CRITICAL SKILLS FOR OPTIMUM PATIENT CARE: Care Coordination and Health Literacy

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1 Thursday, August 20, 2015 CRITICAL SKILLS FOR OPTIMUM PATIENT CARE: Care Coordination and Health Literacy Contributors to the Presentation: Steven A. Estrine, PhD, President & CEO Loan Mai, PhD, Director of Population Based Health Management John A. Darin, CASAC, BBA, Consultant Maria (Sam) Josepher, MPA, Consultant

2 Risk in Population Health: Chronic Disease World Health Organization (WHO), World Health Report: Chronic disease is the leading cause of death and disability. Disease rates are increasing, globally across regions and socioeconomic class. Mortality, morbidity and disability due to major chronic diseases account for 60% of all deaths and 43% of all global disease burden. By 2020, it is expected to rise to 73% of all deaths; 60% of all disease burden. In developing countries, 79% of all deaths are due to chronic diseases.

3 Risk in Population Health: Disease Burden Four chronic diseases with the highest global burden of cost: Cardiovascular diseases (CVD) Cancer Chronic obstructive pulmonary disease Type 2 diabetes Linked by common and preventable biological risk factors (high blood pressure, high cholesterol and overweight) and related major behavioral risk factors (unhealthy diet, physical inactivity and tobacco use).

4 Risk in Population Health: Disease Burden

5 Re-Defining Care: From Acute to Chronic Care A Care Model Transition: From Acute Care Need to Chronic Care Need Working from an acute care model structured first and foremost to prevent, diagnose and treat acute medical conditions leaves little if any room for the social, psychosocial and behavioral dimensions of chronic illness undervalues the importance of a variety of other key facets of chronic illness care, including the influence of lifestyle factors such as nutrition and exercise in preventing or managing a chronic condition, the likelihood of depression or other mental health issues accompanying a chronic condition. Society of Actuaries How the Current System Fails People with Chronic Illnesses.

6 Re-Defining Care: Complex Care Needs https://www.cms.gov/medicare-medicaid-coordination/medicare-and-medicaid-coordination/medicare-medicaid-coordination- Office/Downloads/Dual_Condition_Prevalence_Comorbidity_2014.pdf

7 Re-Defining Care: Complex Care Needs https://www.cms.gov/medicare-medicaid-coordination/medicare-and-medicaid-coordination/medicare-medicaid- Coordination-Office/Downloads/Dual_Condition_Prevalence_Comorbidity_2014.pdf

8 https://www.cms.gov/medicare-medicaid-coordination/medicare-and-medicaid-coordination/medicare-medicaid- Coordination-Office/Downloads/Dual_Condition_Prevalence_Comorbidity_2014.pdf Complex Care Needs: Cost of Care

9 Costs and Risks of Fragmented Care Fragmented care for complex, chronic care needs can cost more than $4,500 over three years with increased poor adherence to recommended treatment. Patients with multiple providers have a higher risk of gaps in treatment, increased risk of acute care and preventable admissions. Poor coordination / high fragmented care of complex care patients associated with $4,542 more annual spending; and more likely to deviate up to nearly 7% of clinical best practices protocols. Visited specialists 6X more often and twice more PCP visits overall. American Journal of Managed Care. Care Fragmentation, Quality, and Costs Among Chronically Ill Patients. May 14, 2015.

10 Population Health Solution 1: Engagement Care coordination for the full range of behavioral (mental health and substance abuse disorders) and medical needs to improve health status and reduce avoidable hospitalizations and emergency room visits. Care coordination positively impacts treatment outcomes and reduces high cost risk.

11 Comprehensive Care Coordination for Complex Needs Care Coordination will: improve chronic medical conditions; reduce/prevent substance abuse relapse; prevent recidivism and lower incarceration risk factors; provide clinical practice models to ensure fidelity in treatment; and assist in determining value-based payment options.

12 Comprehensive Care Coordination for Complex Needs Techniques for Care Coordination will include strategies for: outreach and engagement; comprehensive assessments; individualized care planning; referrals to community partners; coordination of benefits; real-time data utilization for linkages to care; and leveraging data sharing from all stakeholders (previously siloed)

13 Population Health 2: Retention Health Literacy Impact and Need From the National Assessment of Adult Literacy, only 12% of adults have proficient health literacy. Nearly 9 out of 10 adults lacking the skills needed to manage their health and prevent disease. These adults are more likely to experience health as poor (42%) and lack health insurance (28%); more likely to be linked to higher rates of hospitalization and less frequent use of preventive services. Higher health care cost and poor treatment outcome.

14 Health Literacy: A Leverage in Population Health Outcome for Chronic Disease Management Building knowledge and empowering choice: Health Literacy Using opportunities in treatment retention to work toward adherence with the following: skill-building activities; motivation for health knowledge; and improving self care.

15 Health Literacy: A Leverage in Population Health Outcome for Chronic Disease Management The Health Literacy Program is designed to train your staff to help patients: apply health care information such as nutrition and stress management activities to maintain and promote healthy behaviors; understand procedures and processes that promote illness self-management including office visit appointment keeping, medication use and adherence, and following provider recommendations for diagnostic tests; discern emergency VS non-emergency care; communicate with health care professionals; access and use health care information and community resources, including navigators and pharmacy; identify emerging health problems at the earliest stages; and prevent infection and promote community health.

16 Health Outcome Solution: Care Coordination and Health Literacy Tool The application of care coordination and health literacy to better population health outcome, improve alignment with performance measures and optimal outcome. One patient at a time. We are pleased to announce our new SAE CAREs (Clinical and Resource Experts) Podcast Series! Check out our two podcasts on care coordination and health literacy, now available on saeandassociates.com/podcasts/ featuring John Darin and Maria (Sam) Josepher!

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