The Story of the Aging Brain Care Program at Wishard

Malaz Boustani, MD, MPH Associate Director, IU Center for Aging Research

School of Medicine Department of Medicine Division of General Internal Medicine and Geriatrics Center for Aging Research

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Objectives Share the story of developing the Aging Brain Care Program at Wishard • • • • •

The needs The scientific model The implementation The evaluation The future

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Aging Brain Care in the USA •

Any Cognitive Impairment

25% - 40%

•

Dementia

6 % -11%

•

Depression

14%

•

Delirium

16% - 80%

•

Unrecognized Cases:

60% to 80%

•

Behavioral Problems

80%

•

Definitive Anticholinergics:

22% to 26%

•

FDA Approved Drugs:

5% to 10%

•

Antidepressant SSRIs:

48%

•

Off-Label Psychotropics:

20% to 25%

•

ER Visits per Year:

49% (pts) / 21% (CGs)

•

Hospitalizations per Year:

26% (pts) / 11% (CGs)

•

Length of Hospital Stay:

5.9 to 9.2 days

Boustani et al, Aging and Mental Health (In press); Boustani et al, JHM 2010; Schubert et al, JGIM 2008; Schubert et al, JAGS 2006; Boustani et al, JGIM 2005; Callahan et al, JAMA 2006

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IUCAR Reaction 2000 - 2006 • • • • • • •

Proposal ($2 million) to AHRQ Developed the Collaborative Care Dementia Model Evaluated the CCDM in RCT CCDM worked! Drs. CMC and MB traveled to Hawaii, Europe JAMA publication Dr. MB promotion

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The Collaborative Dementia Care PREVENT Model 2000-2006 Primary Care Clinician: -detect and treat delirium -detect and treat BPSD -Enhance cholinergic system by -Prescribe ChEIs -Discontinue Anticholinergic

Caregiver Focus: -Problem solving skills -Counseling -Respite care -Support group

Coordinate and Deliver

Dynamic Feedback

Dynamic Feedback

Clinical Liaison

Expert Team: -Geriatrician -Social Psychologist -GeroPsychiatrist

Coordinate and Deliver

General Environmental Modification: -Medication adherence support -Home safety assessment Callahan et al, JAMA 2006; Austrom et al, Gerontologist 2004; Boustani et al, JCIA 2006

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The Impact of CCDM • NNT = 3.7 • Each 1 point decline in NPI = $250-$400 in health care expenses • CCDM led to 7 NPI point improvement • CCDM saved 1750-$2800 per patient • Improvement in family stress

8

P=0.003 6

4

P=0.012 2 I UC 0

-2

-4 change in

CG Stress

NPI

NPI

Callahan, Boustani et al, JAMA 2006

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Potential Savings for Center of Medicare and Medicaid Services with implementing the CCDM in billions

15

12 9 6

3 0

Boustani & Jermoumi 2012. Scientific Evidence, Current Issues and Future Perspectives. Rene TJ & Wolfgang H (EDS) (ISBN 978-3-89967-811-6).

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Translational Cycle: Epidemiology

Basic Science Lab

Clinical Observation

From Discovery To Delivery

T1 Promising Intervention

Clinical Trial testing

T2 Approved Intervention

Time: 17 yrs Cost: $1.2 billion Generalizability: < 1% Post-Marketing Testing

System and Provider Implementation

T3

Guideline Development Westfall et al, JAMA 2007; Boustani et al, JCIA 2010

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Selecting a change in a complex adaptive health care delivery system A. Selecting an overall content that is based on a systematic evidence review of past research or guidelines. B. Develop a Reflective Adaptive Process implementation team to:

•

Localize the content

•

Localize and or invent the delivery process

•

Monitor the delivery process

•

Monitor the system’s members interactions

•

Detect emergent behaviors

•

Evaluate the impact of the selected change Boustani et al, JCIA 2010

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The Reflective Adaptive Process of Implementation Science • Vision, mission, and shared values (Standardized Minimum Care)

• Time and space for learning and reflection ($$$)

• Tension and discomfort are essential • Diverse improvement teams • Supportive leadership.

• Continuous feedback on performance Stroebel et al, JCJQ&PS 2005; Boustani et al, JCIA 2010; Boustani et al, Aging & Mental Health 2011; callahan et al, Aging & Mental Health 2011

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From “JAMA” to Aging Brain Care Program at Wishard in less than two years! ABC Med Home

ABC Med Home

ABC Med Home

ABC Med Home

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The Aging Brain Clinical Program at Wishard • The Healthy Aging Brain Center (The Center) • Opened January 2008

• The Aging Brain Care Medical Home (The Home) • Opened October 2009

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ABC Performance The Acute Care Service Utility Domain % patients with at least one ER visit Total number of ER visits % patients with at least one hospitalization Total number of hospitalizations Mean/Median length of hospital stay

HABC PCC 28%

49%

124

1143

13%

26%

45

438

5/4

7/4

Boustani et al, Aging & Mental Health 2011

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HABC Performance The Quality of Care Indicator Domain

HABC PCC

% seen at ER again within one week % re-hospitalized within 30 days of discharge % with at least one order of definite anticholinergics % with at least one order of neuroleptics % with at least one order of anti-dementia drugs

14% 11% 19% 5% 55%

15% 20% 40% 5% 13%

% with at least one order of antidepressant drugs % with at least one order of definite anticholinergics and anti-dementia drugs % with at least one LDL order % of patients with LDL < 130 % with at least one HbA1c order % of patients with HbA1c < 8 % with last systolic BP < 160

68% 16% 82% 45% 78% 78% 27%

48% 32% 72% 23% 62% 51% 24%

Boustani et al, Aging & Mental Health 2011

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Standardized Minimum ABC Care 1. Check hospital & ER alerts every day

4. Ongoing Aging Brain Care a)

Manage Depression i. PST ii. SSRI iii. CBT

b)

Manage Cognitive Impairment i. ChEIS (if needed) ii. D/c Anticholinergics iii. Caregiver counseling and education iv. Mediation adherence support

2. Coordinate with inpatient services a) b) c) d) e)

Alert hospital team of presence of CI/ Depression Medications conciliation Connect with family caregiver Request ACE consult Coordinate post discharge transition

3. Post discharge care a) b) c) d) e)

Home visit within 72 hours of discharge Mediation reconciliation Coordinate Home Care visit Coordinate post hospital orders Deliver Delirium protocol and handout

Callahan et al, Aging & Mental Health 2011; Boustani et al, Aging & Mental Health 2011

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ABC Dissemination: CMMI Award 2012-2015 • • • • •

Total target patients: 2000 Primary Care Centers: 10 Saving for CMS per year: $5 million New Workforce: 20 Care Coordinator Assistants and 4 NPs Training & Implementation Packages: •

• • • • • •

Tools only: ABC replication manual; CG Resources Handbook; Care Protocols; HABC-Monitor; ACB scale; ABC Readiness Assessment ABC Basic Training ABC Certified Coordinator ABC certified Physician Consulting on ABC implementation Full Site Implementation Saved Sharing & Franchising

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Thank you! IU Geriatrics