Transcript Slide 1

Chronic Disease and Aging
The 21st Century Healthcare Challenge
Howard Bergman, MD, FCFP, FRCPC
Chair, Department of Family Medicine
Professor of Family Medicine, Medicine and Oncology
The Dr. Joseph Kaufmann Chair of Geriatric Medicine
McGill University
17.3.12
Family Medicine
Médecine de famille
The Shifting Face of Health Care
 From acute to chronic disease
 From institutions to networks of care; from a single site (hospital,
nursing home) to many sites: home, assisted living, supportive
housing, physician’s office, community clinics, ambulatory care
centers, community hospitals, academic health centers,
rehabilitation facilities, nursing homes, palliative care centers
 From a single professional, generally a physician to many health
care professionals: family doctors, specialists, nurses, physical
therapists, nutritionists, social workers, psychologists, etc.
 Expectations/knowledge/Involvement of patients and family
The Shifting Face of Health Care
↑ Complexity
↑ Interdependency
↑ Uncertainty
Increasing preoccupation with costs and
performance leading to increased government
intervention/control/reform
 Continuous change
Aging and Chronic Disease
The Challenge for the 21st Century
 Dramatic
increase in the number of old, in
particular old/old
 Increase in prevalence of chronic disease
– 1 in 5 baby boomers will develop dementia
– Cardiovascular: most important cause of hospital admission
– Diabetes: increasing prevalence with age: 10% over 65
– Cancer: increasing incidence and mortality with age
MCSAC
Growth will be greater at older ages …
Index
250
225
200
175
150
125
100
2010
2015
0-19
MCSAC
2020
20-64
2025
65-74
2030
75-84
2035
85+
Aging and Chronic Disease
The Challenge for the 21st Century
Complex
relationship
– Increase in chronic diseases due to aging as a result
of longer exposure to chronic disease risk factors in
a vulnerable population
– Cumulative impact of chronic disease throughout the
life course contributes to frailty and ultimately
disability and dependency
A
global challenge
– ↑ chronic diseases +↑ life expectancy = Aging with ↑
disability
MCSAC
Heath care systems and the challenge
of aging
Potential for promotion/prevention promoting healthy
aging and in at least delaying onset of frailty and
disability
↑ complex interventions
(technology/surgery/medication) in increasingly older
persons
Health care systems poorly adapted to the management of
chronic disease, frailty and dependency; complexity of
treating chronic diseases and frail older persons
Prevalence of Diabetes in Montreal
Prevalence of Heart Failure
in Montreal
Aging and Chronic Disease
The Challenge for the 21st Century
People
6%
21%
$$$
Those w/multiple chronic conditions
Those w/one chronic condition
72%
Those w/no chronic conditions
33%
31%
36%
•drivers of morbidity, mortality, utilization and costs
•A challenge to quality of life of elderly and healthcare
system sustainability
Source: Kaiser Permanente Northern California commercial membership, DxCG methodology, 2001.
http://www.natpact.nhs.uk/uploads/BobCrane.ppt#270
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Increasing prevalence of chronic
disease
but..
MCSAC
are we getting it right
Optimizing Quality and Best Practice in Primary Care
Percent of people with diabetes receiving care
according to guidelines
100%
60%
40%
20%
Year
20
04
/0
5
20
03
/0
4
20
02
/0
3
20
01
/0
2
20
00
/0
1
0%
19
99
/0
0
Percent
80%
What seniors receive?
Jencks et al., JAMA, 2003; 289:305
ACOVE, Ann Int Med, 2003; 139:740
• AMI – 50-75% receive B-blockers, 43-50% counseled for
smoking
• CHF – 65-68% ACE on discharge
• Stroke – 57% of A-fib on anti-coagulants
• Diabetes – 48-70% have eye exam
• Falls – 3% of fallers have fall examination
• Depression – 26% of those with depressive
symptoms treated or referred
• Medications – 18% of those prescribed new drug
had documented education
• Cognition – 52% of new patients tested
Health and functional status of cancer patients, aged 70 years and older
referred for chemotherapy- preliminary findings
100
80
%
42%
(n=21)
60
40
20
12%
(n=6)
30%
(n=15)
16%
(n=8)
0
Without frailty
With frailty
markers or IADL /
markers but
ADL disability without IADL /
ADL disability
IADL disabled
without ADL
disability
ADL disabled
Retornaz F, Monette J, Monette M, Sourial N, Wan-Chow-Wah D, Puts M, Small D, Caplan S, Batist G, Bergman H.
Usefulness of frailty markers in the assessment of the health and functional status in older cancer patient referred for
chemotherapy Journal of Gerontology:medical sciences. 2008
Life expectancy percentiles for
men.
Life expectancy, years
25
vulnerable
Top 25th percentile
50th percentile
20
Healthy
18
Lowest 25th percentile
14.2
15
With ADL disabilities
12.4
10.8
9.3
10
7.9
6.7
6.7
4.9
5
5.8
4.7
4.3
3.3
2.2
3.2
1.5
2.3
1
0
70 years
75 years
80 years
85 years
90 years
Walter LC et al. JAMA 2001, 285, 2750-2756
95 years
Embracing the heterogeneity and
complexity
Healthy older persons
– Primary medical care, Health
assessment/promotion/prevention
Early frail/low risk/chronic disease
– Primary medical care, Chronic disease management,
detection of vulnerability, preventive home visits
Medium risk/mild-moderate disability
– Primary medical care and home care, chronic disease
management. Specialized Geriatric care,
↑ Disability and “complex” systems of
integrated care
End of life care
Implementation in a coherent system: challenges to explore
Prevention and chronic disease management
Programs for health promotion/prevention
Chronic disease management for clinical priorities
in older persons
– Diabetes, CHF, hypertension, depression, cancer,
dementia
– Potential role of frailty/vulnerability markers
Implementation in a coherent system:
challenges to explore
Population Health Approach
Primary Care Reform
– The Family Medicine Group(GMF): basis for integration
– Example of proposed Quebec Alzheimer Plan
• Collaborative care model ; Partnership MD-Nurse-Patientcaregiver; Nurse navigator
• Community social care (AD support centre)
• Intensive team based case management and multidisciplinary
community based services
• Role of specialty care
• End of life care
http://www.rqrv.com/en/document/alzheimer_report.pdf
http://www.rqrv.com/fr/document/rapport_alzheimer.pdf
Primary Care Medical Reform in
Canada
GMF (Qc); Family Health Teams (Ont);
Medical Home (College of family Physicians
of Canada
– May or may not be in the same building eg BC and
Alberta
Group practice; interdisciplinary practice;
continuity of care with population and
healthcare system responsibility; evolving
remuneration; IT infrastructure: evolving
integration of other healthcare professionals
Priority Action 2
Provide access to personalized, coordinated assessment and treatment services for
people with Alzheimer’s and their family/informal caregivers

Implementation of a service structure based on the chronic-care
model and the collaborative-practice model, introduced
gradually, starting in Family Medicine Groups (FMGs) and
Network Clinics (NCs).
–
The primary care physician and the nurse clinician responsible for
continuity of patient services establish a partnership with each patient
and his or her family for the process of assessment, diagnosis, treatment,
monitoring, and follow-up.
• Approximately 10 to 15 patients with AD per MD = 100-150 per FMG with 10
MDs
– The nurse clinician plays the role of Alzheimer’s nurse care navigator.
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Chronic Disease and Aging in the
Acute Care Setting
↑ of chronic diseases
– ↑ hospitalization
– ↑ hospitalization for Ambulatory Case-Sensitive (ACS)
conditions
– ↑ hospitalization associated with avoidable and costly
complication
> 65
– 37% of admissions
– 50% of hospital days
– ↑ readmission
Siu et al: Health Affairs 2008
Change in profile of
hospitalized patients
Profile of patients on admission
– demography/health promotion and prevention/medical
care
– Treatment/intervention in ambulatory and primary
care
Increasingly complex medical and surgical
interventions on older and older patients
The Challenge of the Aging
Population
 Frailest
elderly ~3% of population are the major client
group, use 30% of health-care resources
 Seniors use 1/3 of all hospital admissions & 1/2 of
inpatient days (2002/2003 Hospital morbidity database)
 Readmission rates 42% in patients >75 years
 Seniors have higher rates of return visits to emergency
 Disconnect between patient needs and hospital practices
= “hostile environment”
 Frail elderly experience further functional decline not
related to acute episode but to hospital practices (Inouye et
al 2000)
 Adverse effects are higher in frail elderly even when
adjusted for age/co-morbidity
High Resource Hospital Patients:
2/3 are Seniors
Majority go home after hospitalization; Account for up to 80% of ALC
days; 30%-40% have a mental health co-morbidity
Health Region: Hospital Inpatient Data
100%
06/07
2,779
100%
80%
2,779
7,902
169,027
1,827
1,827
5%
4,996
60%
80%
11%
36%
97,684
932,221
52,794
67,230
40%
301,035
60%
40%
Other
Inpatients
20%
697,073
34,713
42,298
0%
Population
Inpatients
Discharges
176,992
Bed
Days
20%
0%
Population
Inpatients
Discharges
Bed Days
Source: DAD database CIHI
1Defined
Complex
Inpatients
as discharges not coded as emergency, direct or clinic; excludes stillborns, newborns and day surgery
Disconnect between patient needs
and hospital environment
 The
loss of independent functioning during
hospitalization has been associated with:
(Inouye et al 2000)
Prolonged lengths of hospital stay
Increased readmission
A greater risk of institutionalization
Higher mortality rates
Myth: Elderly patients with chronic diseases are
blocking the system
– It’s only an outflow problem
An appropriate approach …60 years ago
Structured to support continued action on single
disease strategies and approaches; disjuncture and
repetition of activities
Based on reducing LOS of uncomplicated acute
admissions
Patients too complex to fit into standard critical pathways
and treatment models
The complex patients (“acute on chronic”; functional
decline; decreased reserve with age) get lost:
– ↑ LOS;↑ LTC; ↑ Readmissions
Siu et al: Health Affairs 2008: The ironic case for
the chronic disease model in the acute care setting
The Acute Care setting
Re-thinking the approach in a coherent system of care
Engagement with primary medical and community care: a
collaborative care approach
– Transition in and out of the hospital
– Specialty care supporting primary care
• Not necessarily within the hospital
 Engagement with LTC
– Smooth transitions
– Prevention of admissions
Counsell JAMA 20007;
Callahan JAMA 2008;
Boult Journal Geronto Med sciences 2008;
Béland, Bergman et al Journal Geronto Med sciences 2007
Naylor
Present system of care
u
u
Poor communication of best practices
Innumerable programs and models
– The national disease strategies
The Acute Care setting
Re-thinking the approach in a coherent system of care
From the traditional medical and surgical wards to
the collaborative care wards
Clinical processes and organization of care within
the hospital
–
–
–
–
–
Interdisciplinary team directed care based on best practices
Integrate holistic older person evaluation within the acute care process
Physical organization
Hospital environment
Patient and family engagement
Training including end of life care
The Acute Care setting
Re-thinking the approach: the key elements
Aggregating the 3 components in a coherent system
– Pre-hospital
– Intra Hospital
– Post-hospital
Inter disciplinary rather than disciplinary
Partnership: clinicians, managers, the community
Research: a key component
The Chronic Disease Model
questions and issues
u
Can the Chronic Disease Model be
implemented without primary medical reform
– Family Medicine Groups in Quebec
u
How can the Chronic disease(S) model be
integrated into primary care
Beyond the Models
Reflections on key elements
Primary care
What seems to work/needs to be tested
u
u
u
u
u
u
Primary med care: org
infrastructure/remuneration
The multi disciplinary care
u
integrated into primary
medical care
Evolution of relationships among
professionals
u
u
Rapid access to intensive
professional services
u
(professional and social); access
to a wide range of
assisted/supportive housing
Population data/ responsibility
What does not seem to work
Primary med care: organization
/infrastructure/remuneration not
suited to complex continuing care
The programmatic, budgetary
and geographic cleavage
between primary medical and
multidisciplinary care
Parallel play among professionals
Sporadic responsibility
There are no emergencies
hospital
ER/wards
ACE/GAU BEDS
ER/WARD CONSULTATION
DAY HOSPITAL
REHAB
OUTPATIENT
Transition beds
MD/nurse clinician
geriatric consultation
team
DAY PROGRAMS
ASSISTED
LIVING
INTENSIVE TEAM
BASED
CASE MANAGEMENT
COMMUNITY
PROGRAMS
Primary medical care
Primary multidisciplinary care
Specialized
Geriatric Program
Critical role of research in change
Understanding the health and functional status, on
trajectory and costs of the population
Data to help understand why change is necessary
and to make evidence based decisions
Understanding attitudes and expectations of both
clinicians, patients and families
Clinical research and hospital and community
based studies
Evaluative research
Synthesising evidence
Canadian Initiative on Frailty and Aging / Initiative canadienne sur la fragilité et le vieillissement
www.frail-fragile.ca
Conclusion
 A shared vision of the challenge
 A complex challenge
–
–
–
–
data
The long haul
a multi disciplinary approach and a multi-dimensional
integrated strategy
Do not try and boil the ocean