# Presentation: 248497

## AHIC Chronic Care WorkgroupPersons with Disabilities - Additional Opportunities for Providing Value Through Secure Messaging and Remote Monitoring

- Office on Disability
- U.S. Department of Health and
- Human Services
- August 16, 2005

## Office on Disability

- Coordinates the implementation of policies, programs, and special initiatives related to disabilities within HHS and with other Federal agencies, as part of the Presidential New Freedom Initiative
- Heightens the interaction of programs within HHS and with Federal, State, community and valuable private sector partners
- Supports plans and initiatives designed to tear down barriers facing people with disabilities, which prevent them from fully participating and contributing in an inclusive community life

## Definition of Disability

**ADA Definition**
- A person with a disability is someone who:
- Has a physical or mental impairment that substantially limits one or more *major life activities*;
- Has a record of such impairment; or
- Is regarded as having such an impairment
- U.S. Department of Health and Human Services.  The Surgeon General’s Call to Action to Improve the Health and Wellness of Persons with Disabilities.  US Department of Health and Human Services, Office of the Surgeon General, 2005.

**ICF Definition**
- Disability is an umbrella
- term that describes:
- Impairments
- Activity limitations
- Participation restrictions

**Notes:**
I thought it may be helpful to point out the differing definitions of disability to demonstrate the complexities of trying to define disability.  Also, one definition has its roots in policy, while the other has its roots in health promotion.  I know the ICF is a new concept, but based on what I have been hearing at the conferences, it is beginning to get recognition within the world of disability and rehabilitation research, and is the way that much health information will hopefully be classified in the future.

## Characteristics of Disability

- 54 million Americans are living with at least one disability(McNeil, 2001; 1997)
- 52 million of them reside in the community (US Census Bureau, 2002)
- Most individuals will experience a disability at some point in their lives
- Prevalence of disability increases with age
- 7.8% < 15 years of age to 73.6% > 80 years of age (McNeil, 2001; 1997)

**Notes:**
I thought it would be helpful to point out the MOST people with disabilities are in fact residing in the community, and therefore need community-based supports and less “institutional” health care.  It may be beneficial to point out the increasing rate of disability with age for two reasons (1) point out the need for preventative services to reduce this phenomenon and (2) point out the need for more community-focused services for persons with disabilities since there is a rapidly increasing population of older adults that want to “age in place.”

## Slide 5

**Notes:**
I am not sure if you want this level of detail, but I thought it broke out the various disability groups nicely, like you mentioned.  I took this table from the Call to Action.

## Health and DisabilityThe Surgeon General’s Call to Action to Improve the Health and Wellness of Persons with Disabilities, 2005

- Key concepts
- Disability is not an illness
- Good health is necessary for persons with disabilities to engage in all aspects of life
- People with disabilities face unique challenges when trying to access health care

## Barriers to Health Care Access“The health care delivery system in the United States is not structured to care effectively for persons with disabilities.” – Lisa Iezzoni

_**Health Care System**_
- Inadequate health insurance
- Limited rehabilitation and assistive technology coverage
- The “29 month gap”
- Poor communication
- Inaccessible buildings and equipment
- Focus on acute short-term treatments
- Provider education and training
- Attitudes
- Knowledge and skills

_**Population Characteristics**_
- Persons with disabilities are more likely to have never completed high school, to be unemployed, and to live in poverty
- 45.4% of working-age individuals reporting major disability are employed compared to 78.7% of those without disabilities
- 22.7%  of people with “major disabilities” live in poverty compared to 8.9% of those without disabilities

**Notes:**
Paying for technologies, devices and therapeutic interventions to maintain, restore and independent function has never emerged as a public health issue - Iezzoni
29 month gap – approximately 1/3 o persons lacked health insurance during the waiting period, while roughly 40% enrolled in Medicaid, costing the federal and state governments $7.6 billion in 2002. - Iezzoni

## Telecommunication

- Opportunities
- Access to health information
- Enhance and streamline health care delivery
- Improved correspondence
- Removes many communication barriers

- Barriers
- Only 38 percent of persons with disabilities use the internet (Horrigan et al, 2003)
- Cannot afford computers, fees, and adaptive equipment
- Difficult to use internet at public facilities
- Limited exposure (age is a factor)
- Difficult to monitor secondary conditions

## Cost Analysis

- Of an estimated $242.4 billion expenditures in 2001, Medicare spent $31.9 billion on beneficiaries with disabilities (CMS, 2002)
- Persons with disabilities are more likely than others to have public health insurance
- “Reimbursing nursing homes may, in short order, cost Medicaid more than additional personal attendant services (PAS) hours” (Iezzoni, 2006)

## Institutional vs. Community Based Care

**HCBS Waivers**
- Provide services within home or community as cost-effective alternative to institutional care
- Divert or prevent unnecessary institutionalization of individuals
- Request services not otherwise available under Medicaid plan
- Important tool for states to meet requirements of the ADA and Supreme Court Olmstead Decision
- Duckett, M. & Guy, M.  Health Care Financing Review, Fall 2000.  (22):1

**62.8%**

**37.2%**

**Distribution of Medical Long Term Care Expenditures**
**FY 2005**

## Cost Effectiveness 

- CMS has supported research to develop risk-adjustment methodologies for differences in resource use due to health and functional status (Clauser, S, PhD & Bierman, A. Spring 2003.  Significance of Functional Status Data for Payment and Quality.  *Health Care Financing Review, *24, 3).
- Further research is needed to determine costs related to resource use in determining cost effectiveness comparing institutional vs. community-based care
- Research to develop community-based programs to manage health and prevent secondary conditions for persons with disabilities show promise

## Diagnosis 

- International Classification of Diseases (ICD)
- Developed by the World Health Organization (WHO) to categorize disease/disease categories
- ICD-9-CM is based on ICD
- Provides a taxonomy for describing diseases, disorders and injuries
- ICD-10 exists – used outside the U.S.
- ICD-10 being considered in the U.S.
- Harry Feliciano, MD, MPH. *Going Beyond Diagnosis: The International Classification of Functioning, Disability and Health (ICF).*

## Terminal Disability

- Terminal disability is defined by:
- The degree of pathology, impairment and activity limitation associated with a terminal prognosis, and
- The inability of the individual to maintain vital physiological functions in the face of the specific pathophysiologic changes
- Harry Feliciano, MD, MPH. *Going Beyond Diagnosis: The International Classification of Functioning, Disability and Health (ICF).*

## The World Health Organization’s ICF

- International Classification of Functioning, Disability, and Health (ICF).
- Defines and describes domains using categories that are relevant to therapy providers, and not found in ICD-9-CM.
- Standardizes the characterization of structural and functional impairments and helps relate them to activity limitations and participation restrictions
- Includes environmental factors.
- Complements ICD-10
- Harry Feliciano, MD, MPH. *Going Beyond Diagnosis: The International Classification of Functioning, Disability and Health (ICF).*

## Secondary Conditions

- Secondary conditions are directly related to a primary disabling condition
- Common secondary conditions seen with physical disabilities:
- Anxiety
- Incontinence
- Immobility
- Pressure Ulcers
- Pneumonia

## Level of Functioning

- Functional status data on all Medicare beneficiaries serves multiple functions
- Provision of information about health status transitions
- Provision of information that can be used for clinical and health services research
- Supports growing emphasis on promoting independence, preventing functional decline, and avoiding institutionalization when possible
- Fosters analyses of the cost effectiveness of clinical and organizational interventions
- Augments the knowledge base regarding effective interventions to maintain function and independence
- Clauser, S, PhD & Bierman, A. Spring 2003.  Significance of Functional Status Data for Payment and Quality.  *Health Care Financing Review, *24, 3.

## Opportunities

- Universal design for all – e.g., examination tables, examination tools, diagnostic equipment, medical facilities, IT software and hardware.
- Self-management and collaborative care – e.g., increased emphasis on health literacy; prevention and wellness services.
- Improving Consumer-Clinician Access – use of mobile service teams (e.g., OT, PT, MH counselor, LPN) in rural/frontier areas of the US.
- Increased emphasis on looking a disability from a functional perspective to improve client-centered services, avoid institutionalization, and provide data to support effectiveness of interventions, programs and policies