Geriatric study finds team-based care saves lives, money

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By Brian Maffly

The Salt Lake Tribune

When Donna Hansen was diagnosed with diabetes six years ago, she visited her husband’s grave.

"I cried for 10 minute before I realized it wasn’t doing me any good and I went home and did what I was supposed to do," said Hansen, an 80-year-old Intermountain Healthcare patient from Syracuse. What she needed to do was learn to monitor her blood levels throughout the day, inject carefully selected doses of insulin, and stash glasses of orange juice around her home in a constant campaign to keep her blood sugar in check.

Hansen’s daily regimen of needles, meds and blood tests is a lot for anyone to handle, but it can be overwhelming for an elderly widow with multiple chronic illnesses. A few years ago she began participating in a study of more than 3,000 Utah geriatric patients with chronic health care problems, a third of whom received a new highly managed, personalized program of care. The results, published last month in the journal of the American Geriatrics Society, showed decreased rates of mortality and hospitalization among those enrolled in the special program, known as Care Management Plus.

In CMP, a specially trained nurse, or care manager, shepherds a chronically ill person’s primary care to ensure the patient is getting lab work done on time, taking meds at appropriate times and doses, and making optimal lifestyle choices. The system cut costs by shifting work loads from geriatric specialists to nurses.

"Family practice and internal

medicine physicians are drowning in the huge number of things to consider for their patients, especially those with multiple conditions and medications," said co-author Cherie Brunker, Intermountain geriatric chief and a professor of geriatric medicine at the University of Utah’s Center on Aging. "Computer tools and a specially trained care manager can make all the difference."

Medical informatics, which helps care managers stay on top of their patients’ medical histories and care protocols, plays a big role, said lead author David Dorr, an assistant professor of medical informatics and clinical epidemiology at the Oregon Health and Science University in Portland.

"The care manager is embedded in the team and the clinic is run more efficiently as well," said Dorr. "For patients with complex chronic illness, it saves $70,000 per clinic per year."

The study’s findings hold great promise for improving the quality of life for elderly patients while lowering care costs, observers say. The researchers said seniors account for 83 percent of all care spending; two-thirds of them suffer from multiple chronic illnesses. Those with two or more conditions are eight times as likely to die within one year as their age-matched peers; those with three conditions are 40 times more likely to be hospitalized than a peer with just one condition, according to Dorr and his colleagues.

Dorr was studying informatics as a fellow at the University of Utah School of Medicine in 2004 when the study was organized under a grant from the John A. Hartford Foundation. The foundation has since provided a grant to launch CMP programs elsewhere. The Oregon team has so far trained 50 clinics, including 15 in Utah, with more on the way.

"The care managers really added another dimension of care," Brunker said. "It really rounds out the care that physicians provide. I definitely see the value of team members that are able to address patients’ individual needs. It complements the work of the physician really nicely."

Added Ann Larsen, a care manager with Intermountain’s Herefordshire clinic in Roy: "It’s all about team work. We don’t just treat the episodes, we treat the whole patient and their family over the course of their life. A majority of care is one on one. Our goal is prevention, wellness, and independence."

Larsen leads monthly seminars for her patients and teaches them how to manage their illnesses, which can present frightening symptoms at times.

"I lose my energy when my blood sugar goes down," Hansen said. "When it goes up I’m so thirsty and tired, but it’s a different kind of tired than when it’s down."

But Hansen has not been hospitalized for her diabetes, thanks in part to the little tricks Larsen taught her, like keeping orange juice handy to counter blood sugar crashes.

"It went to 36 last night and it was so horrible. I couldn’t think to call any of my kids," she said. "I took care of it. Attitude is a big part of it."

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