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Improving the Care of Older Adults with Common Geriatric Conditions

Improving the Care of Older Adults with Common Geriatric Conditions A Report from the HMO Workgroup

A Report from the HMO Workgroup on Care Management

Improving the Care of Older Adults with Common Geriatric Conditions

A Report from the HMO Workgroup on Care Management

February 2002

This report was written by the HMO Workgroup on Care Management. It does not necessarily reflect the views of the American Association of Health Plans (AAHP), the AAHP Foundation, or The Robert Wood Johnson Foundation.

This publication may be freely reproduced and redistributed without permission; however, neither the report nor its contents may be resold. This report may be cited as: HMO Workgroup on Care Management, “Improving the Care of Older Adults with Common Geriatric Conditions” (AAHP Foundation, Washington, DC, February 2002).

Foreword

The HMO Workgroup on Care Management represents both health plans and group practices that are capitated by health plans for a significant portion of revenues. Health plans and capitated provider groups are referred to, collectively, as Managed Care Organizations (MCOs). Workgroup participants hold senior medical and patient care management positions within their respective organizations, all of which enroll significant numbers of older adults under Medicare capitation, known as Medicare+Choice, contracts. The Workgroup’s activities are lodged at the AAHP Foundation, and AAHP staff members provide invaluable support.

Over the past seven years, the HMO Workgroup on Care Management has met quarterly to discuss ways in which the delivery of care to Medicare beneficiaries can be improved. This report is the seventh to be released. The six other reports released by the Workgroup are:

Identifying High-Risk Medicare HMO Members

Planning Care for High-Risk Medicare HMO Members

Essential Components of Geriatric Care Provided Through Health Maintenance Organizations

Establishing Relations with Community Resource Organizations: An Imperative For Managed Care Organizations Serving Medicare Beneficiaries

Geriatric Case Management: Challenges and Potential Solutions in Managed Care Organizations

Risk Screening Medicare Members Revisited

We are deeply grateful to The Robert Wood Johnson Foundation for its financial and moral support. The primary writer of this report was Eric A. Coleman, MD, MPH, University of Colorado Health Sciences Center and Kaiser Permanente Colorado Region.

Peter D. Fox Chair

Acknowledgments

The HMO Workgroup on Care Management:

Ellen Aliberti, BSN, MS, CCM

Regional Director, Care Management HealthCare Partners Los Angeles, California

Danielle Butin, MPH, OTR

Manager of Health Promotion & Wellness Oxford Health Plans White Plains, New York

Jan Clarke, MD, MPH

In-Patient Program Advocate Health Centers Chicago, Illinois

*Eric A. Coleman, MD, MPH

Associate Professor of Geriatric Medicine University of Colorado Health Sciences Center and Clinical Researcher Kaiser Permanente Colorado Region Denver, Colorado

Richard D. Della Penna, MD

Regional Elder Care Coordinator So. California Kaiser Permanente San Diego, California

Joyce Dubow

Senior Policy Advisor, Public Policy Institute AARP Washington, D.C.

† Peter D. Fox, PhD

President PDF, LLC Chevy Chase, Maryland

Brian Hayes, MD, CMCE

Senior Medical Director Independence Blue Cross Philadelphia, Pennsylvania

Bonnie Hillegass, RN, MHA

Vice President, Medical Management Sierra Health Services, Inc. Las Vegas, Nevada

Christine Himes, MD

Director, Geriatrics and Long Term Care Group Health Cooperative Seattle, Washington

Joy Luque, RN, BSN, CCM

Director, Case Management PacifiCare of California Cypress, California

Paul Mendis, MD

Medical Director Neighborhood Health Plan Boston, Massachusetts

Robert J. Schreiber, MD

Medical Director of Geriatric Services Lahey Clinic Burlington, Massachusetts

Ingrid Venohr, RN, PhD

Director, Senior Programs Kaiser Permanente Colorado Region Denver, Colorado

Nancy A. Whitelaw, PhD

Director, Health and Aging Services Research National Council on Aging Washington, D.C., and Adjunct Investigator Center for Health Services Research Henry Ford Health System Detroit, Michigan

* Served as scientific consultant Served as Convener and Chair

Table of Contents

Section 1

Introduction

1

Section 2

Physical Inactivity

5

Section 3

Falls

13

Section 4

Medication-Related Complications

21

Section 5

Dementia

29

Section 6

Depression

41

Section 7

Undernutrition

53

Section 8

Urinary Incontinence

63

Appendix

Illustrative Process and Outcome Measures

69

Section 1

Introduction

Recommendations for Managed Care Organizations

MCOs should:

Conduct periodic screening and assessment for common geriatric conditions and have effective interventions in place for positively identified older members.

Ensure that primary care practitioners have the tools, incentives, and resources to facilitate identification and appropriate management of older members with common geriatric conditions.

Establish partnerships with community agencies that provide complementary services for older members with common geriatric conditions.

Recognize that geriatric conditions often confound treatment of other chronic illnesses.

Be open to innovations that are not currently part of their benefit structure but may have a positive impact on quality of life for older members.

Traditionally, most of the focus of geriatric care in Managed Care Organizations (MCOs) 1 has been on identifying the relatively small number (3-5%) of older members who account for disproportionate utilization. The main intervention MCOs have offered these high-risk enrollees has been intense, comprehensive case management. More recently, and as will be described in this report, MCOs are beginning to recognize the advantages of broadening this focus to include older members at risk for functional decline and subsequent frail health. These members may not need longitudinal case man- agement but, rather, access to targeted, evidence-based interventions that address specific conditions.

The financial advantages of traditional utilization management have largely been realized, and future savings will likely accrue from investing in “upstream” approaches that prevent costly utilization altogether (e.g., of the hospital or the emergency department). In order to provide excellent geriatric care and simultaneously mitigate “downstream” cost, MCOs need to establish expertise in improving functional reserve in their older members. Functional reserve refers to the capacity of individuals to withstand a threat to their health and functional status. Persons with limited functional reserve take longer to recover, or may not recover, from their illness to the point that they can manage their care at home. These persons may be frail or may be high-risk for becoming frail (i.e., the “pre-frail”).

Functional decline and accompanying frailty is costly (1). Compared with their counterparts, whose functional status worsened over time, direct costs of care for members who maintained high functional status over the same time period were 62 percent lower (2). Further, many of the benefits with regard to both outcomes and costs can be realized in the relatively short time horizon of 6-12 months (3-6). Cost avoidance achieved from implementing interventions described in this report can be used to further sustain such programs.

Reduced functional reserve is frequently multi-factorial, and different combinations of geriatric conditions may contribute to decline in a given individual. Although many conditions threaten functional reserve in older members, seven treatable geriatric conditions serve as the focus of this report:

Physical Inactivity

Depression

Falls

Undernutrition

Medication-related Complications

Urinary Incontinence

Dementia

These conditions represent common problems that adversely affect function and quality of life. They are frequently underdiagnosed and therefore undertreated, and there are effective interventions available. The seven conditions should not be viewed in isolation since they may interact to potentially enhance or confound treatment (7-10). For example, physical inactivity and urinary incontinence both increase risk for falls; use of high-risk medications is a risk factor for both falls and cognitive dysfunction; and social isolation is a risk factor for depression, undernutrition, and physical inactivity. Conversely, greater physical activity has been shown to improve depressive symptoms and reduce the risk for falls.

The Workgroup envisions a “tri-partite” relationship among the MCO, the primary care practitioner (PCP), 2 and the member. MCOs can support the PCP and member towards achieving improved functional outcomes. For example, the MCO can assure that brief and simple-to-use tools to manage these conditions are readily available to PCPs. The MCO can also ensure that programs are available for referral, whether offered by the MCO or in partnership with relevant community-based organizations (11). As discussed in a previous Workgroup report, MCOs can initiate periodic screening and assessment of common geriatric conditions in both newly enrolled and existing members (12). They can also facilitate the availability of evidence-based care pathways for common geriatric conditions that can be accessed by any member of the health care team, or alternatively, by the patient or an informal caregiver.

Primary care practitioners need to manage geriatric conditions. However, systems of care are often not in place to provide them with the time, the tools, the incentives, and the support to consistently identify and assess geriatric conditions. PCPs may be reluctant to address these conditions in the absence of effective and accessible treatment programs for appropriate referral, particularly when they face immediate pressures to attend to more acute medical problems. In contrast, MCOs may have, or can develop, the infrastructure for identification and assessment. MCOs can be instrumental in making these programs available and facilitating the referral process. Further, many of the conditions described in this report

2 Primary care practitioner broadly refers to the primary care physician, nurse practitioner, or a medical or surgical specialist to the extent they assume a primary care role. Nurses, who provided asthma-related information, checked on symptoms, and provided assistance as needed. In addition, members in the program could call these nurses at any time to ask questions or request help.

can be managed by health professionals other than physicians and in locations other than the medical office (e.g., senior centers, self-management groups, physical therapy, and organized incontinence or exercise classes). In order to reduce the threat of care fragmentation, the PCP needs to be continually apprised of the member’s progress.

MCOs can encourage members to take a more active role in their care through ongoing monitoring and positive reinforcement. Strategies to build self-efficacy and self-management skills have been shown to have positive effects on a wide range of health outcomes, including geriatric conditions (13;14). The member has a role in formulating the care plan and bringing in condition-specific materials to share with practitioners. MCO-produced member educational or empowerment materials need to complement MCO-produced PCP education and decision support materials. Thus, the MCO can provide greater self-directed care and can simultaneously prepare PCPs to better manage geriatric conditions.

For example, members with urinary incontinence may be encouraged to play a more collaborative role in their care by gathering condition-specific information prior to their visit (e.g., by completing symptom diaries of incontinent episodes), key questions to ask about their condition (e.g., could my incontinence be due to an infection or my medications?), and information regarding specific programs and treatments about which to inquire (e.g., physical therapist or nurse-led incontinence self-management program).

Treatment of geriatric conditions often requires that older members change their health-related behavior (15-17). Treatment regimens will more likely be followed when they are tailored to the member’s personal goals, such as the ability to attend church, enjoy time with family, or return to work. Adherence can be further enhanced through mechanisms that provide positive reinforcement and sustain attempts at behavioral change. MCOs need to account for a member’s readiness to change when developing new programs. PCPs also need to understand the member’s readiness to change and individual preferences in order to establish meaningful and obtainable goals.

Increasingly, the Center for Medicare and Medicaid Services (CMS) has directed MCOs to include programs that enhance the health status and function of older members in their quality improvement efforts. Nearly all of the interventions for the geriatric conditions discussed in this report lend themselves to continuous quality improvement initiatives such as those required by the National Committee for Quality Assurance (NCQA) and the Quality Improvement Systems for Managed Care (QISMC) regulations applying to MCOs with Medicare and Medicaid enrollees.

The goal of this report is not to dictate the practice of medicine. Rather, it is to draw from a composite of evidence-based literature, best practices, and professional judgment to demonstrate how MCOs can implement effective interventions that enhance functional status and quality of life for their older members. Historically, older persons with multiple coexisting problems have been excluded from therapeutic trials. Consequently, for some of the seven conditions, the evidence base is more developed than for others. Many of the recommended interventions do not represent a large investment to the MCO and are not difficult to undertake. In many cases, the role of the MCO is to make it easy for the clinician to do what is best for the member.

Each condition is developed in a separate section that follows the same format: Clinical Vignette, Recommendations for MCOs, Nature of the Problem, Target Population and Risk Factors, Screening and Assessment, Interventions, Implementation Barriers, Economic Impact, and Reference List. Interactions between the conditions are highlighted. Throughout this report, effective programs that leading MCOs have implemented will be featured for each of the seven geriatric conditions. Examples are drawn from both Workgroup members and other MCOs to highlight that such programs are not only possible but have already been successfully implemented and add value to the respective organizations. The Workgroup acknowledges, however, that there is considerable activity in these areas beyond what is reported herein.

Reference List

(1)

National Institute on Aging. Physical frailty. 1991. National Institutes of Health.

(2)

Leveille S, LaCroix A, Hecht J, Grothaus L, Wagner E. The cost of disability in older women and opportunities for prevention. Journal of Women’s Health 1992; 1(1):53-61.

(3)

Leveille S, Wagner E, Davis C, Grothaus L, Wallace J, et al. Preventing disability and managing chronic illness in frail older adults: a randomized trial of a community-based partnership with primary care. Journal of the American Geriatrics Society 1998; 46(10):1191-1198.

(4)

Burgio K, Locher J, Goode P, Hardin M, McDowell B, et al. Behavioral vs. drug treatment for urge urinary incontinence in old er women: a randomized controlled trial. JAMA 1998; 280(23):1995-2000.

(5)

Stearns S, Bernard S, Fasick S, Schwartz R, Konrad T, et al. The economic implications of self-care: the effect of lifestyle, functional adaptations, and medical self-care among a national sample of Medicare beneficiaries. American Journal of Public Health 2001; 90(10):1608-1612.

(6)

Rizzo J, Baker D, McAvay G, Tinetti M. The cost-effectiveness of a multifactorial targeted prevention program for falls among community elderly persons. Medical Care 1996; 34(9):954-969.

(7)

Tinetti ME, Inouye S, Gill TM, Doucette JT. Shared risk factors for falls, incontinence, and functional dependence: unifying the approach to geriatric syndromes. JAMA 1995; 273(17):1348-1353.

(8)

Singh N, Clements K, Fiatrone M. A randomized controlled trial of progressive resistance training in depressed elders. Journal of Gerontology A Biological and Medical Sciences 1997; 52A(1):M27-M35.

(9)

Dugan E, Cohen S, Bland D, Preisser J, Davis C, et al. The association of depressive symptoms and urinary incontinence among older adults. Journal of the American Geriatrics Society 2000; 48(4):413-416.

(10)

Wolf SL, Barnhart HX, Kutner NG, McNeely E, Coogler C, Xu T. Reducing frailty and falls in older persons: an investigation of Tai Chi and computerized balance training. Journal of the American Geriatrics Society 1996; 44(5):489-497.

(11)

HMO Workgroup on Care Management. Establishing relations with community resource organizations: an imperative for managed care organizations serving Medicare beneficiaries. 1-26. 1999. Washington D.C., AAHP Foundation.

(12)

The HMO Workgroup on Care Management. Risk screening Medicare members revisited. 1-37. 2000. Washington D.C., AAHP Foundation.

(13)

Lorig K, Sobel DS, Stewart A, Brown B, Bandura A, et al. Evidence suggesting that a chronic disease self-management program can improve health status while reducing hospitalization. Medical Care 1999; 37(1):5-14.

(14)

Reuben D, Frank J, Hirsch S, McGuigan K, Maly R. A randomized clinical trial of outpatient comprehensive geriatric assessment coupled with an intervention to increase adherence to recommendations. Journal of the American Geriatrics Society 1999; 47(3):269-276.

(15)

Nigg CR, Burbank PM, Padula C, Dufresne R, Rossi JS, et al. Stages of change across ten health risk behaviors for older adults. Gerontologist 1999; 39(4):473-482.

(16)

Prochaska JO, Velicer WF. The transtheoretical model of health behavior change. American Journal of Health Promotion 1997; 12(1):38-48.

(17)

Simons-Morton DG, Mullen PD, Mains DA, Tabak ER, Green LW. Characteristics of controlled studies of patient education and counseling for preventive behaviors. Patient Education and Counseling 1992; 19(2):175-204.

Section 2

Physical Inactivity

Clinical Vignette

In 1998, Group Health Cooperative was faced with becoming the highest priced Medicare+Choice plan in Washington state. Recognizing an opportunity to combine a member retention strategy with a clinical imperative for senior health, the health plan decided to add a covered physical activity benefit, partnering with senior centers and local health clubs. The strategy has increased member retention and decreased utilization. Those members who took advantage of the added benefit experienced 1.5 fewer outpatient clinic visits over one year compared with those who did not. Furthermore, the 14 percent of members currently using the benefit have become some of the most loyal and most vocal advocates, praising Group Health Cooperative in the community. Finally, Group Health Cooperative has received positive publicity from the local press with numerous articles featuring their “exercising seniors.”

Recommendations for Managed Care Organizations

MCOs should:

Promote physical activity for members irrespective of age, health, or functional status. Physical activity is particularly important for members with chronic illness at high-risk for functional dependence and those contemplating elective surgery, such as knee replacement.

Increase awareness of the benefits of physical activity among older members and encourage them to discuss physical activity with their primary care practitioner.

Provide both practitioners and members with specific tools and guidance to promote regular physical activity.

Establish partnerships with community-based agencies to ensure that physical activity programs are available to their members. MCOs should also participate in state- or city-wide initiatives designed to promote physical activity.

Nature of the Problem

Lack of regular physical activity 3 is a major under-recognized risk factor for chronic health problems, loss of functional reserve, and disability. Either alone or through its contribution to prevalent and costly chronic illnesses, physical inactivity extols significant burden in terms of morbidity and mortality (1). Physical deconditioning, through its adverse effect on physical function, is a contributing factor for extended hospital length-of-stay and need for subsequent post-hospital care in skilled nursing facilities (2-5).

Regular physical activity has been shown to extend life, reduce disability, and improve quality of life in older adults (6-10). It reduces risk for cardiovascular disease, osteoarthritis, osteoporosis, obesity, diabetes, and insomnia. In addition, it significantly reduces risk for three of the conditions featured in this report; falls, depression, and incontinence (6;8;11-19). Consequently, because of the high prevalence of these conditions, older persons potentially have the most to gain from regular physical activity

(6;7;20;21).

Thus, if there is one thing that MCOs can do to improve health outcomes in older members—whether they are robust and healthy or frail and immobile—it is to encourage a program of regular physical activity. The Surgeon General recommends that nearly all persons should accumulate 30 minutes or more of moderate intensity physical activity over the course of most days (6;22). Currently, however, older adults are the most sedentary segment of the adult population (6). Fewer than half of men 70 years of age and older engage in physical activity three or more times per week. In women, the proportion is even lower with fewer than one-third participating in physical activity three or more times per week (23).

Ta rget Population and Risk Factors

MCOs should promote physical activity for members irrespective of age, health, or functional status. Traditionally, MCOs have focused their attention on healthier members and have placed considerably less emphasis on reducing physical inactivity among older members with multiple chronic illnesses, the “pre-frail”, or the frail.

Scientific evidence strongly supports implementation of programs that promote physical conditioning for all members throughout the spectrum from healthy to frail (6-8;24-26). For example, recent studies have demonstrated the value of strength training in frail 80- and 90-year-old nursing home residents (20). Regular physical activity in older adults with chronic illness can potentially reverse loss of mobility (6). Older members with degenerative joint disease of the knees who undergo knee replacement can improve their post-operative recovery through participation in a structured exercise program prior to surgery (27). The minority of community-dwelling enrollees who have particularly high health care costs are another important group for targeted programs that promote physical conditioning.

Screening and Assessment

Physical activity levels of new members can be determined by a mailed screening questionnaire. Taken a step further, the assessment of physical activity can be considered an additional vital sign for all older members, performed at each visit irrespective of health or functional status (1).

Consistent with the Surgeon General’s recommendations for promoting physical activity, a commonly used screening question asks, “How many days in the past week have you accumulated 30 minutes or more of moderate exercise (for example, walking, gardening, cleaning)?” (6). Two more elaborate tools have been used within MCO populations (28). PASE, or the Physical Activity Scale for the Elderly, measures total leisure and work activity through a weighted scoring of hours per activity in the previous 7 days (29). PACE, or Physician-based Assessment and Counseling for Exercise, measures attitudes and behaviors related to physical activity (30).

In assessing older members for participation in a physical activity program, a question that often arises is whether a medical evaluation is needed, such as exercise treadmill testing, to assess the likelihood of adverse cardiac events. For older members who have no active cardiopulmonary symptoms embarking on a moderate-intensity program (as opposed to a vigorous one that causes the person to breathe hard and sweat profusely), formal testing is generally not necessary and is not supported by the current scientific evidence (8;31-34). Furthermore, recommending additional steps such as exercise treadmill testing could deter participation by portraying physical activity as potentially hazardous, when in fact just the opposite message needs to be conveyed. Nevertheless, formal instruments, such as the Physical Activity Readiness Questionnaire (PAR-Q) have been developed to identify persons who may benefit from exercise treadmill testing and ongoing physician monitoring (35). An evaluation by a physical or occupational therapist prior to initiating a program of regular physical activity may be appropriate for some older members, for example, those with impaired balance or mobility who are high-risk for falls.

Interventions

The Surgeon General’s national goal for each person to accumulate 30 minutes or more of moderate intensity physical activity during the course of most days can be achieved in multiple ways (6;22). 4 In this context, the emphasis is on physical activity rather than exercise per se. Physical activity is a broader term that includes activities such as walking, climbing stairs, or regular gardening. A program may emphasize strength, aerobic, balance, flexibility training, or it may be multifaceted. In general, however, the recommendation is intended to convey the message that any type of physical activity is better than none. The initial goal may be to move from no activity to minimal activity, followed by incremental gains as tolerated.

An individual conditioning program should be tailored to the member’s abilities, preferences, and living environment. An older member suffering from osteoarthritis of the knee may benefit most from an emphasis on flexibility and strength training. In contrast, a frail older member with impaired mobility and falls living in an assisted living environment may benefit from a balance program such as

group Tai Chi. This activity has been shown to reduce the risk of multiple falls, fear of falling, and improve ability to perform activities of daily living (14;36). Informal walking programs offered at local shopping malls are a good way to promote physical activity in environments where the weather may not always be conducive.

Tailoring of a program of physical activity also entails deciding whether the physical activity is performed individually or within a group, and whether it is based at home or in a community setting (32). Participation in a structured group exercise program (e.g., at a healthcare facility or in a community senior center) versus a home-based program is a matter of personal preference. Comparable results can be achieved in either (12;37;38). The group setting, however, affords additional benefits by creating an environment for peer support, self-efficacy, and increased socialization that can counteract the negative effects of social isolation and associated depression (29;39;40). Also, members who exercise in a group setting may feel a greater sense of personal safety that might reduce an additional barrier, namely fear of injury. For members who prefer the convenience or privacy of a home-based program, protocols have been developed that use resistance bands, light weights, stationary bicycles, or common household objects such as a chair or a towel (37;41). The National Institute on Aging, among others, has produced a low-cost ($7.00) self-guided home video that begins with 6 minutes of safety tips followed by 40 minutes of balance, strength, and stretching exercises. 5

Multiple studies have shown that PCPs are an important source of motivation for members contemplating the initiation of a physical activity (42;43). 6 Every clinical encounter represents an opportunity to reinforce the benefits of regular physical activity. Thus, MCOs should provide both PCPs and members with specific tools and guidance to promote regular physical activity. MCOs can offer PCPs continuing medical education classes on physical activity counseling and prescription writing. MCOs can also establish partnerships with community programs to facilitate PCP referral of interested members. 7 For example, Oxford Health Plan gives physicians prescription pads that list Oxford- sponsored community walking clubs and the name and phone number of the leader. Members are also encouraged to lead walking programs on their own by acting as a “coach” for peers in their neighborhood.

Similarly, MCOs can encourage members to discuss physical activity with their PCPs, provide members with information about specific types of physical activity programs and their respective benefits (e.g., strength, balance, aerobic), and direct them to available community resources (e.g., senior centers) where they can pursue such programs. For example, PacifiCare provides members with information regarding the benefits of physical activity and an up-to-date listing of available community physical activity programs on their web site.

Older members at Group Health Cooperative are asked yearly about their physical activity as one component of the Lifetime Health Monitoring questionnaire. 8 The underlying premise is that everyone can benefit from regular physical activity, particularly persons with chronic illness or functional

5 The video can be obtained by calling 1-800-222-2225 or online at http://www.nih.gov/nia.

6 Although a discussion of physical activity counseling and motivation is beyond the scope of this report, the reader is referred to several excellent resources

(8;32;42-45).

7 Please see an earlier Workgroup report (46).

8 This annual questionnaire comprises an important component of a Group Health Cooperative member’s overall health promotion and disease prevention care plan.

impairment. Primary care practitioners are encouraged to assess physical capacity, develop an individualized written exercise prescription, and direct patients to either a community- or home-based exercise program. One community-based program in particular, the Lifetime Fitness Program, began in 1993 and is now offered in nearly 30 locations in the Seattle metropolitan area. It offers low-cost, one-hour supervised classes that focus on strength training (with wrist and ankle weights), aerobics, balance, and flexibility. Positive outcomes have included improved balance and flexibility as well as improved overall functional status in members who attended at least two classes per week (12). In addition, Group Health Cooperative has contracted with health clubs throughout the Seattle area to provide senior-oriented exercise classes. Out of approximately 60,000 older Group Health Cooperative members, 9,513 have visited a network contract health club and 3,206 attend the facility at least twice weekly. These classes are a covered benefit for Group Health Cooperative Medicare members.

Health Partners, a mixed group model and IPA MCO serving 800,000 members in Minnesota, encourages members to participate in a wide variety of programs tailored to their interest and motivation for behavioral change. Programs include a mall walking program at the Mall of America (currently 5000 members are enrolled), reduced monthly fees for joining a contract local fitness club, a clinic- based fitness program, and an innovative self-directed walking program entitled, “10,000 Steps”. Nearly 10,000 individuals have participated in the “10,000 Steps” program. It is based on the premise that inactive people take 2,000 to 4,000 steps per day, whereas active people take over 10,000 steps per day. Inactive people need positive reinforcement to increase their level of activity in order to gain the same health benefits. Participants in the program are issued a pedometer (i.e., step counter) that provides positive reinforcement, a personal action planner designed to encourage them to initiate and sustain participation, a log to keep track of steps, biweekly mailed motivational cards for eight weeks followed by bimonthly cards for six months, and an opportunity to enter drawings and win prizes (47). This program has been implemented in various settings, including primary care clinics, disease management programs, worksites, and in community programs as part of a state-wide initiative sponsored by the Department of Health.

Implementation Barriers

There are multiple barriers to improving physical activity levels in older members. Motivation and adherence barriers can be counteracted through PCP encouragement, transportation, and exercising with a partner (8;32;42-45). Further, a lack of knowledge regarding nearby community physical activity programs is common. Fear of crime can deter participation in outdoor programs such as walking. Because of the loss of a spouse, sibling, or friend (and associated social isolation), many older members do not have a partner to participate in a regular conditioning program. Weather that is not conducive to physical activity (e.g., excessive cold or heat) may also preclude regular outdoor exercise. Finally, the myth of the need to “take it easy” in older age is far from eradicated in the minds of many older members.

At the level of the MCO, the geographic distribution of a plan’s membership may complicate the offering of MCO-developed and run physical activity programs. Instead, MCOs may choose to partner with community-based organizations (e.g., senior centers, parks and recreation, YMCA/YWCA). Few PCPs have had formal training in prescribing and monitoring a physical activity program, especially for their older members. Many PCPs feel that they lack the time, prescribing skills, and specific tools that they need to encourage their patients to become more active (44;45;48). The MCO can play a pivotal role in sensitizing PCPs to the central importance of physical activity in older adults, thereby reducing the possibility that negative attitudes do not create barriers to counseling. MCOs can also facilitate the PCP’s role in promoting regular physical activity by providing them with a listing of available community resources, “tear-off sheets” on exercise tips, and a prescription pad to assist their patients in initiating an exercise program to prompt immediate referral.

Economic Impact

Deconditioning, through its adverse effect on physical function, is often a contributing factor to prolonged hospital length of stay or post-hospitalization admission to a skilled care facility (2-5). Alternatively, physical conditioning is one of the most effective strategies for building physiologic reserve (i.e., “pre-hab”), thereby proactively reducing hospital length-of-stay or obviating the need for post-hospital skilled care. In a study by Buchner and colleagues, older community-dwelling adults who were randomized to receive a strength and endurance training intervention had fewer high cost hospitalizations (more than $5,000) and outpatient visits compared with those who were randomized to a comparison group (21). Older women who walk more than four hours per week reduce their risk of hospitalization due to cardiovascular conditions (49).

Health Partners has examined the economic impact of encouraging sedentary members to become physically active one day per week. Based on conservative analyses, they estimate a 4.7 percent reduc- tion in annual costs for each member who achieves this modest increment (50). These findings have been instrumental in decisions to expand their efforts to promote physical activity for members cared for in primary care, disease management, weight management programs, and in community settings such as walking programs offered in local shopping malls.

Enrollees who are candidates for elective joint replacement illustrate the potential economic benefits of physical activity. A physical therapist-led strengthening program focusing on the quadriceps and hamstring muscles in the legs has been shown to delay or prevent the need for subsequent elective knee joint replacement surgery. The cost of the program is estimated around $500 to $1,000 for the physical therapy visits, compared to the cost of knee replacement, estimated around $30,000 (27;51). 9

Cost savings due to the positive influence of physical activity on improved management of chronic illnesses such as hypertension, diabetes, and osteoarthritis are difficult to quantify. For example, older members with adult-onset diabetes who exercise regularly may no longer require pharmacologic therapy or may have fewer complications requiring hospitalization. Hu and colleagues demonstrated that women with diabetes who engaged in regular physical activity had fewer cases of heart disease and stroke (52).

Reference List

(1)

Robert Wood Johnson Foundation. National Blueprint for Increasing Physical Activity Among Adults Age 50 and Older. 2000. Princeton, New Jersey.

(2)

Stearns S, Bernard S, Fasick S, Schwartz R, Konrad T, et al. The economic implications of self-care: the effect of lifestyle, functional adaptations, and medical self-care among a national sample of Medicare beneficiaries. American Journal of Public Health 2001; 90(10):1608-1612.

(3)

Kane R, Finch M, Blewett L, Chen Q, Burns R, Moskowitz M. Use of post-hospital care by Medicare patients. Journal of the American Geriatrics Society 1996; 44(5):242-250.

(4)

Inouye S, Wagner D, Acampora D, Horowitz R, Cooney L, et al. A predictive index for functional decline in hospitalized elderly medical patients. Journal of General Internal Medicine 1993; 8:645-652.

(5)

Hoenig H, Nusbaum N, Brummel-Smith K. Geriatric rehabilitation: state of the art Journal of the American Geriatrics Society 1997;

45(11):1371-1381.

(6)

U.S. Department of Health and Human Services CDC. Physical activity and health: a report of the Surgeon General. Executive summary. 9-14. 1996.

(7)

Buchner D. Preserving mobility in older adults. Western Journal of Medicine 1997; 167(4):258-264.

(8)

American College of Sports Medicine. Exercise and physical activity for older adults. Medical Science Sports Exercise 1998; 30(6):992-1008.

(9)

Guralnik J, LaCroix AZ, Abbott R, Berkman L, Satterfield S, et al. Maintaining mobility in late life: I demographic characteristics and chronic conditions. American Journal of Epidemiology 1993; 137(8):845-857.

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Burgio K, Locher J, Goode P, Hardin M, McDowell B, et al. Behavioral vs. drug treatment for urge urinary incontinence in ol der women: a randomized controlled trial. JAMA 1998; 280(23):1995-2000.

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Camacho T, Roberts R, Lazarus N, Kaplan G, Cohen R. Physical activity and depression: evidence from the Alameda County Study. American Journal of Epidemiology 1991; 134(2):220-231.

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Farmer ME, Locke B, Moscicki E, Dannenberg A, Larson D, Radloff LS. Physical activity and depressive symptoms: the NHANES I epidemiologic follow-up study. American Journal of Epidemiology 2001; 128(6):1340-1351.

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Ettinger Jr W, Burns R, Messier S, Applegate W, Rejeski W, Morgan T et al. A randomized trial comparing aerobic exercise and resistance exercise with a health education program in older adults with knee osteoarthritis. The Fitness Arthritis and Seniors Trial (FAST). JAMA 1997;

277(1):25-31.

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Coleman EA, Buchner DM, Cress ME, Chan BKS, DeLateur B. The relationship of joint symptoms with exercise performance in older adults. Journal of the American Geriatrics Society 1996; 44(1):14-21.

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Fiatrone M, Marks E, Ryan N, Meredith C, Lipsitz L, Evans W. High-intensity strength training in nonagenarians: effects on skeletal muscle. JAMA 1990; 263(22):3029-3034.

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Buchner D, Cress M, DeLateur B, Esselman P, Margherita A, Price R et al. The effect of strength and endurance training on gait, balance, fall risk, and health services use in community-living older adults. Journal of Gerontology A Biological and Medical Sciences 1997;

52(4):M218-M224.

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Section 3

Falls

Clinical Vignette

Mrs. D. is a 76-year-old woman with obesity, macular degeneration, Type II diabetes, asthma, and degenerative joint disease who has experienced two non-injurious falls over the past six months. During a telephone call initiated by an Oxford Health Plan outreach worker, Mrs. D. reported feeling depressed over her inability to perform basic daily activities unassisted, such as using the shower and toilet, doing laundry, and cooking. The outreach worker enrolled Mrs. D. into Oxford’s Activity and Safety Program, and both a physical and an occupational therapist visited her. The therapists ordered adaptive equipment that included a tub bench, grab bars, trolley walker, and a toilet safety frame. Mrs. D. was taught how to use the adaptive equipment, and she subsequently expressed to the therapists that she has more energy, requires less frequent use of her inhaled asthma medications, and relies less on her husband for help with household chores. Approximately two months after enrollment into the program, Mrs. D. proudly reported that, for the first time in two years, she was able to serve dinner to her family without help. Since enrollment in the Activity and Safety Program, she has remained free of falls.

Recommendations for Managed Care Organizations

MCOs should:

Adopt mechanisms to identify older members who have fallen in the past year or who are at high risk for falls and associated injuries, given that over 30 percent of community dwelling older adults fall at least once each year.

Heighten awareness among members and providers of the significance of falls and provide interventions tailored to their level of risk.

Ensure that interventions are available that address the following four risk areas: high-risk medications, deconditioning, home and environmental safety, and visual impairment.

Participate in state-wide initiatives aimed at reducing fall-related injuries.

Nature of the Problem

More than 30 percent of community dwelling older adults fall at least once each year, 50 percent of whom do so repeatedly (1-3). A fall in an older member often represents a sentinel event, heralding the begin- ning of a decline in function. Multiple falls are a marker of physical frailty since falls and associated “fear of falling” frequently lead to reduced activity, social isolation, and, consequently, impaired function (1;2;4). This downward spiral may ultimately lead to loss of independence and nursing home placement (4).

Not all falls result in injury and not all injuries result in healthcare utilization. However, because of the large number of falls, the overall impact on utilization is substantial. Approximately 30-55 percent of falls result in minor injury and about 5 percent of falls result in a fracture (1;5;6). Approximately eight percent of persons older than age 70 seek emergency care for a fall-related injury and 30-40 percent of these emergency visits result in hospitalization with an average length of stay ranging from 8-15 days (2;7-9). The Lahey Clinic in Massachusetts closely examined emergency visits in members over age 65 and found that 45 percent of emergency visits were fall-related in 1997-8. Older patients with fall- related injuries are also more likely to require continued skilled care in a nursing facility following hospitalization (9-12). Further, complications caused by falls are the leading cause of death from injury in persons over age 65 (2;13). Fortunately, proven interventions designed to reduce risk factors for falls have been shown to be effective as well as cost-effective (14).

Ta rget Population and Risk Factors

Most falls are attributable to multiple factors and providers should search for more than one possible etiology. Risks for falls are commonly categorized into (1) intrinsic factors, referring to characteristics of the individual faller, and (2) extrinsic factors, referring to the individual’s environment (1;13;15). Intrinsic factors include physical deconditioning, gait disturbance, vestibular dysfunction, visual deficits, and certain underlying medical conditions such as Parkinson’s disease, dementia, stroke, macular degeneration, and urinary incontinence. Extrinsic factors include high-risk medications, use of alcohol, environmental hazards (e.g., throw rugs, extension cords, poor lighting, and slippery floors), and lack of sturdy shoes with good traction (16).

The most important risk factors on which a MCO should focus are muscle weakness (five-fold risk for falls compared with those without such weakness), balance or gait deficits (three-fold risk), and vision deficits (two and a half-fold risk) (4). Medications are an additional risk factor to consider (17). Classes of medications that are associated with a particularly high risk for falling include: psychotropic drugs, 10 associated with a 73 percent increased risk for falls; medications that suppress abnormal heart rhythms, associated with a 59 percent increased risk; Digoxin, associated with a 22 percent increased risk; and diuretics, associated with an eight percent increased risk (17). Diphenhydramine (Benadryl) and other over-the-counter medications can also contribute to falls as a result of drowsiness, confusion, or interaction with other medications. Finally, environmental factors, including poor lighting or the absence of assistive devices such as grab bars in the bathroom are also important risk factors (16). Each of these individual risk factors can have either additive or synergistic effects when combined (4).

Screening and Assessment

Older persons who fall repeatedly are at highest risk for future falls and are most likely to benefit from targeted intervention (4;18;19). High-risk members can be identified by questionnaires administered either by mail or in the waiting room of a PCP’s office. PCPs, specialists, and emergency department staff are additional sources for identification of high-risk members (20). The most commonly employed screening question for falls inquires about the number of falls in a six-month time interval (21). 11

Administrative data are another way to identify older members who fall. For members enrolled in its Medicare product, Independence Blue Cross monitors emergency department utilization that does

not result in a hospitalization. A case-manager telephones members to conduct a detailed assessment to determine the next course of action. Determining the need for referral to a falls prevention program

is a particular focus of this assessment.

Further assessment after a positive screen often necessitates a gait evaluation. Although more sophisticated tools exist, two simple assessments are adequate for most situations (22). The first one, the timed “Up & Go”, is a test of functional mobility for older members (23). The PCP, nurse, or medical assistant can administer it when the older member is called in from the waiting room, or the receptionist can even administer it before the encounter. During this test, the patient is observed and timed while rising from an armchair, walking 10 feet, turning, walking back, and sitting down again. Patients who cannot perform the test within 20 seconds should be evaluated further (i.e., by a physical therapist) to identify specific problems with gait and balance.

The second tool, functional reach, is a measure of balance that can identify persons who are likely to fall (24). Functional reach, the maximal distance one can reach forward from a standing position without stepping, is measured using a leveled yardstick secured to the wall at shoulder height. Patients who cannot reach more than 10 inches are at increased risk of falling (25).

Other critical components of the assessment besides the gait evaluation include measuring the member’s blood pressure and heart rate as they change positions from lying to sitting to standing and conducting

a comprehensive medication evaluation. The medication evaluation can be performed by the PCP or

by a clinical pharmacist. Particular attention should be paid to medications associated with confusion (e.g., benzodiazepines, Benadryl or diphenhydramine), those that inadvertently lower blood pressure upon standing (e.g., antihypertensives, diuretics, tricyclic antidepressants such as Doxepin, and Amitriptyline), and medications that suppress abnormal heart rhythms (e.g., Digoxin) (17). An evaluation of alcohol consumption is an important component of the medication evaluation.

Environmental assessments focus on home safety. They are most commonly conducted by a nurse or occupational therapist employed by a home care agency and are designed to reduce hazards and make the home more suited to members’ functional level.

Interventions

The falls intervention literature strongly supports the initiation of a multi-factorial falls reduction program, particularly one that targets multiple risk factors in individuals who have experienced repeated falls (19;26;27). Elements of a multi-factorial falls program may address strength and balance, home safety modification, instruction in the use of a cane or walker, and high-risk medication reduction. Although not all older members who fall have correctable contributing factors, a significant number do. Interventions to reduce falls can be categorized into physical activity, environmental interventions, assistive devices, and medication review.

Although physical activity programs designed to build physiologic reserve are the cornerstone of any falls reduction program, they are most effective when they are part of a multi-component risk reduction approach (19;28;29). Physical activity programs, particularly those emphasizing balance and lower extremity strengthening, are associated with a 10-20 percent reduction in falls (30). These programs may be conducted in either a group or individual format. Older adults with repeated falls may require supervision by a physical therapist or trained exercise leader.

Environmental interventions usually entail a home safety assessment, commonly conducted by a nurse, or a physical or occupational therapist from a home care agency. The assessment focuses on reducing hazards such as throw rugs, extension cords, poor lighting, dangerous stairwells and shoes that increase the risk of falling. It also attempts to make the home more suited to the member’s functional level, such as installation of a raised toilet seat, a shower chair, or grab bars near the toilet and tub. With a home self-assessment guide and access to durable medical equipment, some members and their families can improve the safety of their home without the need for a visit from a healthcare professional. In either case, the involvement of a concerned family member or friend can help ensure that the safety recom- mendations are followed. Through partnerships with community agencies, MCOs can help members identify low-cost installers of equipment to promote home safety (e.g., grab bars in the bathroom).

Environmental safety can also be promoted among older adults population-wide. For example, the state of Minnesota has initiated a state-wide campaign aimed at reducing fall-related injury. MCOs can enhance their efforts through partnering with relevant state and local agencies.

Referral to physical and occupational therapy is often the most efficient way for members to obtain and learn how to use assistive devices, such as a single-point cane, a four-point cane, or a walker. Assistive devices can help the older member compensate for a gait or balance disturbance. More appropriate footwear may also be prescribed. The member may also need training from a therapist to learn how to get up safely once a fall has occurred.

Sierra Health Services in Nevada has designed and implemented an extended physical therapy benefit to improve balance, gait and function. Services include a continuum of different levels of supervised therapy. Examples of services include customized individual physical therapy provided in the home, individualized therapy offered in an outpatient facility, supervised group exercise classes, and supervised pool exercise classes. Evaluation of members’ function before and after participation has revealed significant improvements in balance, gait stability, and physical function.

For older persons living alone who are frail or otherwise could not get back up after a fall, a home alert lifeline necklace may be life saving. One push of the button on the necklace can summon help and reduce some of the complications of falls. These devices are available from home health agencies for a monthly fee. PCP encouragement can be instrumental in assuring that members obtain this device and wear it on a regular basis.

Either the PCP or a clinical pharmacist can conduct a comprehensive medication review. To prevent fall-related complications, the overall goal is to reduce use of high-risk medications and to reduce the risk for osteoporosis using proven treatment such as calcium and vitamin D replacement, estrogens, and bisphosphanates (e.g., Alendronate). Sierra Health Services, the Lahey Clinic, Group Health Cooperative, and Kaiser Permanente, Colorado Region, have all invested in clinical pharmacists to assist practitioners and members in their efforts to reduce high-risk medication use.

Many MCOs have adopted strategies to reduce falls among their older members. In collaboration with researchers from Yale, Oxford Health Plan is evaluating the effectiveness of a multi-component risk reduction demonstration program in selected boroughs of New York City. In accordance with the protocol, screened members are identified to participate if they report having fallen over the past six months or if they are worried about falling (i.e., “fear of falling”). Members identified using this approach receive an in-home comprehensive assessment from an occupational therapist and a physical therapist. The goals for these visits are to improve gait, balance, and strength, and to teach compensatory strategies for any functional impairment. Members are also counseled how to access vision and podiatry services.

A registered nurse may conduct an in-home falls risk assessment if the member is 1) currently prescribed

a targeted high-risk medication; 2) has a history of falls associated with dizziness; or 3) the member’s

blood pressure has been observed to drop upon standing. Results from this study are expected in December 2002.

The Lahey Clinic in Massachusetts offers high-risk members a multidisciplinary fall risk prevention

clinic. This clinic is staffed by a geriatrician, a physiatrist (a physician who specializes in rehabilitative medicine), and a physical therapist. Following an evaluation by the physical therapist, the team works with primary care practitioners to implement a falls-reduction care plan with follow-up monitoring. Independence Blue Cross has formed a partnership with its local Area Agency on Aging to conduct home safety evaluations for Medicare members. For members who need home adaptation, it works with a local agency, Children of Aging Parents. Senior Buena Care, a PACE (Program of All-Inclusive Care to the Elderly) in East Los Angeles teaches members how to get up after a fall. Kaiser Permanente, Colorado Region, has developed a falls prevention video entitled, “No More Falls”, which is available

in the public domain.

Implementation Barriers

Many practitioners are not fully aware of the significant threat falls pose to older members or are unfamiliar with effective interventions. Typically, the focus of the evaluation is on the effect of the fall rather than the underlying cause. The first step to implement an effective falls intervention program is

to increase awareness for the hazards of falls amongst the wide range of practitioners that come into

contact with older members (e.g., PCPs, ambulatory care nurses, emergency physicians and nurses, orthopedic surgeons, physiatrists, physical therapists, home care nurses, and case managers). The second step is to encourage them to be proactive. MCOs can play an important role in providing education and simple evaluation tools (e.g., pocket cards with algorithm for diagnosis and treatment of falls).

Another barrier to implementing intervention programs for falls is that this condition currently is not readily assessed from diagnoses that are coded in administrative data. Often it is only the manifestation of the fall (e.g., contusion, dizziness, syncope, laceration, etc.) that is coded. The Lahey Clinic found that the underlying fall was coded in only 47 percent of cases.

Finally, older members may be reluctant to participate in a falls intervention program. They may minimize their problem out of fear that admitting the problem could result in loss of independence. Some older persons also refuse a home safety evaluation for this same reason. Oxford Health Plan refers to its falls- reduction program as an “Activity and Safety Program” to enhance acceptance. Further, some of the interventions described in the previous section involve out of pocket costs (e.g., installation of grab bars in the toilet or a home alert lifeline necklace). Transportation to physical therapy appointments or exercise programs can represent a significant barrier to adherence and subsequent improvement. MCOs can work with members to raise awareness for the fact that falls are often preventable and that, by seeking help, these older members stand to gain rather than lose their independence.

Economic Impact

An estimated eight percent of people over the age of 70 visit an emergency room each year as a result of a fall, about one-third of whom will be hospitalized (4). Further studies have confirmed that, compared with non-fallers, recurrent fallers have significantly higher rates of hospital, emergency department, home health, and skilled nursing facility use (10;14).

The economic impact of multiple-risk factor reduction programs has been rigorously evaluated in two randomized trials. Rizzo and colleagues conducted a cost-effectiveness analysis of a multi-factorial risk reduction program (14). Over the subsequent 12 months, health care costs were reduced by an average of $2,000 per subject compared to a program cost of $925. Savings were primarily attributed to a reduction in hospitalization. The program was found to be even more cost-effective when targeted at older adults with at least four risk factors. 12 Moreover, these savings were realized within the year of program implementation.

Salkeld and colleagues conducted a randomized trial to evaluate the effectiveness of home modification for preventing falls in a population of older adults (31). The main intervention involved an in-home assessment of potential environmental hazards followed by home modification. The authors examined changes in resource use within and between the hospital, home, and community sectors. For subjects who had fallen in the year prior to randomization (i.e., the high-risk group), the authors were able to demonstrate cost savings over the subsequent 12 months of follow-up. This study strongly suggests that in order to be cost-effective, interventions must target those older members at greatest risk.

These analyses demonstrate three important lessons. First, both of these studies point to the potential of community partnerships for delivering high quality cost-effective care, such as with senior centers, meals on wheels, Visiting Nurses Association, physical activity programs and local Area Agencies on Aging (32). Second, both studies demonstrated the importance of targeting resources to members with the highest risk for adverse events. Finally, falls prevention programs can lead to favorable economic outcomes, with gains realized within a year.

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Section 4

Medication-Related Complications

Clinical Vignette

Mrs. J.K. is a 70-year-old female new Lahey Clinic patient who reported a sensation of dizziness and a history of repeated falls. She had recently fallen and had suffered a compound fracture of her humerus. At the time of her first appointment, she was taking 14 different prescribed medications for her multiple chronic illnesses, which included coronary artery disease, diabetes, asthma, depression, anxiety, and a recent stroke. She was living in an assisted living environment and used a wheeled walker due to gait instability.

Her primary care physician suspected that part of Mrs. J.K.’s instability might be attributable to adverse effects of her medications. Together they reviewed all of her medications and found that an error had been made in the dosage of her antidepressant, resulting in her receiving several times the recommended dose.

Mrs. J.K. improved significantly after her primary care physician adjusted her antidepressant and reduced her total number of prescribed medications to nine. She enrolled in a physical activity program and regained her strength. She also participated in community activities that she had previously given up and was able to return to independent living.

Recommendations for Managed Care Organizations

MCOs should:

Implement programs targeting medication-related complications for older members irrespective of whether they offer a pharmacy benefit. Such programs should target overuse, under-use, and misuse of medications.

Improve compatibility of internal and external data systems to maximize the potential use of administrative data (diagnosis, pharmacy, and utilization) for targeted interventions.

Employ pharmacists in a liaison role between pharmacy benefit managers, practitioners, and members.

Provide educational materials and tools to practitioners and members designed to reduce medication- related complications.

Nature of the Problem

The likelihood of medication-related complication increases with the number of medications con- sumed, both prescribed and over-the-counter. Older patients received a disproportionate number of prescribed medications and therefore represent a particularly high-risk group (1-3). Approximately 14 to 24 percent of community-dwelling older adults take medications believed to be inappropriate (1-5). Medication-related complications contribute to common geriatric conditions such as falls, depression, cognitive impairment, and undernutrition (1;6-8).

Medication-related complications are an important factor in hospitalization of older adults. Different studies have reported rates that range from 10 to 31 percent of all hospitalizations and up to 45 percent of all hospital re-admissions (1;9-12). Patients who suffer adverse drug reactions in the hospital have longer lengths of stay, with an associated additional cost of $3,224 per episode (13). Medication- related complications are also a contributing factor in the 32,000 hip fractures reported each year (1).

Medication-related complications also contribute to higher utilization in settings other than the hospital. In one study, 63 percent of older adults experiencing a medication-related complication resulted in a visit to their physician’s office and 10 percent resulted in a visit to the emergency department (14). Although not all of these encounters were avoidable, the fact that medication-related complications increase utilization is well established.

The term “medication-related complications” is used in this report because it incorporates the range of potential problems older members experience, including underuse, overuse, and misuse. Specific examples include polypharmacy; the use of high-risk medications; suboptimal dosing; or underuse of medications for conditions such as congestive heart failure, depression, and chronic pain. The recommendations included in this report are consistent with national efforts to reduce medication errors and improve patient safety (15).

Ta rget Population and Risk Factors

The risk of medication-related complications not only increases with the number of prescribed medications, it also increases with age as a result of reduced physiologic reserve. Aging is associated with a decline in the ability of the liver and kidneys to metabolize medications and eliminate them from the body. In addition, age-related changes in the distribution of fat and muscle throughout the body also contribute to older adults’ sensitivity to adverse effects of certain medications. This sensitivity is heightened with concurrent use of alcohol. Because of these age-related changes in physiologic reserve and fat distribution, older adults often have a narrow therapeutic window between benefit and harm. Virtually any medication can lead to an adverse event.

Medication-related complications increase with the number of medications taken (including both prescribed and over-the-counter) due to problems of confusion over the regimen, non-adherence, and harmful drug-to-drug interaction (1). In addition, improper consumption of a single medication can pose a risk (e.g., long-acting benzodiazepines) (5;16;17). In some cases, the potential risks of the medication outweigh the potential benefits.

Older members making transitions between sites of care (e.g., those who receive short-term care in skilled nursing facilities after being hospitalized) are an often overlooked population at risk for medication-related complications. Their medication regimens require close coordination between prescribers in the hospital, skilled nursing facility, and outpatient settings to avoid inadvertent discontinuation and duplication. Furthermore, the hospital, skilled nursing facility, and community pharmacies may all have different formularies. These different formularies can confound attempts made by the older patient or the PCP to fully comprehend the regimen following discharge.

Because practitioners are prescribing medication regimens that are increasingly complex, older adults with low literacy skills or cognitive impairment are particularly at risk for complications. Similarly, older patients who cannot afford to purchase their medications are also at risk for medication-related complications, particularly due to non-adherence.

Screening and Assessment

The multiple approaches for characterizing high-risk older members have implications for screening and assessment strategies. The initial step, choosing the target population, is determined by the focus of the program, available resources, and the nature of the subsequent intervention. Strategies can target a wide range of potential medication-related complications or focus on those that are associated with certain adverse events, such as falls or confusion. Alternatively, a MCO can identify a cluster of practitioners who care for a substantial proportion of older members and screen older members within just those practices.

Analysis of pharmacy records, particularly claims files or other administrative data can serve to identify high-risk patients. Access to such data facilitates the periodic screening of the entire population of older members. Most MCOs have arrangements that allow access to claims files for their Pharmacy Benefits Manager (PBM). This data can be linked to health plan utilization data to create a more complete understanding of members’ needs. Rather than focus on the number of prescribed medications, PacifiCare uses pharmacy claims data to examine the total number of prescribed pills to be taken daily to identify members who are potentially at risk for complications.

Pharmacy claims data also facilitates screening programs that target specific high-risk medications. For example, Kaiser Permanente, Southern California Region, uses administrative data to identify older members taking long-acting sedatives (e.g., benzodiazepines) and four selected antidepressants (e.g., primary tricyclic antidepressants) based on evidence for their association with confusion, falls, and functional decline. Of the 300,000 Medicare members in this Region, 10 percent were identified as taking at least one high-risk medication and were candidates for further assessment.

However, screening using administrative data has limitations. The data may not capture whether members are in fact taking their medications as prescribed or whether they obtain medications from non-plan sources (e.g., from a non-contracted community pharmacy, a Veteran’s Hospital pharmacy, or friends or family members). In addition, administrative data do not generally reflect use of vitamins, herbal supplements, or other over-the-counter medications.

MCOs that lack access to administrative pharmacy data can still conduct effective screening programs. For example, they can ask new members to complete questionnaires designed to target older members taking more than a predefined threshold number of prescribed medications or those taking a few specific types of high-risk medications. The most commonly employed screening question for medication problems asks about the number of prescribed medications taken. Many plans view taking 5 or 6 distinct prescribed medications as an indicator of potential risk (3;10). However, the absolute number of prescribed medications does not provide insight into the types of medications taken or that the medication is essential to optimize control of a chronic illness. Although a questionnaire may be the preferred method for screening new members, periodic PCP medication review may be more efficient for existing members.

Interventions

For members identified as being at high-risk, potential risk-reduction strategies include interventions conducted by clinical pharmacists, changes to the medication formulary, and enhancements of the roles of PCPs with or without accompanying empowerment of older members. Each of these three strategies is discussed below.

Many successful interventions for reducing the prevalence of medication-related complications have utilized the expertise of clinical pharmacists. In a recent randomized trial, clinical pharmacists’ review of medication regimens in community-dwelling older patients was found to reduce inappropriate prescribing and adverse drug events by approximately 25 percent (18). In another intervention, pharmacists with training in geriatrics telephoned prescribing physicians about modifying potentially adverse drug regimens detected using a computerized surveillance data system. When the prescribing physician was reached, 24 percent of all medication regimens of concern were switched to a more appropriate alternative. This intervention resulted in a change to a lower risk alternative in 40 percent of older adults on long-acting benzodiazepines, medications shown to be strongly associated with falls and confusion (19).

Newly enrolled Medicare+Choice members at Kaiser Permanente, Colorado Region, receive a “new member phone call” by a clinical pharmacist shortly after enrollment and before their first primary care physician visit. During this call, the pharmacist explains the formulary system, the member’s co-pays and cost obligation, and reviews all previously prescribed and over-the-counter medications taken. In conducting the review, the pharmacist identifies problems associated with polypharmacy, potential adverse drug reactions, and certain high-risk medications. The pharmacist also explains conversions from non-formulary to formulary medications, suggests safer alternatives to high-risk medications, and introduces the member to special programs of relevance, such as a pharmacist-run clinic to monitor anticoagulation medications.

Kaiser Permanente, Southern California Region, takes advantage of both their cadre of clinical pharmacists and their administrative pharmacy data system. As discussed earlier, this program focuses on long-acting sedatives (benzodiazepines) and four selected antidepressants (primary tricyclic antidepressants), reflecting the strong evidence for their association with confusion, falls, and functional decline. Use of these medications at any dose triggers an alert.

Approximately 10 percent of members over age 65 were prescribed these classes of medication in 1999. The clinical pharmacists have developed an automated system whereby an alert is faxed to the primary care practitioner the night before the member has a scheduled appointment. The fax calls attention to the potential adverse effects associated with prescribing the medication in older patients and suggests

safer alternatives. Although data are not yet available to evaluate this program, their use of similar “just

in time” prescribing approaches at Kaiser Permanente, Southern California Region, have led to more

appropriate prescribing and cost reduction in conditions such as congestive heart failure and diabetes.

A second strategy is to make changes in formulary composition. This approach can entail removing

medications from the formulary that pose particularly high risk for older members, thereby creating a

“Seniors Only” formulary. Such a formulary might remove long-acting benzodiazepines such as Valium

or tricyclic antidepressants such as Amitriptyline. Group Health Cooperative has adopted such a

program. However, prescribing practitioners are allowed to override the formulary in order to maintain

an older patient on a medication that has been identified as high-risk. For this approach to be effective, it is important that safer alternatives to high-risk medications be available on the formulary.

To reduce medication-related complications resulting from transitions between care settings that have different formularies, another intervention is to foster continuity across sites. Kaiser Permanente, Colorado Region, builds into agreements with contracted skilled nursing facilities that its members in long-term care settings receive medications through the Kaiser formulary. Independence Blue Cross contracts with the Visiting Nurse Association for nurse-conducted medication reviews for Medicare members returning home from the hospital for one of 14 specific discharge diagnoses. 13 The goal of this review is to ensure that members have received the appropriate medications for their conditions from the hospital formulary and to reconcile any potential confusion or duplication between members’ pre- and post-hospital medication regimens.

MCOs can also work with PCPs to enhance their role in reducing medication-related complications. For example, one study demonstrated that a practitioner-led comprehensive review of older members’ medications (often referred to as a “brown bag session”) led to more appropriate medication regimens (10). The MCO provided practitioners with clinical practice guidelines on polypharmacy and laminated pocket cards that included a list of potentially contraindicated medications and suggested safer alternatives. Harvard Pilgrim and other MCOs offer a similar “brown bag” program for its members. These programs strive to discontinue non-essential medications and reduce prescribing or dispensing errors.

MCOs can also provide ongoing education for practitioners to improve prescribing strategies for older patients. PacifiCare has found physician profiling to be particularly effective. At any one time, two to three high-risk medications serve as the focus for the educational effort. Physicians are informed of the program, given the specific evidence-based rationale for the recommendations, and provided with strategies for medication discontinuation and a list of safer alternatives. The physicians are subsequently given periodic profiling reports that portray their performance in reducing prescribing of these medications relative to their peers.

Harvard Pilgrim has developed a similar initiative to reduce the use of particular high-risk medications directed at network physicians. In partnership with its pharmacy benefits manager (PBM), Harvard Pilgrim searches administrative pharmacy data to identify patients who have been prescribed medica- tions thought to pose substantial risk to older adults, referred to as the “gray list.” Physicians are mailed patient-level data on their prescribing patterns in addition to evidence-based information on safer alternatives. There were 867 older patients prescribed “gray list” medications in 1997. Only 39 patients were prescribed these medications in 2001, a 96 percent reduction.

MCOs can enhance their members’ role in reducing medication-related complications. For example, they can support members’ role in managing their own medications, particularly when they receive care in other settings such as the hospital or skilled nursing facility. This might include providing them with a complete medication list that can be conveniently placed in a purse or wallet. MCOs can also provide additional pharmacy services to help their older members adhere to their medication regimens or discontinue particular classes of high-risk medications. Alternatively, MCOs can direct members to programs that provide medications for free or a reduced price. For example, members may be eligible to receive medications through the state Medicaid program, the local Veteran’s Administration hospital, or programs available through pharmaceutical companies.

The pharmaceutical industry has successfully created demand for medication use via direct-to- consumer advertising. Opportunity exists for MCOs to take similar steps to assure appropriate medication utilization or to encourage changes in prescribing to safer alternatives. MCOs can use the forum of a periodic newsletter, lectures, or waiting room posters to “advertise” to older members and encourage them to discuss risk reduction approaches with their PCP. The “advertisement” could also emphasize that not all medical problems require a prescription.

Because of cognitive difficulty, some older members may not be able to assume an active role in their medication management. Kaiser Permanente, Southern California Region, uses new member screening data to identify members who may have difficulty following medication instructions due to cognitive impairment. Members who are identified as having a “severe memory impairment” receive a cognitive functional assessment and an intervention involving the primary care practitioner and pharmacist aimed at discontinuing medications known to cause confusion and simplifying the overall medication regimen. This program also assists these members with identifying a capable person to oversee the administration of their medications.

Implementation Barriers

Barriers to MCOs’ implementing interventions designed to reduce medication-related complications occur at the level of data systems, practitioners, and members. Not having access to members’ pharmacy data because prescription drugs are not a covered benefit is a barrier to many of the interventions discussed. Some of the more effective interventions have merged different data sources to further enhance identification and monitoring of outcomes. Combining disparate data systems, such as pharmacy data, diagnostic data, and utilization data sources can be difficult outside of a fully integrated delivery system. Further, tracking medication use in older patients making transitions across different settings may require access to different pharmacy databases.

Many successful interventions have relied on pharmacists who suggest management strategies to prescribing practitioners. However, practitioners do not always positively receive such suggestions. Practitioners may not be comfortable switching to recommended alternatives or changing a medication prescribed by another practitioner (i.e., a specialist or practice partner). There are steps that can be taken to improve receptivity. These include limiting the suggestions to categories of medications for which practitioners have given prior input, providing the rationale for suggestions with references from credible sources, targeting the prescribing practitioner, and providing information in a way that is minimally intrusive to clinic flow (e.g., a fax the day a patient is to be seen in the ambulatory clinic).

Older members may be reluctant to discontinue particular high-risk medications, even when recommended to do so by their PCP. Members may not have a drug benefit and thus may not be able to afford the prescribed medication. Members with a drug benefit may be concerned about exceeding their annual pharmacy benefit.

Economic Impact

Although empiric evidence for potential cost savings from interventions designed to reduce medication- related complications is limited, it is the Workgroup’s judgment that significant opportunity exists for cost-effective interventions.

In order to better understand factors associated with prolonged length of stay, Group Health Cooperative reviewed records for surgical patients who received post-hospital care in a subacute facility. Overuse of sedating pain medications in both the hospital and the subacute facility accounted for the majority of cases. Through their contribution to delirium and constipation, use of these medications were found to interfere with participation in rehabilitation and thereby delay discharge. This problem is currently being addressed through an educational initiative that targets prescribing practices of hospitalists and surgeons.

All of the PACE (Program of All-Inclusive Care for the Elderly) sites have a mandatory medication review by a clinical pharmacist every 30 days. As a result of this intervention, the PACE site at Henry Ford Health Care System reduced pharmacy expenditures from $178 to $118 per member per month, a 34 percent decline.

Kaiser Permanente, Mid-Atlantic Region, has initiated a hospital-based pharmacy rounding service at two contract hospitals. Pharmacists review patient charts, assess optimal drug therapy, identify candidates for home intravenous therapy, facilitate timely discharge, and serve as a resource to PCPs and nurses. Receptivity to their recommendations has been high, with an acceptance rate approaching 99 percent. This program has achieved savings of $523,907 for a $57,643 investment (20). The savings have come from using alternative medication therapies, optimizing dosing, discontinuing unnecessary medications, and reducing hospital days (e.g., expedited transition from intravenous to oral medication delivery, facilitating earlier discharge home with support to continue therapy, and reducing adverse drug reactions). Kaiser Permanente, Mid-Atlantic Region, is currently expanding this service to their contract skilled nursing facilities.

Reference List

(1)

Government Accounting Office. Prescription drugs and the elderly. GAO/HEHS-95-152, 1-30. 1995.

(2)

Golden AG, Preston RA, Barnett SD, Llorente M, Hamdan K, Silverman MA. Inappropriate medication prescribing in homebound older adults. Journal of the American Geriatrics Society 1999; 47:948-953.

(3)

Nolan L, O’Malley K. Prescribing in the elderly part I: sensitivity of the elderly to adverse drug reactions. Journal of the American Geriatrics Society 1988; 36(2):142-149.

(4)

Wilcox SM, Himmelstein DU, Woolhandler S. Inappropriate drug prescribing for the community-dwelling elderly. JAMA 1994; 272(4):292-

296.

(5)

Stuck A, Beers M, Steiner A, Aronow H, Rubenstein L, Beck J. Inappropriate medication use in community-residing older persons. Archives of Internal Medicine 1994; 154:2195-2200.

(6)

Herings RMC, Stricker BHC, DeBoer B, Bakker A, Sturmans F. Benzodiazepines and the risk of falling leading to femur fractures. Archives of Internal Medicine 1995; 155:1801-1807.

(7)

Chutka DS, Evans JM, Fleming KC, Mikkelson KG. Drug prescribing for elderly patients. Mayo Clinical Proceedings 1995; 70:685-693.

(8)

Katz IR, Sands LP, Bilker W, DiFilippo S, Boyce A, D’Angelo K. Identification of medications that cause cognitive impairment in older people:

the case of oxybutinin chloride. Journal of the American Geriatrics Society 1998; 46:8-13.

(9)

Bero L, Lipton H, Bird J. Characterization of geriatric drug-related hospital readmissions. Medical Care 1991; 29(10):989-1003.

(10)

Fillit H, Futterman R, Orland B, Chim T, Susnow L, et al. Polypharmacy management in Medicare managed care: changes in prescribing by primary care physicians resulting from a program promoting medication reviews. American Journal of Managed Care 1999;

5:8587-594.

(11)

Gerety M, Soderholm-Difatte V, Winograd C. Impact of prospective payment and discharge location on the outcome of hip fract ure. Journal of General Internal Medicine 1989; 4(5):388-391.

(12)

Culler S, Parchman M, Przybylski M. Factors related to potentially preventable hospitalizations among the elderly. Medical Care 1998;

36(6):804-817.

(13)

Bates D, Spell N, Cullen D, Burdick E, Laird N, et al. The costs of adverse drug events in hospitalized patients. JAMA 1997; 277(4):307-311.

(14)

Hanlon J, Schmader K, Koronkowski M, Weinberger M, Landsman P, et al. Adverse drug events in high risk older outpatients. J ournal of the American Geriatrics Society 1997; 45(8):945-948.

(15)

Agency for Health Care Quality Research. Medical errors: the scope of the problem. 1-4. 2000. Rockville, MD.

(16)

Beers M. Explicit criteria for determining potentially inappropriate medication use by the elderly: an update. Archives of Internal Medicine 1997; 157(14):1531-1535.

(17)

Coleman E, Grothaus L, Sandhu N, Wagner E. Chronic care clinics: a randomized controlled trial of a new model of primary care for frail older adults. Journal of the American Geriatrics Society 47(7), 775-783. 1999.

(18)

Hanlon J, Weinberger M, Samsa G, Schmader K, Uttech K, Lewis I et al. A randomized, controlled trial of a clinical pharmacist intervention to improve inappropriate prescribing in elderly outpatients with polypharmacy. American Journal of Medicine 1996; 100(4):428-437.

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Monane M, Matthias D, Nagle B, Kelly M. Improving prescribing patterns for the elderly through an online drug utilization review intervention:

a system linking the physician, pharmacist and computer. JAMA 1998; 280(14):1249-1252.

(20)

Yee DK, Veal JH, Trinh B, Bauer S, Freeman CH. Involvement of HMO-based pharmacists in clinical rounds at contract hospitals. American Journal of Health System Pharmacy 1997;54:670-673.

Section 5

Dementia

Clinical Vignette

Mr. N.L. is a 78-year-old married man with progressive memory loss who presented to the Lahey Clinic. His wife reported that Mr. N.L. had been experiencing increasing difficulty carrying out basic functional tasks such as dressing and bathing and had developed a fear of being left alone. As his sole caregiver, his wife was becoming depressed and overwhelmed. His children, from a previous marriage, have refused to help in his care.

Following a complete evaluation by his primary care physician, Mr. N.L. was diagnosed with Alzheimer’s Disease. His physician initiated treatment with a dementia medication (an acetylcholinesterase inhibitor) and made a referral to a local senior service agency to facilitate obtaining additional services for the member and his wife.

A referral was also made to a local senior day care center, and Mr. N.L. agreed to attend three days per week. During this time, his wife has attended caregiver support groups offered at the local chapter of the Alzheimer’s Association. This respite has not only helped his wife better understand and manage her husband’s condition, it has also led to an improvement in her depression. In appreciation for the care and assistance her husband has received, she made a philanthropic contribution to the clinic in the form of an ongoing annuity.

Recommendations for Managed Care Organizations

MCOs should:

Work with practitioners and members to increase awareness of dementia to facilitate early identification and appropriate management.

Enhance practitioners’ ability to diagnosis and manage dementia by providing education, facilitat- ing linkages to community agencies and caregiver support groups, and increasing awareness of the negative effect of dementia on the management of comorbid conditions to promote the highest level of functional independence possible.

Involve the member’s family and caregivers as an integral part of the care team and provide education and community linkages to support their efforts.

Encourage practitioners to communicate with not only the member with dementia, but also with his or her family and caregivers to facilitate the execution of the care plan.

Encourage members with dementia and their families to participate in planning regarding advanced directives for health decisions as well as for financial and legal matters.

Partner with local agencies serving older adults with dementia and their caregivers to assure that appropriate services are available in the community.

Nature of the Problem

The growing population of older members with dementia presents formidable challenges to MCOs. The progressive cognitive deterioration associated with dementia interferes with self-care activities, management of other comorbid conditions, and personal safety. As a result of this cognitive decline, older members experience problems following treatment instructions, reporting symptoms, taking medications appropriately, keeping appointments, and participating in rehabilitation programs (1;2). Dementia also exacts a significant toll on the health of family caregivers, many of whom may already be in poor health and may also be members of the same MCO (3-6).

Multiple studies have documented that older persons with dementia experience higher total costs of care compared to those without dementia. Taylor and colleagues found that, in 1994, average total costs (including inpatient, ambulatory, home health, skilled nursing facility, hospice, and durable medical equipment) for persons with dementia were $6,021 versus $2,310 for persons without the diagnosis (7). Gutterman and colleagues reported mean total annual costs that were approximately 1.5 times higher in Medicare MCO patients with dementia compared to those without dementia (8). Per capita Medicare expenditures for patients with dementia have been found to be nearly twice the average for all Medicare beneficiaries, with inpatient care accounting for 63 percent of expenditures (9). Weiler and colleagues demonstrated that persons with dementia were twice as likely to be hospitalized compared to persons without dementia (10). Similarly, older persons with dementia frequently have a longer mean length of stay (11). The higher rate of inpatient utilization is commonly attributed to the role of dementia in complicating the care of other acute and chronic conditions and prolonging discharge planning (12).

However, not all studies have demonstrated this relationship. McCormick and colleagues compared Group Health Cooperative members without dementia to those with dementia and found that the latter had lower costs during the last 3 years preceding death (13). The relationship between dementia and cost of care may depend on which stage of the condition is examined (i.e., early versus late dementia).

By adversely affecting the management of other comorbid conditions, such as heart failure, chronic pulmonary disease, and cerebrovascular disease, dementia can contribute to higher costs of care. In one study, 93 percent of persons with dementia had at least one comorbid condition, and 61 percent had 3 or more (14). Newcomer and colleagues found that mean annualized Medicare expenditures for congestive heart failure patients with dementia were $16,067 compared with $6,463 for congestive heart failure patients without dementia (15). Similar cost relationships were found for heart attack, stroke, diabetes, chronic lung disease, and hip fracture (8;15). Coexistent depression and dementia has also been associated with significantly higher utilization than depression without dementia (16).

These findings reflect, in part, the fact that persons with dementia have difficulty reporting symptoms and following prescribed treatment regimens. Such delays in reporting exacerbation of comorbid con- ditions may lead to situations that require greater treatment intensity to stabilize the problem, such as

an emergency department visit or hospital admission. Persons with dementia are also more likely to experience falls and associated fractures, medication-related complications, and undernutrition. Thus, whether due to independent effects on utilization and costs or negative effects on the management of other prevalent and costly comorbid conditions, there are powerful financial incentives for identifying and treating dementia in MCOs.

Current estimates suggest that 5-10 percent of persons over age 65, and nearly 50 percent of persons over age 85, are afflicted with dementia (3). Alzheimer’s disease is the most common cause of dementia in the United States, accounting for at least two-thirds of all cases. Vascular dementia is the second most common etiology. 14

Dementia is often unrecognized or misdiagnosed, particularly in its early stages. A two- to three-year delay in diagnosis is not uncommon (17). In one study, 65 percent of patients with probable dementia and 82 percent of patients with mild cognitive impairment did not have an assessment documented in their medical record (17). Harvard Pilgrim found that primary care physicians were unaware of the diagnosis of dementia in 50 percent of cases. Correct recognition can prevent costly and inappropriate treatment resulting from misdiagnosis and give patients and their families time to prepare for the challenging financial, legal, and medical decisions that lie ahead (3).

Ta rget Population and Risk Factors

Although dementia is not an inevitable consequence of growing older, advanced age remains an important risk factor. Increasing scientific evidence suggests that in a minority of cases there may be a familial predilection, pointing to the importance of obtaining a family history for dementia in older patients (3). Other risk factors include prior history of stroke or transient ischemic attacks, Parkinson’s disease, alcoholism, or head injury severe enough to cause loss of consciousness.

Screening and Assessment

Early diagnosis is critical to improving management of members with dementia. Given the increasing prevalence of dementia with advancing age, an argument could be made to screen all members greater than 75 years of age. Screening programs can also be developed that encourage members and caregivers to seek care in the setting of particular “trigger” symptoms. Additional tools have been developed to facilitate screening by any member of the healthcare team, including the PCP, nurse, case manager, or receptionist. PCPs should be aware of particular situations that might indicate the presence of demen- tia, including confusion over medications, one or more episodes of delirium, unexplained falls, or a motor vehicle crash.

Kaiser Permanente, Southern California Region, asks all new members, “During the past few months, have you had increasing problems with severe memory loss?” Kaiser researchers have compared the utility of this single question with more rigorous dementia screening instruments as well as review of

the medical record. Among those new members who answered affirmatively to the single question, 89 percent were subsequently found to meet criteria for cognitive impairment or dementia.

The Alzheimer’s Association has developed a 10-item “Warning Signs of Dementia” (Table 1) which consists of a list of common trigger symptoms that are suggestive for dementia. These symptoms are similar to those included in the screening guidelines developed by the Agency for Health Care Policy Research (AHCPR)(3). Both the Alzheimer’s Association and the AHCPR trigger symptoms were designed to promote greater awareness for dementia by the healthcare team. Further assessment for dementia is recommended when health care providers detect positive answers to either these trigger symptom questionnaires or evidence of more global cognitive impairment.

Similar screening tools have been developed

that rely on self-report from family members and caregivers. The Alzheimer’s Association, in collaboration with the National Chronic Care Consortium, has developed a 5-item questionnaire 15 to be completed by a family member or caregiver (Table 2). “The Memory Problems Checklist” is another such instrument that has been validated against more formal tests of cognition (18). An affirmative response to 5 of the 11 questions suggests the presence of dementia and the need for further assessment.

Table 1. Warning Signs for Alzheimer’s Disease (Developed by The Alzheimer’s Association)

Have you noticed changes like these in someone you know?

Forgets things more often.

• Has problems doing familiar things.

Puts things in strange places.

Forgets common words or uses wrong words.

• Has frequent problems with complicated tasks.

• Has a major change in personality (confused, suspicious, or afraid).

• Is confused about where they are (or what time of day it is).

• Has lost interest in doing things (or loses interest quickly if not encouraged).

• Has sudden change in mood or behavior.

Does things that don’t seem to make sense.

Positive findings in any of these areas generally indicate the need for further assessment for the presence of dementia.

Table 2. Family Questionnaire (Jointly developed by The Alzheimer’s Association and National Chronic Care Consortium)

 

In your opinion, does the person in question have problems with any of the following? (Please circle the appropriate answer)

Repeating or asking the same things over and over?

not at all

mild

severe

Remembering appointments, family occasions, holidays?

not at all

mild

severe

• Writing checks, paying bills, balancing the checkbook?

not at all

mild

severe

• Deciding what groceries or clothes to buy?

not at all

mild

severe

• Taking medications according to instructions?

not at all

mild

severe

Relationship to patient

(spouse, son, daughter, brother, sister, grandchild, friend, etc.)

Administrative records are generally not a reliable means for identifying persons with dementia as the diagnosis is infrequently and inconsistently coded in the hospital, emergency department, or ambulatory settings (9;15).

Following a positive screen, a detailed evaluation is appropriate. In most cases this entails a more comprehensive mental status test. No single test has been found to be clearly superior. The Folstein Mini-Mental Status Evaluation (MMSE) is the most widely recognized and has been tested in individuals with different education, socioeconomic, and cultural backgrounds (19). Other tests include the Blessed Orientation-Memory-Concentration and the Short Portable Mental Status Questionnaire (20;21).

In practice, PCPs may not have adequate time or resources to administer the more comprehensive assessments (e.g., the MMSE), which has prompted the development of shorter evaluations (22). These include the Clock Drawing test and the Time and Change test (23;24). These tests are brief and simple and have been shown to correlate with more rigorous evaluations including the MMSE (24;25). The Clock Drawing test entails asking the patient to draw the face of a clock and place the hands at a pre-designated time. There are several scoring systems, the most commonly employed of which is the “Simple Scoring System.” It entails awarding a point for: the approximate drawing of a clock face, the presence of numbers in sequence, the correct spatial arrangement of numbers, the presence of clock hands, clock hands that approximately show the correct time, and clock hands that depict the exact time. Missing one or more points is indicative of cognitive impairment. A formula has been developed to convert this clock-drawing score to a MMSE Score [MMSE= 2.4 (Clock Score) + 12.7] (26).

The Time and Change test has two parts. First, the patient must correctly interpret the time of a clock face set at 11:10. Two attempts are allowed for a correct response within a 60-second period. Second, three quarters, seven dimes, and seven nickels are placed in front of the patient, who is prompted to give one dollar in change. Two attempts are allowed for a correct response within a 120-second period (23).

Results on a mental status exam alone is not sufficient to make the diagnosis of dementia. Additional components of the assessment include a focused history, a physical exam, and a functional status evaluation. Because making the diagnosis of dementia can be difficult in the setting of depression or medication-related complications, a depression evaluation and a comprehensive medication review (with particular attention to medications with sedative or anticholinergic properties) are also recommended. Family and close friends are invaluable sources of information on whether the member’s functional needs are being met in the current environment. Obtaining a brain imaging study, such as a CAT scan or MRI, as a routine component of the evaluation is not supported by current scientific evidence (27).

Kaiser Permanente, Colorado Region, refers members with dementia to a Senior Care Coordinator who conducts a comprehensive assessment that consists of an evaluation of the member’s medical needs, mental status, informal caregiving resources, vision, and hearing. With the member’s consent, the Senior Care Coordinator makes a referral to the local chapter of the Alzheimer’s Association. Following an assessment and care planning session, the Alzheimer’s Association staff person then discusses the care plan with the Senior Care Coordinator to ensure coordinated care.

Interventions

The expected positive outcomes for the care of patients with dementia differ from traditional outcomes of care (28;29). For example, expected positive outcomes may include improved management of other comorbid conditions, improved referral rates to community organizations such as the Alzheimer’s Association, improved caregiver physical and mental health status, fewer injuries attributed to home safety, and lower rates of institutionalization.

Dementia can be treated through both non-pharmacologic and pharmacologic means, which can be employed either separately or concurrently. Treatment often entails the participation of both the mem- ber and informal caregiver(s). As with all of the geriatric conditions discussed in this report, MCOs need to do more than encourage PCPs to detect problems such as dementia. Rather, they need to provide them with brief and efficient screening and assessment instruments, facilitate linkages to com- munity resources, provide access to care managers and social workers skilled in the dementia care, and encourage adherence to post-diagnosis treatment guidelines. Although some aspects of dementia man- agement may take place outside of the clinic, the ongoing role of the primary care team in managing medications (i.e., avoiding medications that may negatively affect cognitive function), encouraging advanced care planning, and careful monitoring to avoid health crises remains critical to the success of any intervention.

Nonpharmacologic approaches are primarily aimed at training caregivers to handle disruptive behavior, facilitating referral to available resources for persons with dementia and their caregivers, and ensuring the member’s safety. Resources which may help patients and caregivers include caregiver education programs, adults day care programs, and respite programs. Local chapters of the Alzheimer’s Association offer support groups for caregivers with dementia that specifically address managing disruptive behavior. Mittelman and colleagues have shown that providing family caregivers with a comprehensive support and counseling program is effective in delaying time to nursing home placement by more than 30 percent (30). This program consisted of six sessions offered over four months and was followed by a support group that met on an ongoing basis. Hepburn and colleagues demonstrated that a family training intervention aimed at improving knowledge and skills significantly improved outcomes for both persons with dementia and their caregivers (31).

Local Area Agencies on Aging (AAAs) are another important resource to support family members and friends in their role as caregivers. For example, the Lahey Clinic partners with its local AAA for in-home assessment and caregiver support for older members with dementia.

The Lahey Clinic also partners with local AAAs that provide adult day health programs for persons with dementia. These programs provide the opportunity for appropriate activities and socialization for persons with dementia and regular short-term respite for their caregivers. To facilitate care coordina- tion, AAA representatives provide regular feedback to Lahey practitioners. Sierra Health Services has partnered with local adult day health programs to provide respite to caregivers who need to access community resource programs such as support groups offered by the Alzheimer’s Association.

Completion of advanced directives early in the course of the illness while the member has insight and can participate in the discussion is another reason for MCOs to initiate programs aimed at early detection

of dementia. The objective of these discussions is to encourage the member to make informed decisions regarding which types of treatment are acceptable and to designate the most appropriate person to assist with health care decisions should the member be incapacitated (i.e., a durable power of attorney for health care). These discussions are important because many older adults with dementia receive treatment that is either inconsistent with their preferences or is of questionable therapeutic efficacy. For example, tube feeding (placing a tube through the nose and into the intestine or placing a tube through the skin into the person’s intestine to directly provide liquid nutritional supplement) has received much attention in the media and the scientific literature. In most circumstances, this intervention does little to prolong life or improve quality of life and can often result in medical complications (32;33). A recent study found that 90 percent of persons with end-stage dementia received treatments believed to be burdensome yet had no documentation in their records that any discussion took place regarding goals of care (34).

Pharmacologic management seeks to slow the rate of decline in cognitive function and facilitate the management of disruptive behavior. The medications do not provide a cure, and pharmacologic management may not be as widely applicable to persons with dementia as the non-pharmacologic strategies discussed above. Three memory-enhancing prescribed medications currently available to reduce disease progression include Donapezil (Aricept), Rivastigmine (Exelon) and Galantamine (Reminyl). Non-prescribed medications include vitamin E and Ginko Biloba. Treatment benefits of these medications have been modest. However, because there is no reliable way of predicting which patients will benefit, a one-to-two month trial may be appropriate. 16 MCOs can serve as an educational resource to clinicians unfamiliar with these medications and those designed to control associated behavioral disturbances. Several excellent sources are available on the effective management of behavioral symptoms of dementia (3;35-37).

Three MCOs in Southern California, Kaiser Permanente, Scripps Health, and University of California San Diego, have developed a partnership to improve the care of their members with dementia. The MCOs are collaborating with Meals on Wheels, the Caregiver Resource Center, and the local chapter of the Alzheimer’s Association in order to develop a web-based standardized intake for persons diagnosed with dementia. After giving permission, older members and their caregivers are asked to provide information only once, thereby reducing the burden of multiple intake questionnaires. This intake facilitates sharing of information among the three relevant community providers on a “need to know” basis. The three MCOs have defined a minimum level of quality dementia care that all members should receive including care management, ensuring that members obtain necessary services (i.e., Medicaid, adult day services, respite care) and support for informal caregivers.

Similarly, at the Centura Senior Life Center in Colorado, the MCO case manager communicates electronically (with appropriate safeguards for confidentiality) with the Alzheimer’s Association chapter case manager about the management of common older patients with dementia. These approaches reduce the burden on members to complete multiple surveys and facilitate communication between relevant practitioners and community agencies.

Finally, MCOs can go beyond the purview of direct patient care to support the care of members with dementia. They can work collaboratively with local community agencies to ensure that appropriate services are available to serve members and their informal caregivers. Table 3 provides representative examples of the types of community resources available to assist persons with dementia and their caregivers. In addition to ensuring that practitioners are aware of these community resources, MCO collaboration may also entail developing strategic relationships with individual agencies (e.g., serving on the community board) or developing strategic relationships with the leadership of community-wide providers of dementia care.

Table 3. Community Resources of Potential Benefit to Persons with Dementia

Case Management Services

• Educational Programs • Support Groups • Low Cost Counseling • Crisis Counseling and Hotlines • Bereavement • Advance Directives • Legal Services • Financial Planning

• Adult Day Care

• Housing Assistance (Assisted Living, Board and Care)

Respite Care

• Home Health Services

• Meals on Wheels

• Long Term Placement

Implementation Barriers

It has taken many years for dementia to be accepted as medical condition rather than being considered a normal manifestation of growing older. Clinicians may mistakenly believe that persons with dementia are unable to experience improvements in function or quality of life and, therefore, not invest time or resources in their care. The absence of tools, incentives, and resources to support PCPs in the identification and management of members with dementia is yet another barrier. Persons with dementia comprise a relatively small portion of a primary care practice. PCPs often do not have adequate time or training to administer and interpret comprehensive mental status assessments (22). Finally, PCPs may not feel that providing linkages to community agencies or supporting informal caregivers is within their scope of responsibility.

Denial on the part of the member and their caregivers is another barrier to implementing dementia programs. Given the historical stigma of the diagnosis and the absence of a cure, encouraging members to participate in self-administered screening programs can be difficult. Also, family members may not disclose symptoms of cognitive impairment to a practitioner, believing that they are protecting the loved one from being exposed or institutionalized. Family members may help older patients compensate for their cognitive decline at the expense of their own health. Not having a caregiver that can both assist the member and serve as an advocate for obtaining care is another barrier to diagnosis and management.

Economic Impact

Current evidence suggests significant potential for reducing hospital use for persons with dementia, such as by targeting these patients at the time of admission and initiating strategies to prevent delirium or improve its management (39;40). Careful attention to prevention of pressure ulcers and urinary tract infections is also important. Collaborative management arrangements with psychiatric facilities may also reduce hospitalization of persons with dementia who experience behavioral disruption that cannot be managed in the ambulatory setting.

Evidence is growing that early identification of dementia reduces use of ambulatory services. McCormick and colleagues demonstrated that ambulatory visits decreased following diagnosis of dementia (41). Making the diagnosis appears to help members and family members better understand the change in health status and allay feelings of distress. Programs that facilitate early detection and support members potentially lead to more appropriate outpatient utilization.

Fostering more effective management of behavioral symptoms through family and practitioner educational programs may reduce hospital and nursing home use (30). Shelton and colleagues found that providing persons with dementia and their caregivers with additional supportive services led to a 40 percent reduction in hospitalization utilization among caregivers. These services included an initial in-home assessment conducted by a nurse case manager, identification of medical and psychosocial problems and service needs for both the patient and the caregiver, and the development of a detailed care plan. Care plans were developed in conjunction with the patient and caregiver and were shared with the primary care physician. Case managers provided authorization and monitoring of all services for a monthly capitation rate for each patient (5).

Favorable economic impact for persons with dementia may also be achieved by improving management of concurrent comorbid conditions. Advancing age is a risk factor for chronic conditions besides dementia, including congestive heart failure, chronic obstructive pulmonary disease, diabetes, and arthritis. Dementia can confound treatment of these conditions through poor adherence to diet and medications. Further, patients with these conditions and concurrent dementia may be less likely to receive early intervention for an exacerbation of a chronic condition due to underreporting of sentinel symptoms. Suboptimal management of these conditions can precipitate higher utilization of ambulatory, emergency, and hospital services.

For example, older persons with dementia who fracture their hip may not be able to fully comprehend post-surgical rehabilitation instructions. If this lack of comprehension is not taken into account, their recovery can be prolonged and their risk of re-fracture heightened. This is not to say that persons with dementia do not benefit from interventions such as surgery to repair a fractured hip. Persons with dementia, in an appropriately tailored surgical and rehabilitative care program, can achieve similar levels of functional improvement and rates of return to community living as persons without dementia

(42-44).

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Section 6

Depression

Clinical Vignette

Mr. B. is a 75-year-old member of Independence Blue Cross who experienced recurrent hospital admissions for congestive heart failure. Traditional attempts at improving the management of his disease were attempted, but without success. An astute care manager wondered whether additional factors complicated his care. She screened for depression and found Mr. B. to be depressed. She also learned that, following the death of his wife, he failed to comply with his medication regimen and began drinking excessively. Mr. B. stated that the attention he received from the staff in the hospital was his only source of counseling for his depressed mood. The case manager brought the depression to the attention of his primary care physician and facilitated referral to the plan’s behavioral health program. Mr. B.’s mood, energy, and participation in the self-care of his congestive heart failure gradually improved. His only subsequent contact with the hospital was on the anniversary of his wife’s death, when he visited to deliver flowers and chocolates to the nursing staff as an expression of his appreciation.

Recommendations for Managed Care Organizations

MCOs should:

Heighten awareness among both members and practitioners of the impact of depression on quality of life and on the management of other acute and chronic conditions.

Regard older members with chronic illnesses and those receiving rehabilitation for conditions such as stroke and myocardial infarction as candidates for targeted screening.

Support the development of evidence-based treatment programs that include primary care teams (formal or informal) with expertise in diagnosing and treating depression in older adults, active monitoring of patients started on treatment, and consultation from mental health specialists for patients who do not improve with treatments offered by the primary care team.

Ensure that primary care practitioners have the tools, incentives, and resources to facilitate identifi- cation and appropriate monitoring of older members with depression.

Facilitate effective communication between primary care and mental health services. Whether mental health services are internal or external (i.e., “carve-outs”), MCOs should ensure that they communicate with the primary care practitioner, offer expertise in geriatric psychiatry, prescribe medications that are accessible to members via the medication formulary, and manage members across the care continuum.

Nature of the Problem

Depression has a significant impact on both function and quality of life in older adults and is associated with greater use of health care services (1-11). Depression can be more disabling than diabetes, angina, lung problems, or back ailments (11;12). The reciprocal relationship between disability and depression has been clearly established, and effective treatment for depression can significantly improve quality of life in older adults (13).

Older patients who suffer from both depression and other chronic medical conditions have worse outcomes than those without depression (3;10;14;15). Depressed older persons with cardiovascular disease and stroke have significantly higher rates of mortality and morbidity compared to those without depression (16;17). Further, older patients with depression achieve less benefit from rehabilitation for conditions such as stroke, Parkinson’s disease, heart disease, pulmonary disease, and hip fracture (6;18). In the outpatient setting, untreated depression can complicate the management of common and costly chronic illnesses, including diabetes, asthma, and congestive heart failure (19).

Depressed older patients incur significantly higher inpatient and outpatient costs than do those patients who do not suffer from depression. After controlling for co-morbidity, depressed patients have been found to have about 50 percent higher mean total costs than persons without depression, attributed to higher utilization in every category of care (i.e., emergency department, primary care, medical specialty, medical inpatient, pharmacy, laboratory) (5;7;20-22). These patients have been found to have 38 percent more visits and 61 percent higher total charges in the outpatient setting compared with non-depressed older patients (22). In the time period immediately following a heart attack, older patients with depression have 41 percent higher total costs compared with those without depression (23).

Estimates for the prevalence of major depression by treatment setting are as follows: 5-10 percent of community-residing outpatients, 30-40 percent of persons recently hospitalized, and 15-30 percent of older persons residing in long-term care facilities (6;24). The prevalence of minor depression is believed to be greater, although the epidemiology is less well developed.

Depression in late life differs from its manifestation in younger populations. The predominant symptoms in older adults may be a lack of interest in activities or a loss of energy in contrast with depressed mood, which is more common in younger adults. Suicide is more common in late life, with older male adults comprising the highest risk of all age groups (25). Depression is often accompanied by other conditions discussed in this report, including dementia, undernutrition, and urinary incontinence (26-28).

Many depressed older individuals are not appropriately diagnosed and do not receive treatments of established efficacy, whether in managed care or fee-for-service delivery systems (14;29-32). Garrard found that only half of patients with self-reported depression were detected by their health care practitioners (33). Even when primary care physicians do diagnose depression, they infrequently provide treatment that is in accordance with evidence-based practice (22;34;35).

Ta rget Population and Risk Factors

Certain situational or social risk factors are associated with an elevated risk for depression. Older persons who are socially isolated with little informal support are at greater risk for depression, as are older persons who have experienced either a change in their ability to function in prior roles or a decline in physical independence. Similarly older adults making transitions between sites of care (e.g., transition from hospital to a skilled nursing facility) are another high-risk group. Loss of a spouse, family member, close friend, or a pet can also increase risk. Chronic pain, alcohol and substance abuse, and terminal illness approaching the end of life represent additional important factors.

Members with chronic medical conditions are also at risk, particularly those who have Parkinson’s disease or who recently experienced a heart attack or stroke (24;36). By virtue of this association, significant numbers of older members enrolled in disease management or case management programs are likely to be depressed. Because of a high likelihood for relapse (nearly 40 percent), a prior history of depression is a significant risk factor for developing depression in the future (6).

Finally, older white men are the highest risk group for suicide (37). An astounding 75 percent of these men visited their primary care physician within the preceding month of their deaths; however, their symptoms were largely unrecognized and untreated (6).

Screening and Assessment

Brief screens for depression can be administered as part of mailed screening to members or during scheduled outpatient visits and annual examinations. Screening can also be targeted to older members who exhibit the risk factors described in the previous section (e.g., post-myocardial infarction or stroke) or those receiving care in certain settings (e.g., admission to subacute care). Receptionists at selected VA general medicine clinics have been trained to administer brief screening tools for depression to patients while they are waiting for their appointment. PacifiCare members have the opportunity to download education materials and self-screen for depression using an instrument available on its web site as part of a program entitled, “Taking Charge of Your Depression.” Members who score above a predetermined threshold are advised to discuss their results with their primary care physician.

The most widely used screening question for depression inquires whether an individual often feels “sad or blue” (sometimes “sad or depressed” is substituted). The principal advantage of this question is its ease of use and acceptability by older patients. It has been directly compared with more formal depres- sion screening instruments such as the 30-item Geriatric Depression Scale (GDS) and found to have

comparable predictive accuracy (one question—sensitivity = 0.69, specificity = 0.90; GDS—sensitivity

= 0.54, specificity = 0.93) (38;39). MCOs that ask this question find a high incidence of undiagnosed

depression among their enrolled older population. For example, Group Health Cooperative has found that, on average, 23 percent of screened older members answer yes to the single “sad or blue” question, as do 11 percent of older Kaiser Permanente, Colorado Region, newly enrolled members, 16% of Oxford members, and 17 percent of Sierra members.

Similarly, Whooley found that a screen comprised of two simple questions was comparable to screening using more comprehensive instruments (40). These questions were: “During the past month have you often been bothered by feeling down, depressed or hopeless?” and “During the past month, have you often been bothered by little interest or pleasure in doing things?” Mulrow compared nine different screening instruments and found no significant difference in predictive accuracy (41).

Administrative data have not traditionally been employed as a means for screening for depression, but

a number of studies have used such data to identify patients for quality improvement efforts for depression in primary care (42-46). They can serve to identify members with such risk factors such as previous diagnosis or treatment of depression; high use of medical services; and high-risk medical conditions such as heart disease, stroke, Parkinson’s disease or dementia. In collaboration with their pharmacy benefit managers, MCOs can also use administrative data to identify members who are on antidepressants or who have recently received escalating dosing of pain medications. Kaiser Permanente, Colorado Region, uses administrative data to identify members who have experienced the death of a spouse in the past three months. After obtaining consent, a Widowed Person Services volunteer invites the recently widowed member to one of four support groups held in the Denver metropolitan area.

Members who respond affirmatively to a simple depression screen require further assessment. This may involve such tools as the Geriatric Depression Scale (GDS), the Hamilton Depression Scale, the Beck Depression Inventory, or the revised Diagnosis and Statistical Manual (DSM IVR) (38;47;48). These validated tools have been used extensively in older populations.

Other important components of a depression assessment in addition to use of formal depression appraisal tools include evaluation for social isolation, cognitive decline (dementia and depression often present concurrently), substance abuse (alcohol in particular), and suicidal ideation. In addition, medications that may contribute to depressive symptoms, such as Digoxin, beta-blockers, steroids, and sedative/ hypnotic medications, need to be considered. Assessing the adequacy of pain control in the setting of chronic pain is another component in the evaluation of depression.

Interventions

Older adults respond to treatment for depression and are as likely to improve with early intervention as are younger adults (49;50;51). Most studies have focused on treatment of major depression, although interest in minor depression is increasing (6;51;52).

The hallmarks of successful treatment programs entail collaboration between mental health specialists and PCPs (i.e., depression care teams), active follow-up of patients started on treatment, and additional

monitoring visits in primary care. The collaboration between PCPs and mental health specialists can be face-to-face, telephonic, or via written communication. These teams can either be structured formally (i.e., having the same mental health specialists attend primary care clinics on certain days) or informal (ad hoc communication about a given patient or patients). In addition, decision support is another effective tool in depression management. For example, practitioners who initiate pharmacologic therapy may receive a reminder to re-evaluate symptom response and consider adjusting the dose of medication after six weeks. Although most of these strategies have been developed and tested in group and staff model MCOs, creative adaptations of these models in other settings appears feasible (19;53;54).

Depression is a chronic illness with high rates of recidivism that can be reduced most effectively with pharmacologic treatment, brief cognitive behavioral therapy, or the two in combination (50;51). Overall, controlled trials have demonstrated that these approaches are safe and effective for both major and minor depression (50;55).

One of the more promising approaches for treating depression in older adults is to provide the primary care team with greater support and mental health expertise. Many older members prefer to be treated in the primary care setting rather than being referred to a mental health practitioner, in part due to a perceived stigma of the latter. Katon and colleagues have conducted studies to demonstrate the value of bringing a collaborative mental health treatment team into Seattle-based primary care clinics at Group Health Cooperative in Seattle. This multifaceted intervention was designed to provide greater support for the role of primary care practitioners to meet the needs of depressed patients and emphasized the importance of active monitoring of symptoms and relapse prevention. Patients received frequent monitoring visits, which alternated between the mental health team and the primary care practitioner. Close attention was paid to patient education, compliance with treatment guidelines, tolerance of therapy, and medication adjustment. This approach was shown to both improve outcomes of depression and satisfaction among both patients and providers (42;56). Group Health Cooperative, Kaiser Permanente, Northern California Region, the Lahey Clinic, and Health Care Partners have all developed programs that integrate mental health specialists into primary care settings.

Building on the lessons of Katon’s collaborative model, the John A. Hartford Foundation and the California Health Care Foundation have recently funded a randomized trial in seven health care systems with 18 participating primary care clinics that specifically targets older adults. 17 Following identification through screening and referral, a depression specialist (either a registered nurse, social worker, or a clinical psychologist) works collaboratively with the primary care practitioner to initiate treatment with medications or problem-solving behavioral therapy (six to eight sessions). The depression specialist also obtains additional expertise through consultation with a geriatric psychiatrist. Symptom monitoring and adherence to the care plan are monitored through regular clinic visits as well as telephone follow- up. The latter has been shown to be an effective adjunct in depression care (57). Preliminary analyses suggest that this approach is feasible, acceptable to practitioners, and effective as about 70 percent of persons receiving the intervention experienced improvement in depression scores.

Physical activity is becoming recognized as an important intervention strategy for reducing depressive symptoms (58-63). Blumenthal and colleagues studied older adults with major depression and found that aerobic physical activity may be as effective as antidepressant therapy (64). Additional studies have shown that regular physical activity offers a protective effect on depressive symptoms (65;66). Recent intervention trials have demonstrated that progressive resistance training improved scores for depression (52;60). Sierra Health Services makes a special effort to provide depressed members access to structured exercise programs. Because depression may rob many older adults of the motivation and energy needed to participate in such programs, antidepressants or psychotherapy are initially provided to members in order to overcome potential inertia that may impede participation in a physical activity program.

MCOs can be instrumental in ensuring that PCPs have the necessary tools and access to collaborative mental health expertise. They also need population-based systems of care to facilitate identification and appropriate follow-up (67). Physicians affiliated with MCOs that provide greater infrastructure for geriatric care reported that they were much more likely to address geriatric issues, including depression (68). Rollham and colleagues recently demonstrated improved quality of depression care by using a computerized mood module to identify patients at risk, notifying the PCP via an interactive email alert generated through the electronic medical record system, and presenting the PCP with patient-specific treatment recommendations (69).

Many plans offer programs designed to prevent or reduce depression. Sierra Health Services administers the 15-item GDS following a positive response to the “sad or blue” screening question. Members with a score that is consistent with major depression are referred to a behavioral health program. Members whose score is consistent with minor depression are referred to situational counseling or a support group. Follow-up scores on the 15-item GDS have revealed significant improvement with over 70 percent of members no longer meeting criteria for depression.

Group Health Cooperative has developed a clinical roadmap for depression that incorporates screening and management of both major and minor depression. Older members are initially identified at health maintenance visits using the “sad or blue” screening question. Members who respond affirmatively are assessed for major or minor depression. Those members that meet criteria for either major or minor depression are entered into a depression registry to facilitate treatment and ongoing management.

Members with major depression receive pharmacologic and behavioral therapy. Group Health Cooperative is actively developing strategies for improving the management of members with minor depression. A second “clinical roadmap” for senior care is exploring the role of physical activity programs and optimizing management of comorbid conditions that may contribute to depressive symptoms (i.e., urinary incontinence and functional deficits) to improve outcomes.

Implementation Barriers

Many PCPs do not feel confident in their diagnosis and management skills for depression and are often frustrated by their practice environment (19;70-72). However, simply providing greater PCP education alone is unlikely to be sufficient (73). Lack of time and tools to support treatment and monitoring, and a lack of coordination between primary care, mental health, and social services all represent additional barriers to

improved care. These barriers are supported by a study conducted by Meredith and colleagues. Their surveys of physicians in staff model and network model MCOs revealed that staff model physicians were more likely to report time limitation as a major barrier, while network physicians were more likely to report poor access to mental health specialists as a major barrier (74).

Older patients themselves may inadvertently create barriers to diagnosis and treatment. They may perceive

a stigma to acknowledging impaired mental health in general, and to depression in particular (75). They may

deny and consequently underreport symptoms, or they may implore their PCP to evaluate their multiple somatic complaints in an effort to attribute their symptoms to a diagnosis that is more acceptable to them than depression (4;57). MCOs can provide older members with education regarding the adverse effects of depression on quality of life and management of their other conditions, while assuring them that depression can be effectively treated. Older members and their significant others need to be encouraged to report depressive symptoms and discuss treatment with their PCP. For example, Oxford Health Plan enlists the services of a geriatric psychiatrist to work collaboratively with care managers to identify members with depressive symptoms and encourage them to discuss their concerns with their PCP.

Finally, external contracting (i.e., “carve-outs”) for behavioral health services can create additional barriers to comprehensive care. Many of the managed behavioral health contractors lack expertise in geriatric mental health (i.e., geropsychiatrists and geropsychologists). Medications prescribed by the contract program may not be on the formulary for the pharmacy benefits manager (PBM). Furthermore, because older members making transitions between sites of care are at particularly high risk for depression, contract programs cannot simply attend to only those members in the ambulatory setting. Often, the primary care team does not have access to contract mental health records and interprovider communication is particularly challenging in the setting of depression due to concerns over patient confidentiality. Such concerns preceded recent Federal legislation (i.e., Health Insurance Portability and Accountability Act or HIPAA) and can be overcome by patient consent. Thus, these “carve out” arrangements have the potential to further fragment geriatric care.

Economic Impact

Although treatment for depression may reduce both inpatient 18 and general medical costs, whether this reduction offsets the initial investment in providing better care for depression remains unclear (8;76;77). Untreated depression can further increase costs to the delivery system by complicating the management of other chronic medical illnesses (7;23;78). Campbell and colleagues found that physicians who diagnosed depression and anxiety at higher rates than their peers had lower per capita costs, ordered fewer unnecessary tests, had lower rates of patient referral to specialists, and were less likely to admit their patients to the hospital for potentially avoidable reasons (79). Revicki and colleagues compared patients receiving recommended versus less-than-recommended antidepressant therapy over

a 6-month time period. Those patients who received recommended therapy had lower mean total costs

($1,872 versus $2,622), with differences primarily attributable to significantly lower non-mental health- related inpatient costs (8).

Treatment of depression requires an investment in resources, including medications and mental health expertise. Sturm and Wells suggest that practice guidelines for depression can improve overall cost effectiveness of care (29). However, delivery systems may need to initially increase their depression care-related costs. For example, although attempts to shift away from the use of mental health special- ists can decrease immediate costs, functional outcomes for depression are often worse (29).

Kaiser Permanente, Colorado and Southern California Regions, have confronted this cost trade-off in their selection of formulary medications. The use of a particular class of antidepressants, Selected Serotonin Receptor Inhibitors (SSRIs) represents one of their single highest drug expenses. Although less expensive options are available, these Regions decided to provide SSRIs based on evidence suggesting that the lower cost medications lead to higher non-medication costs, attributed to intolerance, side effects, and non-compliance (80).

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Section 7

Undernutrition

Clinical Vignette

Mrs. S.C. is an 84-year-old Kaiser member with asthma who was recently widowed after 51 years of marriage. She lives alone and her children live out of state. During an acute visit to her primary care physician, she complained of worsening shortness of breath and fatigue. Her physician believed that this exacerbation was due to the fact that Mrs. S.C. had stopped taking her breathing medications. However, the physician also noticed that her weight had decreased 11 pounds since her last visit 6 months before. After a metabolic work-up did not reveal any contributing factors, the physician referred her for further evaluation to the Senior Care Coordination program. Using a functional screen, a nutrition screen, a depression screen, and a cognitive screen, the Senior Care Coordinator learned that the weight loss was an important clue to a more complex decline in her ability to care for herself and manage her chronic lung disease. Depression, social isolation, alcohol use, and mild cognitive impairment combined to interfere with her consuming regular meals and taking her medications. The Senior Care Coordinator arranged for her to attend a local senior center five times a week and to receive visits from a companion on weekends. At the senior center, she benefited not only from the daily nutritious meals but also from greater social interaction. The staff at the senior center reminded her during the week to use her breathing medications, and her companion did the same over the weekend. She regained her weight, and her asthma remained in excellent control.

Recommendations for Managed Care Organizations

MCOs should:

Educate practitioners regarding the central role of undernutrition in chronic disease management and functional rehabilitation.

Promote the evaluation of body weight as a routine vital sign taken at each medical encounter. Members who experience a weight loss of 10 pounds or greater over the past six months should receive further assessment.

Ensure that nutritional status is a focus of care management and disease management programs.

Encourage practitioners to evaluate older members for undernutrition upon admission to hospital, subacute, and home health care since patients undergoing care transitions represent an under- recognized high-risk group.

Establish linkages with community nutrition programs and work with practitioners to facilitate referrals.

Nature of the Problem

The management of many chronic diseases can be improved with proper attention to nutrition, enhancing both health and quality of life outcomes for older members (1). There is significant evidence for the role of nutrition therapy in the management of cardiovascular disease, heart failure, high blood pressure, diabetes, osteoporosis, and pre-dialysis kidney failure (1). Inadequate nutritional status also contributes to the development of pressure ulcers, anemia, infection, dehydration, and hip fractures (2).

Poor nutritional status contributes to longer hospital length of stays, higher rates of re-hospitalization, higher total health care costs, higher complication rates, and higher mortality rates (3-7). This longer hospital length of stay is attributable, in part, to longer recovery time from surgery, prolonged ICU stays, and adverse effects on rehabilitation (8-14). In one study, older patients at-risk for undernutrition 19 were found to have longer average length of stay (six versus four days), have higher average hospital cost ($6,196 versus $4,563), use more home health care services, and require more post-hospital subacute care (15).

As many as 15 percent of community dwelling and 35-65 percent of hospitalized older adults suffer from inadequate nutritional status (16). Although undernutrition offers an excellent opportunity for upstream” intervention, it often goes unrecognized and unaddressed (17). Manson and Shea found primary care physicians did not record a diagnosis of malnutrition or weight loss in approximately 50 percent of cases and did not prescribe specific therapy (e.g., nutritional supplements) in more than 75 percent of such cases (18). Similar studies have documented lack of awareness among practitioners caring for hospitalized older adults (5;19;20).

Undernutrition has traditionally been underaddressed, whether by MCOs or PCPs, for multiple reasons. MCOs may not cover certain nutritional therapies (e.g., nutritional supplements) and, consequently, may be reluctant to identify members at risk. PCPs have commonly viewed nutritional problems as being in the domain of social services rather than medicine. However, because undernutrition adversely impacts the management of many chronic diseases and functional rehabilitation, it is incumbent on MCOs and PCPs to address this problem.

Ta rget Population and Risk Factors

Risk for poor nutritional status increases with age, mostly attributable to a higher prevalence of diseases that affect nutritional status, the associated need for multiple medications, changes in internal organ function, and socioeconomic factors such as isolation and inadequate income. Relevant chronic illnesses include congestive heart failure, chronic lung disease, cancer, hyperthyroidism, hip fracture, dementia, and intestinal malabsorption syndromes. Older members receiving hospital or post-hospital care are at particularly high risk for undernutrition and accompanying poor outcomes of care. Disease and age- related changes in both kidney and liver function also increase risk. Sensory loss, including loss of taste and smell, are additional risk factors, as are neurologic deficits that interfere with swallowing, such as stroke and dementia. Medication use may lead to undernutrition due to adverse effects on nutrient absorption or effects on appetite and swallowing. Social isolation, depression, widowhood, inadequate financial resources, alcoholism, and poor dentition are also associated with poor nutrition (1;21).

Screening and Assessment

Screening can be conducted through questionnaires mailed to new members and through clinician referral or administrative data for existing members. Admissions to the hospital, skilled nursing facility, case management or disease management, or home nursing visits are all opportunities to assess nutri- tional status. The most widely used screening tools include an assessment of weight loss, serum albumin, the Nutrition Screening Initiative (NSI) DETERMINE Checklist, and Body Mass Index (BMI).

Examination of weight loss is among the simplest tools for identifying undernutrition in older members. Weight loss of more than 10 pounds in the previous six months is considered to be a positive screen. 20 The distinction regarding whether weight loss was intentional or not does not appear to influence the association with adverse outcomes (22). Older adults reporting a weight loss of 10 pounds or greater are at significant risk for experiencing functional decline over the next three years (23). MCOs have considerable experience with this screening approach, as this question comprises one of the items on the PraPlus (24). At Group Health Cooperative, primary care practitioners routinely ask members who have scheduled annual evaluations whether they have experienced a 10-pound weight loss during their scheduled annual evaluation. Some MCOs enter patients’ weight into an electronic medical record that can serve as an additional resource for identifying existing members at risk.

The potential use of administrative data for risk identification has prompted interest in the role of laboratory biomarkers. Serum albumin appears to have the greatest utility and is the most studied. Albumin levels below 3.5 grams/deciliter have been associated with prolonged hospitalization and rehospitalization, higher cost of care, infectious complications, functional limitation, and mortality (3;5;25-29). In the setting of significant acute illness, injury, or inflammatory conditions, however, albumin levels may not be reliable (30).

Friedmann and colleagues examined the relationship between nutritional status and hospital readmission. They demonstrated that a combined measure of change in weight and serum albumin was the best predictor of 90-day re-admission rates following hospitalization (sensitivity of 50 percent, a specificity of 100 percent, and a positive predictive value of 90 percent) (4). Although MCOs have traditionally not employed lab data for risk screening, information on nutritional parameters such as albumin could be requested from their laboratory vendors.

The NSI DETERMINE Checklist is the result of a multidisciplinary effort that was supported by over 30 national medical, nutrition, and aging organizations (31). The Checklist is used by Area Agencies on Aging to identify older adults who might benefit from programs such as Meals on Wheels. The 10- item checklist can be administered by self-report or over the phone. A Spanish version is available. High scores on the NSI DETERMINE Checklist are associated with depression and functional disability (32).

The NSI DETERMINE Level II Screen is a comprehensive assessment tool with 34 check box items that include questions regarding weight change, living and eating habits, alcohol and medication use, depression, dentition, and limitations in functional status. Jensen and colleagues found that a subset of items on this screen identified older persons at risk for hospital admission (33). Select items from the P ra (Probability of repeat hospital admissions) (34) and the NSI Level II Screen were comparable in identifying patients at risk for hospitalization. These items included eating problems (difficulty chewing or swallowing, pain in mouth, teeth or gums), weight loss, consumption of special diets, and taking three or more medications daily. 21

The Geisinger Clinic in Pennsylvania identified newly enrolled Medicare risk members who reported a weight loss of 10 or more pounds in the previous six months based on their responses to the NSI DETERMINE Level II Screen. The prevalence of weight loss in this population was found to be more than eight percent. In addition, those members who had lost weight were more likely to have functional impairment (26). Independence Blue Cross incorporates the 11-item NSI Checklist into its screening and assessment form for Medicare members (35). Preliminary analysis has supported the role of this screening tool for identifying older members who might benefit from proactive case management and intervention.

Although the NSI DETERMINE Checklist is the most widely used screening tool for undernutrition, its utility for identifying older adults at risk has not been adequately quantified (36). In particular, it has been criticized for having poor test characteristics (sensitivity 46 percent, specificity 46 percent, positive predictive value 38 percent), retaining items that are not significantly associated with the outcomes of interest, and including items that are not amenable to intervention by either the PCP or the MCO (1;37). These concerns have prompted questions as to whether all 11 items need to be administered and whether the NSI DETERMINE Checklist has greater utility as a tool to promote awareness among providers rather than as a screening tool.

BMI (defined as weight in kilograms divided by height in square meters) has been principally used in large national studies of nutritional disorders. Research evidence suggests that persons with low BMI have greater mortality, health care expenditures, and functional impairment compared with persons with normal BMI (38-41). Older patients with a BMI of 17 or less appear to be at high risk for mortality, while persons with a BMI between 17 and 21 appear to be at moderate risk. The National Institutes on Health recommends using a less restrictive BMI threshold of 18.5 for identifying the presence of undernutrition. However, the utility of the BMI as a clinical screening tool remains to be determined.

For members who have a positive screen for nutritional risk, further assessment is warranted. Key elements of an evaluation for reversible contributing factors include a diet history, determining whether dental or swallowing problems affect dietary intake, and evaluating whether physical or cognitive func- tional impairment are interfering with the ability to acquire and prepare nutritious meals on a daily basis (30). Persons experiencing swallowing difficulties may benefit from an evaluation by a speech therapist. Cultural factors that may affect food choices should also be examined. In addition, members who suffer from undernutrition should be evaluated for the presence of depression and social isolation. Given the prevalence of thyroid disease in the older population and its association with weight change, laboratory evaluation of thyroid status is often indicated. Finally, a complete medication review should be conducted with particular attention to medications that adversely effect appetite such as Selective Serotonin Re-uptake Inhibitors (SSRIs) and Digoxin.

Interventions

In general, nutritional interventions designed to reduce the risk of poor nutritional status in older managed care populations have been achieved using both MCO and community resources (42). Such interventions need to account for members’ cultural preferences, financial resources, access to community programs, and literacy.

Oxford Health Plan has implemented a nutrition screening and intervention program for its Medicare members. The nutrition survey, adapted from the Nutrition Screening Initiative (31), is administered telephonically to all new members residing in specific New York counties. High-risk members receive a telephone call from an Education & Outreach Associate, who designs an intervention tailored to the individual’s functional status and nutritional practices. Examples of interventions include arranging a visit to a registered dietitian, referral to a congregate meal site, and providing the member with simple tools that facilitate meal preparation (e.g., a tool that helps persons with arthritis open a jar or can). High-risk members’ primary care practitioners receive detailed reports regarding the specific areas of nutritional concern and recommended interventions.

In one borough, 24 percent of the 4,380 screened Oxford Medicare members were identified as high- risk. Education and Outreach workers telephoned these patients to discuss responses to the survey, answer questions, and recommend interventions. A follow-up letter summarizing the call and recommendations was sent to both the member and his or her primary care practitioner. High-risk

members received an additional phone call within two weeks to reinforce recommendations and help overcome any barriers. Fifty-seven percent of high-risk members were receptive to the recommended interventions and met established goals. Examples of these goals included obtaining formal assistance to get food into the home on a regular basis (e.g., Meals on Wheels) and working with an occupational therapist to overcome functional barriers to meal preparation. Six months later, members were mailed the same nutrition survey, and 38 percent of responding members originally classified as high-risk no longer met these criteria.

As discussed earlier, Independence Blue Cross employs the NSI DETERMINE Checklist as part of its initial health risk screen for new Medicare members. The interventions for those identified as nutritionally underserved include nutritional counseling, access to discounted meals on wheels, and case management. Independence Blue Cross also provides practitioners with incentives to refer patients and collaborate with health plan care managers. Frequently, members needing high-intensity care management have nutritional needs. Practitioners working with care managers receive $50 for the first month and $25 for each subsequent month of the patient’s enrollment in the program.

Reuben and colleagues have developed interventions for patients identified using laboratory data. Older attendees of an ambulatory clinic were screened for low albumin (less than 3.8 g/dl). Those who screened positive underwent a comprehensive in-home assessment by a registered nurse. Specific problems affecting nutrition included lack of economic resources, functional impairment, dental disorders, and medication side effects. Referrals to a social worker, dentist, physical therapist, and greater vigilance in monitoring of medication levels in the blood were examples of tailored protocols for high-risk patients. On average, this assessment generated a mean of 4.2 recommendations per participant. Three months after the intervention, patients were found to have a significant increase in serum albumin (43).

Finally, the Geisinger Health Care System in Pennsylvania has implemented a nutrition risk-screening program among its rural members (26;44). In one pilot study, among 417 health plan members screened, 16 percent met criteria for high-risk and were provided with case management. Twenty-six of these 67 high-risk members received a targeted intervention and completed a follow-up survey at six months. Ten of the 67 high-risk members were subsequently determined to no longer meet risk criteria.

Implementation Barriers

Lack of awareness of the central role nutrition plays in chronic disease management and rehabilitation remains one of the greatest barriers to implementation of effective interventions. Of the seven conditions discussed in this report, undernutrition appears to receive the least attention from health care practitioners. Most physicians received little training on the nutritional needs of older adults from their medical school and residency curriculum. Oxford Health Plan surveyed participating practitioners and found that nutrition was among the top three areas for which they lacked confidence in formulating a care plan or knowing when and where to refer. 22 A pervasive attitudinal barrier is the misconception that nutritional problems belong in the realm of social programs rather than medical care. MCOs can

promote continuing medical education on the role nutrition plays in chronic illness management, functional status, and quality of life. Further, MCOs can work with PCPs to help facilitate referrals to relevant community agencies. Sierra Health Services has found that members are more likely to attend classes on nutrition when advised to do so by a physician.

Older members may perceive a stigma to accepting assistance from financial programs such as food stamps or congregate meals. MCOs can be instrumental in educating members regarding the importance

of nutrition in maintaining health and encouraging the PCP to further reinforce this message.

Community programs may inadvertently create barriers to meeting the needs of older members. For example, they may require the completion of application materials that are long or that do not account for low literacy levels. The services they offer may not reflect cultural preferences in the planning and preparation of meals. Lastly, in many communities, programs such as Meals on Wheels have long waiting lists.

Economic Impact

A recent Institute of Medicine report maintains that expanded coverage for nutrition therapy will

generate economically significant benefits to Medicare beneficiaries and to the Medicare program itself, through reduced healthcare expenditures (1).

Oxford Health Plan has found the costs for Medicare members in its high-risk nutrition intervention

to be $30 per member per month (PMPM) lower over the subsequent 24-month period compared to

a matched control group. In an attempt to determine whether specific targeting might further improve the cost-effectiveness of the nutrition intervention, Oxford examined outcomes among particular sub- groups. Members with selected diagnoses achieved even greater savings. For example, those with diabetes and neurological diseases experienced savings of $73 PMPM and $79 PMPM, respectively.