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12 Community-Based and Transitional Care
Pages 407-432

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From page 407...
... CHTs include care coordinators, nutritionists, behavioral and mental health specialists, nurses and nurse practitioners, and social, public health, and community health workers. Whereas these trained resources already exist in many communities, working with home health agencies, hospitals, health plans, and community-based health organizations, he suggests that a CHT's added benefit lays in coordination of these resources in the interest of addressing transitional care, palliative care, and prevention services.
From page 408...
... In his paper, Jeffrey Levi of Trust for America's Health presents the organization's collaboration with the Urban Institute, which focuses on developing an economic model that demonstrates the impact of certain community-based prevention programs targeting chronic diseases on healthcare costs. Based on their analysis, he reports that an investment of $10 per person per year in proven community-based programs to increase physical activity, improve nutrition, and prevent smoking and other tobacco use could save the country more than $16 billion annually within 5 years -- a return of $5.60 for every $1 invested.
From page 409...
... The MEPS datasets provide nationally representative estimates of healthcare spending, insurance status, use of medical services, sources of payment, and disease prevalence along with a broad set of socioeconomic characteristics for the noninstitutionalized civilian population in the United States.
From page 410...
... . CHTs include care coordinators, nutritionists, behavioral and mental health specialists, nurses and nurse practitioners, and social, public health, and community health workers.
From page 411...
... . Transitional care Medicare Payment Advisory Commission (MedPAC)
From page 412...
... . Studies have shown that increased adherence posts a substantial return on investment; for example: 7:1 for diabetes, 5.1:1 for hyperlipidemia, 3.98:1 for hypertension; and a reduction in overall healthcare spending of 15 percent for patients with chronic heart failure (Esposito et al., 2009; Sokol et al., 2005)
From page 413...
... . Funding and Financial Incentives Making CHTs available to all beneficiaries enrolled in traditional feefor-service Medicare would cost $1 billion annually in federal grants.3 Because reimbursement for crucial elements of effective chronic disease management -- education, patient counseling, care coordination, and patient monitoring -- is limited in fee-for-service Medicare, payment reforms assume a powerful role in incentivizing the adoption of CHTs and the development of accountable health teams that also include hospitals and specialists.
From page 414...
... contract with CHTs to manage medically complex patients and at-risk clients. Payment reforms that support and promote coordinated care and lower volume of services should encompass changes 4 The seven conditions are heart failure, chronic obstructive pulmonary disease, pneumonia, acute myocardial infarction, coronary artery bypass graft, percutaneous transluminal coronary angioplasty, and a general category of "other vascular" conditions.
From page 415...
... Now, palliative care programs are increasingly found in hospitals -- the main site of care for the seriously ill and site of death for 50 percent of adults on average nationwide (Brown University Center for Gerontology and Health Care Research, 2001)
From page 416...
... . Palliative medicine is now an American Board of Medical Specialties-approved subspecialty with 10 parent boards and the Accreditation Council for Graduate Medical Education has certified the first 55 postgraduate fellowship training programs (American Academy of Hospice and Palliative Medicine, 2009)
From page 417...
... ; staffing ratios determined by hospital size; staff trained, credentialed, and/or certified in palliative care; and access and responsiveness 24 hours per day, 7 days per week. These elements are designed to focus on better outcomes for patients through relief of physical and emotional distress; improved patient–family– professional communication and informed, patient-centered decision making; and coordination and continuity of care across the many transitions experienced by patients with complex chronic and serious illness (Morrison and Meier, 2004; National Consensus Project for Quality Palliative Care, 2004; National Quality Forum, 2006)
From page 418...
... * Imaging $ 890 $ 949 $ 58 $1,673 $1,540 -$133 FIGURE 12-4 Hospital palliative care reduces costs: Cost and intensive care out Figure 12-4.eps comes associated with palliative care consultation in eight U.S.
From page 419...
... . Assuming that palliative care programs should be seeing most patients who die in the hospital, plus the approximately triple this number of hospitalized patients with advanced and complex chronic illness who are discharged alive (Siu et al., 2009)
From page 420...
... COMMUNITY PREVENTION AND HEALTHCARE COSTS Jeffrey Levi, Ph.D. Trust for America's Health In July 2008, Trust for America's Health contracted with the Urban Institute to assess the effect on healthcare costs of certain proven community-based prevention programs that targeted some of the most expensive chronic diseases.
From page 421...
... • Provide incremental payments to hospitals and nursing homes providing palliative care services to patients in high-need categories, with phase in of financial penalties over several years for failure to provide such services. • Require access to quality non-hospice palliative care services for eligible beneficiaries in all proposed models of payment reform (including bundled payments, accountable care organizations, and the patient-centered medical home)
From page 422...
... . And the financial benefits are just as impressive: an investment of $10 per person per year in proven community-based programs to increase physical activity, improve nutrition, and prevent smoking and other tobacco use could save the country more than $16 billion annually within 5 years -- a return of $5.60 for every $1 invested.
From page 423...
... So, even as we discuss the implications of community-based prevention efforts, the issues here are complex and far reaching, and they require an investment commensurate with the role of communities in driving health. What Is Community-Based Prevention?
From page 424...
... Community-Level Interventions Can Reduce Chronic Disease Levels Again, the findings from the research are groundbreaking. Regardless of chronic condition targeted, most interventions targeted fell into four categories: physical activity, nutrition, obesity, and smoking cessation.
From page 425...
... Chronic disease often leads to disability or frailty that may necessitate TABLE 12-4 Net Savings by Payer: 5 Percent Impact at $10 per Capita Cost (in 2004 dollars) 1-2 Years 5 Years 10-20 Years Medicare $487 million $5.213 billion $5.971 billion Medicaid $370 million $1.951 billion $2.195 billion Private Payers/Out of Pocket $1.991 billion $9.380 billion $10.285 billion SOURCE: Reprinted with permission from Trust for America's Health, 2008.
From page 426...
... The stimulus bill invested $650 million to introduce community-based prevention programs and study their impacts. Even so, the paradigm shift is significant.
From page 427...
... 2000. The future of the palliative medicine fellowship.
From page 428...
... 2008. Research funding for palliative medicine.
From page 429...
... 2008. Cost savings associated with us hospital palliative care consultation programs.
From page 430...
... 2008. Meeting American Council of Graduate Medical Education guidelines for a palliative medicine fellowship through diverse community partnerships.
From page 431...
... 2006. The rise in spending among Medicare beneficiaries: The role of chronic disease prevalence and changes in treatment intensity.
From page 432...
... 2008. Associations between end-of life discussions, patient mental health, medical care near death, and caregiver bereave ment adjustment.


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