Thursday, January 26, 2012

#CISummit Chronic Disease Management moderated by @atul_gawande


Panel 2

Care Delivery/Chronic Disease Innovation Case Study

Moderator: Atul Gawande, MD, MPH

Surgeon, Writer, Public Health Researcher 

Kenneth Coburn, MD, MPH

Chief Executive Officer and Medical Director, Health Quality Partners (HQP) 

Alan Hoops

Chairman and Chief Executive Officer, WellPoint/CareMore 

Debbie James

Vice President, Healthways Fitness Division, Healthways 

Mary Naylor, PhD, RN

Professor in Gerontology, University of Pennsylvania School of Nursing
How do we care for patients that normally slip through the net.

Debbie James - HealthWays

Physical Activity improves health. Silver Sneakers Fitness Program. Better health at lower cost for seniors.

46% of participants in the program have never been into a fitness center.

Engagement - get them there... keep there.

Access and Variety are important factors. 

Need access (within 5 miles)

Create community - Social is important.

Customize programs for older adults. Make them comfortable and take away fear of the unknown.

Program leads to better health at lower costs.

23-37% lower cost for silver sneakers members.

9M Medicare Advantage and Medicare Supplement Program members have access to Silver Sneakers.

Ken Coburn - Health Quality Partners

Community-based care management.

Aim: improve health, independence and reduce suffering of chronically ill older adults.
 Focus on preventive services.

Person-centered model. A long haul relationship.

Run in parallel with Primary Care Providers.

200 Performance measures used internally.
35 Nurse interventions.

"A High contact sport"

9 year program..

Looking for technology partners to develop program further. 

Mary Naylor - U of Penn School of Nursing

The Transitional Care Model - A 20 year old model. 
Nurses as hub of a care giving model.

A huge opportunity in community-based organizations to get seniors back on their feet. 

We have know since 1999 that this program works Shame on US Health Care! Surely a lawyer is going to take a class action suit against the medical community.
Scale TCM across the system
Deploy TCM workforce
Improve and Sustain....

Data driven quality improvement.

Alan Hoops - CareMore

50% of members in special needs plans.

Address chronic diseases and conditions.

A platform that looks for system breakdowns and replace with something that works.

50% reduction in hospitalization amongst dialysis patients. Simply by placing case managers in the dialysis unit. Divert to appropriate care instead of defaulting to ER visits.

Chronic Care management
Episodic Care management 
Predictive modeling and intervention

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