Seniors with multiple chronic conditions: 4 tips

The inability to coordinate care for these seniors leads to more health problems, and higher costs.

Picture it: A glass bowl in a 67-year-old’s kitchen is filled with three different kinds of pills. They include a medication to address her hypertension, a pain reliever because of her recent hip reconstruction, and an anti-anxiety drug. The woman has been told by her medical team to take three pills a day, so she does. She reaches her hand into the jar after breakfast each day and takes out three pills-with no regard for what she’s taking.

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“That’s a very dangerous scenario,” says Mara McDermott, vice president of federal affairs for CAPG, a trade association for physician organizations around the country. “She’s not taking the medications she needs, and she’s probably getting too much of what she doesn’t need.”

According to the U.S. Department of Health and Human Services’ Agency for Healthcare Research and Quality, patients with multiple chronic conditions (MCC) have two or more chronic illnesses at the same time. Chronic conditions include both physical and behavioral health conditions that last a year or more, and require ongoing medical care and/or limit physical abilities.

Lattimer RNThe inability to coordinate care for seniors with MCC is harmful to those patients, it places an additional burden on their families-and it’s also very expensive. A recent USA Today analysis of county-level Medicare data revealed that more than 4 million of the two-thirds of seniors who have MCC-about 15%– have at least six chronic diseases. More than 41% of the $324 billion spent on fee-for-service Medicare is spent on these very sick patients.

Better medication management is key to improved care coordination for patients with MCC, says Cheri Lattimer, RN, executive director at the Case Management Society of America. “It doesn’t matter where you are in the system, patient and family caregivers need to understand when patients need to take the medications and why. They need to know when they need to be refilled, and who to contact with questions.”


NEXT: Home visits and care transitions


Home visits and care transitions

McDermottThe elderly patient taking three random pills from the jar on her kitchen table points to why having a team-based approach-one that includes visits to patients’ homes-is key to coordinating care for seniors dealing with MCC, says McDermott. Team-based conversations among primary-care providers, social workers, and behavioral health specialists, will help, according to McDermott.

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“This is all about making sure the care team is thinking about the entire picture,” she says. “There are member groups within CAPG that send someone into seniors’ homes to assess [fall] risk. They’ll look for loose carpets or to see if there’s a handrail in the shower.” This information, McDermott says, is then fed back to the patient’s care team.

The transition from the primary-care provider to the specialist is an area where a coordinated care approach can be helpful, says Lattimer. “The receiving physician has to view the patient’s records and their current medications [before they see the patient]. They have to know what they’re dealing with. And this also has to be coordinated with the family caregivers. Otherwise, the patient is spending half the visit providing background information.”


NEXT: Appointment and medication refill reminders


Appointment and medication refill reminders

Coordinating care among different specialists can be overwhelming for seniors, says Elena Rios, MD, president and chief executive officer of the National Hispanic Medical Association. That’s why appointment reminders are critical.

Finding out how a patient wants to receive communications-phone call, text, or e-mail-is also important, she says. The best way to capture this information from patients is in the new patient intake form the patient fills out before their initial visit.

Language and cultural awareness

Cultural awareness and English language proficiency also matter with MCC patients, says Rios. She notes that Hispanics come from countries with unique cultures-such as Mexico and Puerto Rico-and the diets and cultural values are different, even the way the Spanish language is spoken is different. “These are patients with very close-knit families, with lots of cultural baggage and assets,” she says. “Some people come here and never leave the language of their country or background, especially since we’re so close to Latin America."

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Rios says that providers need to recognize which patients have limited English proficiency, and provide the appropriate level of services.


NEXT: Patient-centric approach


Patient-centric approach

Lattimer says that provider organizations can have the greatest impact on coordinating care for MCC patients when they support the patient and their family caregivers, while providing them with the skills to self-manage their conditions. She’s encouraged by the Centers for Medicare & Medicaid Services’ (CMS) moves to alter payment models and performance measures that are tied to those payment incentives.

Related:Payment reform shifts to high gear

“The writing is on the wall,” she says. “As we’re moving forward on the Affordable Care Act, we know that CMS is changing and driving what we call the alternative payment method. So, not fee-for-service, but paying for value, paying for outcomes, and paying for patient satisfaction. You’re seeing it in how the core measures are changing at the hospital level. You’re seeing it in a lot of the payment codes that are being brought forth-for transitions of care and care coordination and new chronic care management codes.”