Newswise — Experts on care transitions and chronic care management programs are available for interviews as part of Healthy Aging Month. Grantees funded by the John A. Hartford Foundation can provide insights on care programs that are under consideration as part of various national health care reform proposals.
"As the debate around health insurance reform goes forward," says Corinne H. Rieder, EdD, Executive Director of the John A. Hartford Foundation, America's leading philanthropy funding solutions to improve the health of older adults, "we need to hear the voices of medical experts and ensure that legislation not only expands access to the uninsured, but truly enhances care for the nation's largest consumers of health care"older adults."
The Hartford-funded experts available for interviews include Drs. Eric Coleman, Chad Boult, David Dorr, and Bruce Leff. To arrange interviews with any of these experts for articles during Healthy Aging Month, contact Connie Hofmann at 610-687-5495.
ERIC COLEMAN, MD, MPH, leads Care Transitions Interventions. (www.caretransitions.org) Dr. Coleman is a Professor of Health Care Policy and Research and Geriatric Medicine at the University of Colorado, Denver. An authority on the problem of fragmented or uncoordinated care, Dr. Coleman recently described in the New England Journal of Medicine how more than $17 billion is wasted every year because of high Medicare re-hospitalization rates, caused in part by poor communication and follow-up care.
His work is the inspiration for the Medicare Transitions Act of 2009 (S. 1009), introduced by Senator Michael Bennet (D-CO). Already in use in more than 150 hospitals and health care systems, the Care Transitions Intervention is a self-management model that teaches patients leaving the hospital to take a more active role in their own care. Key elements of the program include:
- A low-cost, low-intensity intervention including a single home visit and three follow-up phone calls over a 30-day period.
- A trained Transitions Coach who shares self-management skills, builds confidence, and provides tools to help patients get their needs met during this vulnerable time.
- Sustained reductions in hospital readmissions for patients out as long as six months.
- A net annual cost savings of $300,000 per transitions coach.
CHAD BOULT, MD, MPH, MBA, has created, tested, and disseminated Guided Care. (guidedcare.org)
Dr. Boult is a geriatrician, a health services researcher, and a Professor in the Johns Hopkins Bloomberg School of Public Health. Guided Care is a comprehensive health care model for the 20-25 percent of older Americans with multiple chronic conditions. Improving care for these chronically ill patients, who now consume 80 percent of all Medicare spending, is a reform priority.
In Guided Care, a registered nurse partners with primary care physicians and uses information technology to provide care coordination, transitional care, access to community resources, monthly monitoring, and coaching for self-management.
- Guided Care is cost-effective, with a net savings of $1,365 per patient, per year, an 11 percent savings over usual care.
- Guided Care improved quality of care and caregiver and physician satisfaction in the first year of a federally-funded, multi-site study.
- The Guided Care team is providing support and assistance for medical practices in eight states that seek to participate in the Centers for Medicare and Medicaid Services upcoming Medical Home Demonstration project.
DAVID DORR, MA, MD, designed Care Management Plus. (www.caremanagementplus.org) Dr. Dorr is an internist and Assistant Professor of Medical Informatics and Clinical Epidemiology at the Oregon Health and Science University. Moving beyond electronic medical records, Care Management Plus helps health care teams make meaningful use of health information technology to create a "medical home" in a primary care setting. With a nurse providing care coordination, Care Management Plus helps patients, families, and caregivers manage complex illness.
Pilot studies of Care Management Plus at Intermountain Health care demonstrated:
- Hospital admissions for Care Management Plus patients were 20 to 40 percent lower.
- Cost-effective: savings were almost twice the cost of the program.
- Mortality rates were 20 percent better than patients in a control group.
- Patients, particularly those with diabetes and depression, were better able to achieve self-care guidelines for their disease.
- More than 80 clinics " including several rural ones " are trained in Care Management Plus.
BRUCE LEFF, MD, leads the Hospital at Home program. (www.hospitalathome.org) Dr. Leff is a geriatrician and Associate Professor of Medicine and Health Policy and Management at Johns Hopkins Schools of Medicine and Public Health. He developed this innovative alternative to hospitalization: providing hospital-level acute care in older Americans' own homes.
Legislators are considering paying bonuses to hospitals providing superior care to Medicare patients with heart attacks, heart failure, and pneumonia. Hospital at Home has a track record of excellent care for pneumonia, congestive heart failure, and other conditions.
Care through Hospital at Home has been proven safe, high-quality, and hospital-level.
- Hospital-contracted complications are reduced.
- Caregiver stress is improved; patient and family satisfaction is high.
- Health care costs are one third lower.
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About the John A. Hartford Foundation
Founded in 1929, the John A. Hartford Foundation is a committed champion of training, research and service system innovations that promote the health and independence of America's older adults. Through its grantmaking, the Foundation seeks to strengthen the nation's capacity to provide effective, affordable care to this rapidly increasing older population by educating "aging-prepared" health professionals (physicians, nurses, social workers), and developing innovations that improve and better integrate health and supportive services. The Foundation was established by John A. Hartford. Mr. Hartford and his brother, George L. Hartford, both former chief executives of the Great Atlantic and Pacific Tea Company, left the bulk of their estates to the Foundation upon their deaths in the 1950's. Additional information about the Foundation and its programs is available at www.jhartfound.org.
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