prevention
Enhanced management and coordina- 6. Improved coverage
tion of chronic conditions (e.g., ease of
access to appropriate providers)
2. Improved patient safety
Decrease in errors
Decrease in avoidable hospitalizations
Improved medication management
3. Enhanced patient role and satisfaction
Promotion of shared responsibility for
health (e.g., support for healthy behav-
-iors and lifestyles)
Improved self-management of chronic
conditions
Increased health literacy and under-
standing of care plans
Informed decision making
j:
,,
Improved communication among team
members and between patients and
team members
Shared values and goals among team
members
Increased satisfaction on the part of
health professionals
5. Reduced clinical waste
Decrease in overuse
Reduced use of services to treat compli-
cations arising from errors
Improved satisfaction of patients and
informal caregivers (including manag-
ing burden and providing respite for
informal caregivers)
Customized care not one size fits all,
but care that takes account of patient
preferences, culture, family circum-
stances, and needs
4. Enhanced workforce productivity
Development of effective multidiscipli-
nary teams
More appropriate benefit package for
the chronically ill (e.g., coverage of
prescription drugs, educational and
support services)
Coverage of benefits for which there is
evidence to substantiate effectiveness
Coverage for some chronically ill indi-
viduals who otherwise would have been
uninsured
7. Establishment of a strong public-private
partnership
Healthier community measurable
decrease in the incidence of chronic
conditions and the associated disease
burden
Improved capabilities at the state and
community levels to address health care
issues and to collaborate and invest in
health system improvements
DEMONSTRATION ATTRIBUTES
It is anticipated that demonstration projects
in this category would focus initially on a subset
of Medicare beneficiaries, perhaps those with
one or more conditions requiring intensive
ongoing management. Over time, however, the
projects would expand to include all of the
chronically ill. Demonstrations would include
interventions falling into two broad categories:
(1) redesign of the personal health care delivery
OCR for page 31
Chronic Care
system, and (2) establishment of community-
wide health promotion initiatives. Initially' most
attention will likely be focused on the first
category. Over time, the demonstration sites
should shift attention and resources to the
second category, which has much potential to
reduce the burden of chronic illness in a
community.
In the area of personal health care, demon-
stration sites would be expected to establish
comprehensive chronic care management
programs including the following elements:
.
Evidence-based treatment programs for all
of the leading chronic conditions that affect
the population being served. Many
individuals involved in the demonstration
project will have more than one condition
requiring active management.
Services to detect and minimize the conse-
quences of geriatric syndromes, including a
decline in cognitive (e.g., Toss of memory)
and physical (e.g., visual Toss, hearing
impairment) functioning.
.
.
..
Services to meet the preventive, acute, long-
term care, and other health care needs of
patients with chronic conditions.
Extended outreach and coordination with
social and environmental services, provided
through formal (e.g., meals on wheels,
senior centers, transportation services,
assisted-living environments) and informal
(e.g., faith-based institutions, family and
friends) means.
With regard to population-level health inter-
ventions, prevention and management of
chronic conditions often involve modifications
in behavior (e.g., proper diet, exercise, avoid-
ance of nicotine, moderate use of alcohol)
Community-wide educational campaigns and
other popuiation-leve! interventions may be the
most effective way of accomplishing these
objectives.
Each demonstration project would involve
five components: (~) establishment of a coordi-
nating structure (or strengthening of an existing
one), (2) development of chronic care manage-
ment programs, (3) ICT support, (4) innovative
approaches to payment and to recognizing and
rewarding achievement, and (5) learning
collaboratives and community-wide educational
efforts. These components are discussed in turn
below
Establishment of a Coordinating
Structure
As discussed above, demonstration projects
In this category are intended to lead to the estab-
lishment of exemplary chronic care manage-
mentprogramsforindividualsandcommunity-
wide initiatives focused on improving popula-
tion health. Accomplishing these objectives will
require new structures that extend beyond the
traditional personal health care delivery system.
During the first year of the project, grant
recipients would be responsible for establishing
a broad-based coordinating structure with
participation from all important stakeholders,
including consumer groups; the medical
community; hospitals; health plans; the public
health community; local, state, and federal
governments; the business community; and
others. This coordinating structure should have
(or develop) the capability to (~) provide strong
leadership for the demonstration, (2) work with
providers to organize chronic care management
programs, (3) develop necessary ICT infrastruc-
sure, (4) implement payment and quality moni-
toring programs, and (5) provide knowledge
management support and sponsor learning
collaboratives.
The committee recognizes that 1 year is an
ambitious time frame for building a coordinat-
ing structure, and encourages DHHS to consider
selecting sites where some form of coordinating
structure already exists. For example, a collabo-
rative effort aimed at achieving sizable
improvements in cancer care has been estab-
lished in the state of Georgia (Georgia Cancer
Coalition, 2002), and a diabetes initiative is
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~ Chronic Care
under way in New York State (IDEATel, 2002~.
In other communities, an initial grant recipient
may be an academic health center, a consortium
of providers, or a professional or hospital asso-
ciation with the potential to provide leadership
and a commitment to establishing a broader-
based structure; in these instances, however, the
planning phase may need to be longer.
In communities where medical groups,
health plans, or other providers have developed
or are seeking to develop chronic care manage-
ment programs, such programs might serve as a
strong foundation for broader community-wide
efforts. The Centers for Medicare and Medicaid
Services (CMS) also has disease management
and coordinated care demonstration projects
under way that focus on improved care delivery
for specific beneficiaries through changes in
payment, benefits, and organization of care
(Centers for Medicare and Medicaid Services,
2002; U.S. Depatlt~ent of Health and Human
Services, 2001~. These efforts, too, might repre-
sent a strong foundation for a more expansive,
community-wide effort. These types of health
care delivery programs alone would not qualify
as a demonstration. However, they might well
constitute the first step toward establishing
community-wide efforts with the capacity to
provide coordinated health and social services,
as well as community-wide educational and
public health campaigns, and to cultivate a
learning environment with the potential to
contribute to greater health care redesign within
a community (and ultimately nationwide).
;-
During the first year, grant recipients would
also be responsible for developing a comprehen-
sive plan for the 3-year implementation phase of
the project. This planning effort should result in
a detailed operational plan specifying the
patients to be enrolled, services to be provided,
subcontracts to be initiated with vendors, cTini-
cians and institutions to be involved, payment
mechanisms, and community outreach and
educational endeavors. If waivers from various
state or federal regulatory requirements will be
required (e.g., waivers from states' licensure
requirements for health professionals to enable
telecommunications services across a two-state
32
demonstration project, or waivers from state
scope-of-practice acts to allow for multidiscipli-
nary team management), these should be identi-
fied and secured within the first 12 months.
Strong leadership will be critical to the suc-
cess of all the demonstration projects given the
profound cultural and organizational changes
that must occur within the health care commu-
nity. There should also be a willingness on the
part of health care professionals and organiza-
tions to develop new relationships, especially
ones that go beyond the boundaries of the tradi-
tional medical care system. The mission and
operations of health care organizations would
need to reflect a greater commitment to both
individual health care and population health
initiatives. In many communities, health care
providers would need to strike a new balance
between collaboration and competition. It would
be the responsibility of the leadership of the
coordinating structure to identify cornmunity-
specific barriers and to identify solutions (e.g.,
establishing coordination across insurance
plans, forging relationships between existing
disease management programs and the overall
chronic care initiative).
Development of Chronic Care
Management Programs
Unlike much acute, episodic care, effective
care for the chronically ill is a collaborative
process, best carried out through a systematic
approach (don Korff et al., 1997~. Wagner et al.
(1996) have identified five important elements
of chronic care programs:
.
Eviblence-base~l, planned care Guidelines
and protocols applicable to each of the lead-
ing chronic conditions that affect the popu-
lation being served must be incorporated
into practice.
Multidfisciplinary team approach—Delivery
of care is generally through a multidiscipli-
nary team (both health and social services)
with well-def~ned relationships and respon-
sibilities. Members of the team must have
OCR for page 33
Chronic Care
flexibility in allocating time and resources
to meet the needs of each patient for educa-
tion and support.
.
.
.
:-
Patient information There must be
systematic approaches to providing counsel-
ing, education, information feedback, and
other support to patients (Brown, 1990;
DeBusk et al., 1994; Mullen et al., 1987~.
Clinical knowledge and expertise Both
patients and clinicians should have ready
access to knowledge and specialized exper-
tise through such means as teleconferenc-
ing, referrals to specialists, computer
decision support systems, and collaborative
care models (in which primary care provid-
ers and specialists practice together at least
some of the time) (Barton and Schoenbaum,
1990; Katon et al.' 1995; Litzelman et al.,
1993; McCulloch et al., 1994; Vinicor et al.,
1987~.
Supportive information systems Effective
mechanisms for sharing information among
team members and between patients and
team members (e.g., computer-based
records, registries) are critical. Also helpful
are systems that provide reminders for
preventive care and necessary follow-up,
and track patient compliance with treatment
plans (Dickey and Petitti, 1992; Turner et
al., 1990~.
The coordinating structure would be respon-
sible for working with groups of providers in
the community to organize chronic care
management programs. In nearly all cases,
extensive team building would be required to
forge closer and more collaborative working
relationships among various types of health care
professionals. A high priority should be placed
on designing care processes that are sensitive
and accommodating to the needs of health care
professionals. The greatest success would come
from the alignment of well-designed systems
accompanied by financial and other incentives
to motivate providers. Attention should also be
focused on the design of programs and care
processes that have the potential to reduce
health disparities.
In some communities, disease management
programs sponsored by medical groups, health
systems, or health plans may serve as initial
building blocks. However, the chronic care
management programs in these demonstration
projects are intended to differ Tom typical
disease management programs in several impor-
tant ways. First, these programs are intended to
serve beneficiaries with many different chronic
conditions (and often with multiple conditions),
while disease management programs tend to be
limited to a specific disease. Second, these
programs should provide for all of patients'
preventive, acute, and chronic care needs, not
just services for the treatment of a specific
disease. Finally, those who develop programs
would be required to participate in collaborative
community-wide efforts focused on prevention
and health promotion.
Information and Communications
Technology Support
A major component of these demonstrations
should be the expanded use of TCT to improve
care for the chronically ill. Specifically, ICT
would enable the following improvements:
1. Better communication
Web-based dissemination of knowledge
(relative to both specific diseases and
chronic care management)
Sharing of learning experiences
between patients and clinicians, among
clinicians, and among patients
E-maiT communication between patients
and clinicians and among clinicians
Telemedicine, including the use of
home monitoring devices (e.g., for
glucose monitoring) that transmit
results via the Web
33
OCR for page 34
i Chronic Care
Provision of Web-based reminders
(e.g., for flu shots, physical activity, and
diet) to patients and clinicians
Electronic health risk appraisal and
feedback reports
Ongoing patient communication with
support groups
Electronic access to patient records
(as information becomes computerized),
with appropriate safeguards for patient
confidentiality
2. Chronic care registries
Central repository for patients' care
plans and other important health, cTini-
cal, and service information
Patients' access to their care plans in
hart/copy or electronic form
Real-time access to all information in
the repository by patients and their
providers to improve coordination and
care delivery
3.
Tracking and monitoring of patients'
progress
.
Medication order entry systems-
computerized prescriptions with centralized
repository of information for patients
4. Creation of a "paperless" clinical environ-
ment
Reporting of results from laboratories
and imaging centers
Consults with specialists
Emergency encounters
Clinicians notes
5. Advanced decision support systems for
clinicians and patients
34 11
All demonstrations should involve major
advances in the first three areas listed above
during the 3-year project.
Some consideration should also be given to
building on efforts already under way. Potential
applicants that have already made progress in
the first three areas would be expected to
develop more advanced ITC capabilities in the
last two areas above during the demonstration
period. There might also be some opportunity to
transfer the knowledge and technology devel-
oped in a specific location to new demonstration
projects starting up in other locales.
One example of an initiative already under
way is the diabetes telemedicine collaborative in
New York State (IDEATel, 2002~. This project
is led by Columbia University and includes
several major medical centers, hospitals, and a
home for the aged located in New York City
and upstate New York; CMS; and the American
Diabetes Association. CMS has provided a $28
million grant in support of this project, and vari-
ous commercial vendors have made in-kind
contributions, including home monitoring
equipment and high-speed Bernet lines. A total
of 1,500 patients have been enrolled in this
randomized controlled teal; one-half are in the
intervention group and the other half in a
control group. Computers with devices that read
blood sugar, take pictures of skin and feet, and
check blood pressure are placed in the homes of
those in the intervention group. Patients are
responsible for checking their blood sugar,
blood pressure, and other factors. They receive
educational material on diabetes and specific
recommendations, reminders, and instructions
for managing their disease. The program builds
on Columbia University's Web-based clinical
record technology and uses an automated care
guideline system to analyze patient data and
issue automated alerts to clinicians when certain
information varies from predetermined values.
Patients have access to their own clinical infor-
mation.
Development of this TCT infrastructure
would likely take place in phases over the dura-
tion of the demonstration, but there should be a
comprehensive plan and timeline for the devel-
opment and deployment of various capabilities.
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Chronic Care
Innovative Approaches to Benefits,
Copayments, Provider Payment, and
Accountability
Initially, these demonstration projects
should focus on Medicare beneficiaries. Each
site would establish eligibility criteria for
participation in its demonstration project (e.g.,
beneficiaries with one or more of the five most
common chronic conditions). Some sites may
prefer to include all beneficiaries with chronic
conditions from the beginning, while others
may wish to start with a smaller subpopulation
and expand at a later date.
A major component of all of the demonstra-
tion projects in this category would be the flexi-
bility to innovate in such areas as benefits
coverage, beneficiary copayments, provider
payments, and accountability. Careful design,
ongoing evaluation, and sharing of learning
experiences in these areas of program design
would be critical.
Within the overall constraint of budget
neutrality, demonstration sites should be given
the flexibility to use Medicare funds in ways
that would yield the greatest benefits in terms of
improved patient and population health. One
financing approach would be for CMS to
provide the coordinating structure, with a capi-
tation payment to cover all the care needs of the
participating patients (i.e., preventive, acute,
and chronic care). The coordinating entity
should have the flexibility to provide the
expanded benefits necessary for chronic care
management.
Regular Medicare does not cover certain
services that are often important for care of the
chronically ill, including patient education and
support, telemedicine (e.g., e-mail, home moni-
toring), and prescription drugs. For example, it
may be possible through the coverage of
prescription drugs and frequent monitoring of
patients via e-mail to decrease office encounters
and hospital episodes. In establishing an appro-
priate capitation payment rate for a demonstra-
tion site, CMS should strive to achieve budget
neutrality and to correct geographic inequities in
payment. The committee cautions CMS not to
attempt to address cost concerns by setting capi-
tation rates at levels that are unreasonably low
or below current fee-for-serv~ce (FFS) expendi-
ture rates. Participation of health plans in Medi-
care + Choice program, which also uses capi-
tated payments, has been declining and this may
be because payment rates are lower than FFS
expenditures and these plans are expected to
provide enhanced benefits. CMS might also
consider establishing a national payment rate for
chronic care demonstration sites, with a
geographic adjustment for differences in the
cost of practice. This would correct for
geographic variability in payment rates that is
not tied to differences in cost of practice.
The coordinating entity in each demonstra-
tion site would be responsible for (~) determin-
ing the amount of funds to be used for commu-
nity-wide prevention and other initiatives, and
(2) establishing payment methods for chronic
care management programs. It would be impor-
tant for each demonstration site to establish
robust cost accounting systems at the level of
both the coordinating entity and the providers of
care.
Demonstration sites would be encouraged to
experiment with various provider payment
methods, especially ones that reward perform-
ance achievement. Numerous options have been
identified for motivating providers to improve
their performance (Bailit Health Purchasing,
2002~. For example, a capitation payment to a
chronic care management program that enrolls
beneficiaries with diabetes might be contingent,
in part, upon achievement of certain predeter-
mined performance thresholds (e.g., more than
85 percent of beneficiaries have had an annual
eye and foot exam; 75 percent have LDL
cholesterol levels below 100; less than 20
percent have hemoglobin Ale above 8~. An-
other option is to provide chronic care manage-
ment programs with annual bonuses (e.g., 2-5
percent of capitation payments) based on
achieving certain performance goals. Each
demonstration site should also ensure that
payments to providers are properly risk-adjusted
to reflect the more extensive care needs of the
OCR for page 36
~ Chronic Care
frail elderly, the disabled, and those with multi-
ple chronic conditions.
Demonstration sites should consider provid-
ing stronger incentives to patients to encourage
self-management. To a great extent, patients
play a critical role in the ongoing management
of chronic conditions, which frequently require
major lifestyle changes, including improved
diet, exercise, and smoking cessation. Patient
incentives might include variable cost sharing,
such as discounted Medicare Part B premiums
for those who follow care plans. Of course, all
chronic care management programs should
provide patients with the tools and medical and
social support necessary to encourage healthy
behaviors.
Demonstration projects should engage in
various foes of public reporting of progress
and quality data. Each demonstration ~roiect
should produce a progress report describing
programmatic accomplishments. Each project
should also be accountable to the public for
showing improvements in the functioning and
satisfaction of the chronically ill enrolled in the
program, and over the long run, reductions in
the state-wide (or community-wide) incidence
and prevalence of chronic conditions. Demon-
strations might also involve public reporting of
comparative performance information on organ-
ized chronic care management programs and
providers. Although much of the focus of the
chronic care demonstrations should be on redes-
igning care delivery, the committee believes
these efforts would be more effective if under-
taken in an environment that provides ongoing
feedback to clinicians and patients.
provide special knowledge management assis-
tance to demonstration sites in the form of
syntheses of the evidence in selected areas,
special chronic care Web sites for clinicians and
patients, and a rapid response system for key
clinical or treatment questions that might arise
during the demonstration project.
DHHS, in collaboration with private foun-
dations, should ensure that each demonstration
site has the resources necessary to establish a
state-wide learning collaborative for clinicians
involved in the care of patients with selected
chronic conditions. In such collaboratives,
participating members would commit to com-
mon goals and related performance measures
for improving chronic care. DHHS should also
provide resources needed to sponsor public
education efforts targeted at both consumers and
clinicians, with an emphasis on primary preven-
tion, early identification, and slowing of the rate
of progression of chronic diseases. Special
attention should be focused on cultivating
Learning Collaboratives and
Community-Wide Educational Efforts
Each demonstration project should include
efforts to assist clinicians and patients in gain-
ing access to scientific knowledge, practice
guidelines, certified protocols, identified best
practices, and decision support tools. Some con-
sideration should be given to whether the
National Library of Medicine and the Agency
for Heaithcare Research and Quality might
36 i~
patient- and clinician-led quality improvement
efforts. The Robert Wood Johnson Foundation
is providing support for a limited number of
regional chronic care learning collaboratives,
and there might be an opportunity to build on
this synergistic effort already under way
(Improving Chronic Illness Care, 2002~.
POSSIBLE DEMONSTRATION
EXPANSIONS
Although the primary focus of these demon-
strations is on Medicare beneficiaries, all
demonstration projects should have a tentative
plan from the beginning for expansion beyond
Medicare to other public and private payers.
The structures and programs developed by the
demonstration projects are intended to benefit
all people in the community both those with
chronic conditions and those without who might
delay or avoid the onset of such conditions
through primary prevention. It is also important
to note that many people with chronic contli-
tions are covered by more than one insurance
program (e.g., dual eligibilities under Medicare
and Medicaid) or will move from one insurance
OCR for page 37
Chronic Care
plan to another dunng the course of a project
with changes in eligibility status (as regards age,
income, and employment). The goal is to
develop community-wide care delivery
programs and supports that are available to all
people, thus minimizing or avoiding some of the
disruptions in care delivery and patient-
clinician relationships that often result from
. .
c nanges In Insurance coverage.
Some demonstrations might also expand
beyond insured populations to provide coverage
or services to certain uninsured individuals
(e.g., uninsured cancer patients). Studies consis-
tently document that sizable amounts of health
care resources represent overuse (i.e., about 20
to 30 percent of patients receive services that
expose them to more potential harm than good)
(Schuster et al., 1998~. Medical errors, another
type of quality problem, also consume health
care resources resources used to treat those
who are harmed as a result of those errors. One
objective of some of the demonstration projects
in this category may be to identify ways to
remove "quality waste" (i.e., overuse and
errors) from the system, and redistribute these
resources to care of the uninsured (who
frequently experience underuse, whereby
patients do not receive services from which they
would likely have benefited). DHHS and state
governments should also consider providing
grants or other financial incentives to encourage
demonstration expansions aimed at the unin-
sured.
Although such expansion to all payers and/
or the uninsured would be difficult for most
demonstration sites to accomplish within the
4-year demonstration time frame, it may be
possible to identify some sites that have already
taken steps in this direction and to build quite
rapidly on these previous accomplishments. For
example, an initiative in Maine Healthy
Future Partnership for Quality is now in its
5th year (Healthy Futures and the Maine Center
for Public Health, 2002~. This community-based
health reform initiative serves six small towns
in central Maine. Patients enrolled in the
program include both insured and uninsured
individuals, with services for the uninsured
being covered by a I O percent surcharge on the
fee for each insured participant. The surcharge
is paid by the participating insurers, which
include Anthem Blue Cross/Blue Shield, Cigna
HealthCare, MaineCare (the state Medicaid
program), and Hannaford Brothers. Thus far,
the initiative has focused on patient education
(regarding health behaviors, prevention, and
disease management) and improved access to
primary care and preventive services.
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Representative terms from entire chapter:
chronic conditions
