Health Affairs Briefing

WASHINGTON – A collaborative care program that supports both Alzheimer’s patients and caregivers saved an Indiana health care system more than $1 million during its initial yearlong test period.

The Healthy Aging Brain Center (HABC) at Eskenazi Health in Indianapolis saved $2,856 per patient per year, while costing just $618 per patient to administer, Dr. Dustin French said at a briefing on Alzheimer’s disease hosted by Health Affairs. "The cost to administer the program comes to about $1.69 per patient per day – way less than the cost of a cup of coffee," Dr. French said.

The HABC creates individual care plans for patients with newly diagnosed memory disorders, including Alzheimer’s, mild cognitive impairment, and late-life depression. A team of physicians, social workers, and nurses works with the patient, caregiver, and family members. After the initial assessment, there is ongoing, unlimited support in the form of clinic visits and phone contact.

The individual care plans target a number of problem areas, including self-management, problem-solving, medication management, dealing with depression, managing cardiovascular risks, caregiver emotional and physical health support, transition of care across settings, and managing acute care issues.

The pilot ran from 2008 to 2009 with an initial cohort of 303 patients. A total of 1,453 patients did not enroll, mostly because the program was not being widely publicized at that point. If all eligible patients had enrolled, the annual cost savings would top $6 million, said Dr. French, the study’s primary investigator. He is a faculty member at the Center for Healthcare Studies at Northwestern University and a research scientist at Veterans Affairs Health Services Research and Development Service, both in Chicago.

The HABC patients were referred by primary care physician, self, or family member. The primary reasons for referral were memory problems (88%) or behavioral problems (12%), including wandering and agitation. The comparison group was similar in diagnosis and behavioral issues. Outcomes were cost and savings data extracted from Eskenazi Health’s accounting system and adjusted for comorbid illness, hospital charges and length of stay, and mortality (Health Aff. 2014;33:613-8).

The average risk-adjusted HABC patient cost savings was $3,474, compared with the control group. Half of that was in decreased inpatient expenses and the other half was in decreased emergency department and related outpatient costs. After subtraction of the $618-per-patient administration cost, the annual net per-patient savings was $2,865. This left an estimated net savings of $865,368 for the HABC cohort of 303 patients and $5,015,136 if all 1,756 patients had been enrolled.

The study could help lay a business foundation that might encourage payers to take notice of this kind of an intervention program, the authors noted. The current system does not encourage "the development of innovative health care delivery models" such as the one at the HABC, nor does it reimburse for caregiver support, such as telephone backup, unless it’s delivered in a remote locations.

"Reimbursement processes ... fail to address the complex needs of patients with dementia, which require multifaceted care. Unfortunately, these needs are often not fully addressed until the patient is institutionalized and the medical costs have begun to mount," the investigators wrote in their report.

The federal government may be waking up to the possibilities. The HABC program was awarded a grant from the Center for Medicare & Medicaid Innovation, which supported this study and allowed Eskenazi Health to expand the program to more than 2,000 Medicare beneficiaries with dementia or late-life depression.

"If we can do this in Indiana, anyone can do it anywhere," Dr. French said.

Dr. French had no disclosures. Several of his coauthors are employees of Eskenazi Health.

msullivan@frontlinemedcom.com

On Twitter @Alz_Gal

WASHINGTON – A collaborative care program that supports both Alzheimer’s patients and caregivers saved an Indiana health care system more than $1 million during its initial yearlong test period.

The Healthy Aging Brain Center (HABC) at Eskenazi Health in Indianapolis saved $2,856 per patient per year, while costing just $618 per patient to administer, Dr. Dustin French said at a briefing on Alzheimer’s disease hosted by Health Affairs. "The cost to administer the program comes to about $1.69 per patient per day – way less than the cost of a cup of coffee," Dr. French said.

The HABC creates individual care plans for patients with newly diagnosed memory disorders, including Alzheimer’s, mild cognitive impairment, and late-life depression. A team of physicians, social workers, and nurses works with the patient, caregiver, and family members. After the initial assessment, there is ongoing, unlimited support in the form of clinic visits and phone contact.

The individual care plans target a number of problem areas, including self-management, problem-solving, medication management, dealing with depression, managing cardiovascular risks, caregiver emotional and physical health support, transition of care across settings, and managing acute care issues.

The pilot ran from 2008 to 2009 with an initial cohort of 303 patients. A total of 1,453 patients did not enroll, mostly because the program was not being widely publicized at that point. If all eligible patients had enrolled, the annual cost savings would top $6 million, said Dr. French, the study’s primary investigator. He is a faculty member at the Center for Healthcare Studies at Northwestern University and a research scientist at Veterans Affairs Health Services Research and Development Service, both in Chicago.

The HABC patients were referred by primary care physician, self, or family member. The primary reasons for referral were memory problems (88%) or behavioral problems (12%), including wandering and agitation. The comparison group was similar in diagnosis and behavioral issues. Outcomes were cost and savings data extracted from Eskenazi Health’s accounting system and adjusted for comorbid illness, hospital charges and length of stay, and mortality (Health Aff. 2014;33:613-8).

The average risk-adjusted HABC patient cost savings was $3,474, compared with the control group. Half of that was in decreased inpatient expenses and the other half was in decreased emergency department and related outpatient costs. After subtraction of the $618-per-patient administration cost, the annual net per-patient savings was $2,865. This left an estimated net savings of $865,368 for the HABC cohort of 303 patients and $5,015,136 if all 1,756 patients had been enrolled.

The study could help lay a business foundation that might encourage payers to take notice of this kind of an intervention program, the authors noted. The current system does not encourage "the development of innovative health care delivery models" such as the one at the HABC, nor does it reimburse for caregiver support, such as telephone backup, unless it’s delivered in a remote locations.

"Reimbursement processes ... fail to address the complex needs of patients with dementia, which require multifaceted care. Unfortunately, these needs are often not fully addressed until the patient is institutionalized and the medical costs have begun to mount," the investigators wrote in their report.

The federal government may be waking up to the possibilities. The HABC program was awarded a grant from the Center for Medicare & Medicaid Innovation, which supported this study and allowed Eskenazi Health to expand the program to more than 2,000 Medicare beneficiaries with dementia or late-life depression.

"If we can do this in Indiana, anyone can do it anywhere," Dr. French said.

Dr. French had no disclosures. Several of his coauthors are employees of Eskenazi Health.

msullivan@frontlinemedcom.com

On Twitter @Alz_Gal

WASHINGTON – A collaborative care program that supports both Alzheimer’s patients and caregivers saved an Indiana health care system more than $1 million during its initial yearlong test period.

The Healthy Aging Brain Center (HABC) at Eskenazi Health in Indianapolis saved $2,856 per patient per year, while costing just $618 per patient to administer, Dr. Dustin French said at a briefing on Alzheimer’s disease hosted by Health Affairs. "The cost to administer the program comes to about $1.69 per patient per day – way less than the cost of a cup of coffee," Dr. French said.

The HABC creates individual care plans for patients with newly diagnosed memory disorders, including Alzheimer’s, mild cognitive impairment, and late-life depression. A team of physicians, social workers, and nurses works with the patient, caregiver, and family members. After the initial assessment, there is ongoing, unlimited support in the form of clinic visits and phone contact.

The individual care plans target a number of problem areas, including self-management, problem-solving, medication management, dealing with depression, managing cardiovascular risks, caregiver emotional and physical health support, transition of care across settings, and managing acute care issues.

The pilot ran from 2008 to 2009 with an initial cohort of 303 patients. A total of 1,453 patients did not enroll, mostly because the program was not being widely publicized at that point. If all eligible patients had enrolled, the annual cost savings would top $6 million, said Dr. French, the study’s primary investigator. He is a faculty member at the Center for Healthcare Studies at Northwestern University and a research scientist at Veterans Affairs Health Services Research and Development Service, both in Chicago.

The HABC patients were referred by primary care physician, self, or family member. The primary reasons for referral were memory problems (88%) or behavioral problems (12%), including wandering and agitation. The comparison group was similar in diagnosis and behavioral issues. Outcomes were cost and savings data extracted from Eskenazi Health’s accounting system and adjusted for comorbid illness, hospital charges and length of stay, and mortality (Health Aff. 2014;33:613-8).

The average risk-adjusted HABC patient cost savings was $3,474, compared with the control group. Half of that was in decreased inpatient expenses and the other half was in decreased emergency department and related outpatient costs. After subtraction of the $618-per-patient administration cost, the annual net per-patient savings was $2,865. This left an estimated net savings of $865,368 for the HABC cohort of 303 patients and $5,015,136 if all 1,756 patients had been enrolled.

The study could help lay a business foundation that might encourage payers to take notice of this kind of an intervention program, the authors noted. The current system does not encourage "the development of innovative health care delivery models" such as the one at the HABC, nor does it reimburse for caregiver support, such as telephone backup, unless it’s delivered in a remote locations.

"Reimbursement processes ... fail to address the complex needs of patients with dementia, which require multifaceted care. Unfortunately, these needs are often not fully addressed until the patient is institutionalized and the medical costs have begun to mount," the investigators wrote in their report.

The federal government may be waking up to the possibilities. The HABC program was awarded a grant from the Center for Medicare & Medicaid Innovation, which supported this study and allowed Eskenazi Health to expand the program to more than 2,000 Medicare beneficiaries with dementia or late-life depression.

"If we can do this in Indiana, anyone can do it anywhere," Dr. French said.

Dr. French had no disclosures. Several of his coauthors are employees of Eskenazi Health.

msullivan@frontlinemedcom.com

On Twitter @Alz_Gal

WASHINGTON – During the last year of life for community-dwelling elders, up to three-fourths of hospital visits might have been avoidable.

Nursing home residents also were susceptible to potentially unnecessary admissions, with about 50% experiencing at least one avoidable visit during the final months, Dr. Zhanlian Feng said at a briefing to unveil the April special issue of Health Affairs, "The Long Reach of Alzheimer’s Disease."

Dementia was a significant contributor to hospital and emergency department use: Those with dementia were 74% more likely to have a potentially avoidable hospitalization and 51% more likely to have had a potentially avoidable ED visit.

The researchers did not speculate on what care might have been more appropriate for these patients, said Dr. Feng, a senior research public health analyst in the Aging, Disability, and Long-Term Care program at RTI International, Waltham, Mass. It does, however, suggest a very high level of caregiver anxiety about dealing with a loved one’s acute health issues.

"It’s much more challenging to provide care and support for someone who is living at home," he said in an interview. "Whenever their loved one gets worse, the caregiver is worried about how to respond to the new crisis. Often they believe their only option is the emergency department."

At-home care "is probably a big driver of hospital utilization," among the elderly, and one to which policy makers may be blind, he said in an interview.

"There are many initiatives designed to reduce hospitalizations among the elderly, but they focus almost exclusively on nursing homes, and don’t target people with dementia in particular. In the community setting, there is very little discussion on how to accomplish this."

At the briefing, Dr. Feng discussed his study, which was published April 7 in Health Affairs (Health Aff. 2014;33:683-90). It looked at hospitalization and emergency department use among more than 12,000 Medicare beneficiaries who were included in the Health and Retirement Study during 2000-2008. The study included four outcomes: 5-year hospital/ED utilization among elders with and without dementia, and hospital/ED utilization among both groups within the last year of life.

Potentially avoidable conditions were considered to be those that could have been effectively dealt with in the patients’ out-of-hospital care setting with community-based resources or within a long-term care or nursing home facility.

Some of these problems included heart failure and chronic obstructive pulmonary disease, blood pressure complications, hyper- and hypoglycemia, diabetes, dehydration or diarrhea, electrolyte imbalances, constipation or fecal impaction, urinary and respiratory tract infections (including some pneumonias), and skin ulcers. Problems relating to malnutrition and asthma also were included.

There were some differences among these groups, however. "For example, acute, severe diarrhea due to gastroenteritis or food poisoning can often be managed in nursing homes without hospitalization, but patients with the same condition in the community may require hospitalization."

ED visits that resulted in admission weren’t included because the authors assumed that those represented unavoidable admissions. They conducted a multivariate analysis that controlled for age, gender, race/ethnicity, income, education, marital status, other insurance, chronic health problems, self-reported health, and the ability to perform activities of daily living.

Dementia was significantly more common among nursing home residents than among community residents (84% vs. 12%). Almost half (44%) of those who died had dementia in the last year of life.

Dr. Feng said that more than a quarter of community-dwelling elders with dementia (27%) were hospitalized each year, a rate significantly higher than that among those without dementia (19%). And, he said, significantly more of these admissions were considered potentially avoidable among dementia patients (8% vs. 5%).

Significantly more ED visits occurred among those with dementia (24% vs. 18%) with significantly more deemed potentially preventable among dementia patients (5% vs. 3%). And significantly more patients with dementia were admitted as a result of these visits (19% vs. 12%).

After adjustment for the variables, dementia was a significant contributor to all of these outcomes. Dementia patients were 74% more likely to have an avoidable hospitalization and 51% more likely to have an avoidable ED visit than were patients without dementia.

Nursing home residents also had high hospital and ED utilization each year, but there were no significant differences between those with and without dementia. Still, Dr. Feng said, "About half of these hospitalizations and ED visits might have been preventable."

Utilization skyrocketed in the last year of life, he said. About 80% of community dwellers, regardless of dementia status or living situation, had at least one hospitalization or ED visit during that time, and up to 75% of these might have been unnecessary.

Significantly more patients with dementia had an ED visit as well (50% vs. 44%). Among both groups, about 38% of hospitalizations and up to 14% of ED visits could have been unnecessary.

Among nursing home residents during the last year of life, there were no significant differences in utilization between dementia and non-dementia patients. But up to half of this utilization might have been dealt with in the facility, rather than through a hospital admission, he said.

"It is really striking to me how, in the last year of life, the rate jumps so high," Dr. Feng said. "This finding of so many potentially avoidable hospitalizations suggests that there is a lot of room for improvement in quality of care, which could very well lead to improvements in quality of life for our elderly."

The study was funded in part by the Office of the Assistant Secretary for Planning and Evaluation in the Department of Health and Human Services. Dr. Feng had no financial disclosures.

msullivan@frontlinemedcom.com

On Twitter @alz_gal

WASHINGTON – During the last year of life for community-dwelling elders, up to three-fourths of hospital visits might have been avoidable.

Nursing home residents also were susceptible to potentially unnecessary admissions, with about 50% experiencing at least one avoidable visit during the final months, Dr. Zhanlian Feng said at a briefing to unveil the April special issue of Health Affairs, "The Long Reach of Alzheimer’s Disease."

Dementia was a significant contributor to hospital and emergency department use: Those with dementia were 74% more likely to have a potentially avoidable hospitalization and 51% more likely to have had a potentially avoidable ED visit.

The researchers did not speculate on what care might have been more appropriate for these patients, said Dr. Feng, a senior research public health analyst in the Aging, Disability, and Long-Term Care program at RTI International, Waltham, Mass. It does, however, suggest a very high level of caregiver anxiety about dealing with a loved one’s acute health issues.

"It’s much more challenging to provide care and support for someone who is living at home," he said in an interview. "Whenever their loved one gets worse, the caregiver is worried about how to respond to the new crisis. Often they believe their only option is the emergency department."

At-home care "is probably a big driver of hospital utilization," among the elderly, and one to which policy makers may be blind, he said in an interview.

"There are many initiatives designed to reduce hospitalizations among the elderly, but they focus almost exclusively on nursing homes, and don’t target people with dementia in particular. In the community setting, there is very little discussion on how to accomplish this."

At the briefing, Dr. Feng discussed his study, which was published April 7 in Health Affairs (Health Aff. 2014;33:683-90). It looked at hospitalization and emergency department use among more than 12,000 Medicare beneficiaries who were included in the Health and Retirement Study during 2000-2008. The study included four outcomes: 5-year hospital/ED utilization among elders with and without dementia, and hospital/ED utilization among both groups within the last year of life.

Potentially avoidable conditions were considered to be those that could have been effectively dealt with in the patients’ out-of-hospital care setting with community-based resources or within a long-term care or nursing home facility.

Some of these problems included heart failure and chronic obstructive pulmonary disease, blood pressure complications, hyper- and hypoglycemia, diabetes, dehydration or diarrhea, electrolyte imbalances, constipation or fecal impaction, urinary and respiratory tract infections (including some pneumonias), and skin ulcers. Problems relating to malnutrition and asthma also were included.

There were some differences among these groups, however. "For example, acute, severe diarrhea due to gastroenteritis or food poisoning can often be managed in nursing homes without hospitalization, but patients with the same condition in the community may require hospitalization."

ED visits that resulted in admission weren’t included because the authors assumed that those represented unavoidable admissions. They conducted a multivariate analysis that controlled for age, gender, race/ethnicity, income, education, marital status, other insurance, chronic health problems, self-reported health, and the ability to perform activities of daily living.

Dementia was significantly more common among nursing home residents than among community residents (84% vs. 12%). Almost half (44%) of those who died had dementia in the last year of life.

Dr. Feng said that more than a quarter of community-dwelling elders with dementia (27%) were hospitalized each year, a rate significantly higher than that among those without dementia (19%). And, he said, significantly more of these admissions were considered potentially avoidable among dementia patients (8% vs. 5%).

Significantly more ED visits occurred among those with dementia (24% vs. 18%) with significantly more deemed potentially preventable among dementia patients (5% vs. 3%). And significantly more patients with dementia were admitted as a result of these visits (19% vs. 12%).

After adjustment for the variables, dementia was a significant contributor to all of these outcomes. Dementia patients were 74% more likely to have an avoidable hospitalization and 51% more likely to have an avoidable ED visit than were patients without dementia.

Nursing home residents also had high hospital and ED utilization each year, but there were no significant differences between those with and without dementia. Still, Dr. Feng said, "About half of these hospitalizations and ED visits might have been preventable."

Utilization skyrocketed in the last year of life, he said. About 80% of community dwellers, regardless of dementia status or living situation, had at least one hospitalization or ED visit during that time, and up to 75% of these might have been unnecessary.

Significantly more patients with dementia had an ED visit as well (50% vs. 44%). Among both groups, about 38% of hospitalizations and up to 14% of ED visits could have been unnecessary.

Among nursing home residents during the last year of life, there were no significant differences in utilization between dementia and non-dementia patients. But up to half of this utilization might have been dealt with in the facility, rather than through a hospital admission, he said.

"It is really striking to me how, in the last year of life, the rate jumps so high," Dr. Feng said. "This finding of so many potentially avoidable hospitalizations suggests that there is a lot of room for improvement in quality of care, which could very well lead to improvements in quality of life for our elderly."

The study was funded in part by the Office of the Assistant Secretary for Planning and Evaluation in the Department of Health and Human Services. Dr. Feng had no financial disclosures.

msullivan@frontlinemedcom.com

On Twitter @alz_gal

WASHINGTON – During the last year of life for community-dwelling elders, up to three-fourths of hospital visits might have been avoidable.

Nursing home residents also were susceptible to potentially unnecessary admissions, with about 50% experiencing at least one avoidable visit during the final months, Dr. Zhanlian Feng said at a briefing to unveil the April special issue of Health Affairs, "The Long Reach of Alzheimer’s Disease."

Dementia was a significant contributor to hospital and emergency department use: Those with dementia were 74% more likely to have a potentially avoidable hospitalization and 51% more likely to have had a potentially avoidable ED visit.

The researchers did not speculate on what care might have been more appropriate for these patients, said Dr. Feng, a senior research public health analyst in the Aging, Disability, and Long-Term Care program at RTI International, Waltham, Mass. It does, however, suggest a very high level of caregiver anxiety about dealing with a loved one’s acute health issues.

"It’s much more challenging to provide care and support for someone who is living at home," he said in an interview. "Whenever their loved one gets worse, the caregiver is worried about how to respond to the new crisis. Often they believe their only option is the emergency department."

At-home care "is probably a big driver of hospital utilization," among the elderly, and one to which policy makers may be blind, he said in an interview.

"There are many initiatives designed to reduce hospitalizations among the elderly, but they focus almost exclusively on nursing homes, and don’t target people with dementia in particular. In the community setting, there is very little discussion on how to accomplish this."

At the briefing, Dr. Feng discussed his study, which was published April 7 in Health Affairs (Health Aff. 2014;33:683-90). It looked at hospitalization and emergency department use among more than 12,000 Medicare beneficiaries who were included in the Health and Retirement Study during 2000-2008. The study included four outcomes: 5-year hospital/ED utilization among elders with and without dementia, and hospital/ED utilization among both groups within the last year of life.

Potentially avoidable conditions were considered to be those that could have been effectively dealt with in the patients’ out-of-hospital care setting with community-based resources or within a long-term care or nursing home facility.

Some of these problems included heart failure and chronic obstructive pulmonary disease, blood pressure complications, hyper- and hypoglycemia, diabetes, dehydration or diarrhea, electrolyte imbalances, constipation or fecal impaction, urinary and respiratory tract infections (including some pneumonias), and skin ulcers. Problems relating to malnutrition and asthma also were included.

There were some differences among these groups, however. "For example, acute, severe diarrhea due to gastroenteritis or food poisoning can often be managed in nursing homes without hospitalization, but patients with the same condition in the community may require hospitalization."

ED visits that resulted in admission weren’t included because the authors assumed that those represented unavoidable admissions. They conducted a multivariate analysis that controlled for age, gender, race/ethnicity, income, education, marital status, other insurance, chronic health problems, self-reported health, and the ability to perform activities of daily living.

Dementia was significantly more common among nursing home residents than among community residents (84% vs. 12%). Almost half (44%) of those who died had dementia in the last year of life.

Dr. Feng said that more than a quarter of community-dwelling elders with dementia (27%) were hospitalized each year, a rate significantly higher than that among those without dementia (19%). And, he said, significantly more of these admissions were considered potentially avoidable among dementia patients (8% vs. 5%).

Significantly more ED visits occurred among those with dementia (24% vs. 18%) with significantly more deemed potentially preventable among dementia patients (5% vs. 3%). And significantly more patients with dementia were admitted as a result of these visits (19% vs. 12%).

After adjustment for the variables, dementia was a significant contributor to all of these outcomes. Dementia patients were 74% more likely to have an avoidable hospitalization and 51% more likely to have an avoidable ED visit than were patients without dementia.

Nursing home residents also had high hospital and ED utilization each year, but there were no significant differences between those with and without dementia. Still, Dr. Feng said, "About half of these hospitalizations and ED visits might have been preventable."

Utilization skyrocketed in the last year of life, he said. About 80% of community dwellers, regardless of dementia status or living situation, had at least one hospitalization or ED visit during that time, and up to 75% of these might have been unnecessary.

Significantly more patients with dementia had an ED visit as well (50% vs. 44%). Among both groups, about 38% of hospitalizations and up to 14% of ED visits could have been unnecessary.

Among nursing home residents during the last year of life, there were no significant differences in utilization between dementia and non-dementia patients. But up to half of this utilization might have been dealt with in the facility, rather than through a hospital admission, he said.

"It is really striking to me how, in the last year of life, the rate jumps so high," Dr. Feng said. "This finding of so many potentially avoidable hospitalizations suggests that there is a lot of room for improvement in quality of care, which could very well lead to improvements in quality of life for our elderly."

The study was funded in part by the Office of the Assistant Secretary for Planning and Evaluation in the Department of Health and Human Services. Dr. Feng had no financial disclosures.

msullivan@frontlinemedcom.com

On Twitter @alz_gal