Chronicity and Aging: The Geriatric Imperative

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1 Chronicity and Aging: The Geriatric Imperative Steven L. Phillips, MD Medical Director Sanford Center for Aging Professor, Clinical Internal Medicine University of Nevada, Reno School of Medicine dhs.unr.edu/aging

2 Objectives Objective 1 Define chronic conditions and the impact on quality of life. Objective 2 Provide a structured framework around care plan development and implementation. Objective 3 Describe the intersection between chronic conditions and healthcare utilization.

3 Chronic Diseases in the Elderly Diabetes Mellitus 15-25% Hypertension 10-15% Coronary Artery Disease 10-14% Arthritis/DJD 10-13% Emphysema 5-7% Dementia 5-7% Depression/Anxiety 3-5% Cerebrovascular Disorders 3-5%

4 A Century of Change Life Expectancy 47 years 75 years Usual Place of Death Home Hospital Most Medical Expenses Paid by Family Paid by Medicare Disability before Death Usually not much 2 years, on average Field MJ, Cassel CK, eds. Approaching Death: Improving Care at the End of Life. Washington, DC: Institute of Medicine, Committee on Care at the End of Life, National Press, 1997

5 Change in the New Century Age 85 or Older Long Term Care Costs-- Medicaid Americans with Chronic Conditions 4,200,000 9,000,000 $137 Billion $281 Billion 125 million 175 million 81% with > 1 chronic condition

6 Americans Current Health Care Expenditures Expenditures Birth Life Span Death

7 Change in the New Century Age 85 or Older Long Term Care Costs-- Medicaid Americans with Chronic Conditions 4,200,000 9,000,000 $137 Billion $281 Billion 125 million 175 million 81% with > 1 chronic condition

8 Most elderly people are relatively healthy; however, nearly all can expect to be chronically ill for an extended period at the end of their lives. Linn, J, 2003.

9 Chronic Illness Among the Elderly Non-fatal Chronic Illness Arthritis Hearing Loss Visual Impairment

10 Chronic Illness Among the Elderly Non-fatal Chronic Illness Gradually worsen, but seldom pose a threat to life Contribute substantially to disability and health care costs

11 Chronic Illness Among the Elderly Serious, Eventually Fatal Chronic Conditions Cancers Organ System Failures Dementia Strokes

12 Chronic conditions are the leading cause of illness, disability, and death in Medicare beneficiaries. Disease Percent of Medicare beneficiaries with disease Percent of total Medicare spending CHF 14% 43% Diabetes 18% 32% T. G. Thompson, Secretary of HHS; 2004

13 Trajectories of Chronic Illness: Service Needs Across Time

14 Short Period of Evident Decline Mostly Cancer Function (High to Low) Time (Decline to Death)

15 Long-Term Limitations with Intermittent Serious Episodes Mostly Heart Failure and Lung Failure Function (High to Low) Time (Decline to Death)

16 Prolonged Dwindling Mostly Dementia, Disabling Strokes, Frailty Function (High to Low) Time (Decline to Death)

17 Analysis of Medicare Claims Short Period of Evident Decline 20% Long-Term Limitations with Exacerbation 20% Prolonged Dwindling 40% Sudden Death and Not Yet Classified 20%

18 Current System Organized by Setting Hospital Nursing Facility Home Doctor s Office

19 Impedes continuity of care across settings and across the changing challenges of worsening illness

20 Chronic Illness and Medicare 20% of Medicare beneficiaries Have 5 or more chronic conditions Account for over 2/3 of Medicare spending See 14 different doctors in a year Have almost 40 office visits R. A. Berenson, MD, Senior Fellow, Urban Institute

21 Number of Chronic Conditions Percent Chance of Unnecessary Hospitalization in Medicare Beneficiaries 1 1% 5 13% 8 27% R. A. Berenson, MD, Senior Fellow, Urban Institute

22 Target Population DM People diagnosed with a specific disease CCM People at high risk for costly adverse medical events and poor health outcomes Reliance on Evidence-Based Treatment Guidelines DM High CCM Low to Medium Reliance on protocols and standardized approaches DM High CCM Low Use of non-medical social support services DM Low CCM High

23 1. Community Resources and Policies 2. Health System Organization of Health Care 3. Self-Management Support 4. Delivery System 5. Decision Support 6. Clinical Information Systems Informed, Activated Patient Productive Interactions Prepared, Proactive Practice Team Functional and Clinical Outcomes Chronic Care Model, Ed Wagner, MD

24 Target Population DM People diagnosed with a specific disease CCM People at high risk for costly adverse medical events and poor health outcomes Reliance on Evidence-Based Treatment Guidelines DM High CCM Low to Medium Reliance on protocols and standardized approaches DM High CCM Low Use of non-medical social support services DM Low CCM High

25 Comprehensive Geriatric Assessments Older adults with any of the following could benefit from a comprehensive geriatric assessment: Living alone, Unexpected weight loss, Increasing weakness, Decreasing mobility, Multiple chronic conditions, Memory complaints and/or Frequent hospitalizations Two referral options are available: 1. In person at the Geriatric Specialty Clinic located at the Sanford Center for Aging in Reno, Nevada 2. Via telemedicine through the Renown network throughout northern Nevada Both services include an assessment by a physician, a pharmacist and a social worker who specialize in geriatric care. Call (775) for details.

26 Sanford Center for Aging Geriatric Specialty Clinic Steven L. Phillips, MD (775) Special thanks to the EJC Foundation for support of this geriatric series.