# Presentation: 534984

## Abandoning the Silos: Population Segmentation that Enables Clinical Excellence (and Useful HIT)

- March 22, 2006
- Joanne Lynn, MD, OCSQ  joanne.lynn@cms.hhs.gov
- Co-Authors:
- Barry Straube, MD, Director OCSQ and Chief Medical Officer CMS
- Karen Bell, MD, MMS, Director, Office of HIT Adoption, ONC
- Steve Jencks, MD, OCSQ
- Robert Kambic, PhD OCSQ

## The Silos - Disease categories organize medical knowledge

- The Center to Improve Care of the Dying

***The Silos***** - Disease categories organize medical knowledge**

**Hypertension**_**        **_
**Diabetes**
**Stroke**
**Alzheimer’s Dementia**
**etc.**

## The Silos - Providers/sites organize 

- The Center to Improve Care of the Dying

***The Silos***** - Providers/sites organize **
**health care delivery**

**Hospital  Doctor’s office Nursing home  Hospice     etc.**

## Claims of excellence fall in a cross-hatch – 

**Claims of excellence fall in a cross-hatch – **
**	****	****	****	****one setting, one disease**

- Hospital       Doctor’s office    Nursing home       Hospice       etc.

- Medical
-    diagnosis

- Program/site

- Hypertension
- Diabetes
- Stroke
- Dementia
- etc.

***But people with serious chronic illness have ***
***multiple diagnoses and use multiple settings. Thus, our understanding of ***_**excellence**_*** fails***

## Building a Better Concept

- Can’t reflect current provider array
- Can’t defend current dysfunctions
- Can – anchor in service to the patient
- Can – build on shared priorities of groups
- Can – enable point-of-service customization
- Try it out - serious illness, last years of life

## Divisions by Health Status, in the Population and Among Persons with Eventually Fatal Chronic Illness

***Mild Chronic, consistent with  usual role***

***Healthy***

***Chronic, progressive, eventually fatal illness***

**Divisions by Health Status, in the Population and Among Persons with Eventually Fatal Chronic Illness**

- A

- B

- C

**Notes:**
How many people are in this category?  Relying on business data from Franklin Health, at any one time about 1-2 percent of adults under 65 years of age have serious, eventually fatal chronic illness, and about 3-5 percent of those over 65.  That’s the rate in cross-section.  Over our life-spans, though, about three-quarters of us have a period of being so ill that we cannot take care of ourselves, and that period averages 2-3 years.  The patient’s dependency involves family members in caregiving; women now spend as much time in eldercare as in care of children.  The numbers of persons facing serious chronic illness will at least double over the coming twenty years, as the baby boom encounters old age.  Until now, lives with serious chronic illness have been largely invisible:  very few evening television stories, for example, include this phase of life.   Yet, people with eventually fatal chronic illnesses use substantial resources, often inefficiently, and they and their families are profoundly disappointed with the difficulties they encounter in using the “care system.” 
 What is life like for people living in that wedge of eventually fatal chronic illness?  Our research team started with the considered opinion that most people might follow one of three major courses, or trajectories. 

## First “end of life” Trajectory

**Onset of incurable cancer**

**-- Often a few years, but decline usually < 2 months**

**First “end of life” Trajectory**

- Function

**Death**

**High**

**Low**

**Possible hospice enrollment**

**Notes:**
In these schematic diagrams, function or general well-being is on the Y-axis, with good health at the top and death at the bottom.  The X-axis is the passage of time in the end of life of a stereotypical patient.
First is the trajectory that undergirds the society’s stereotype of dying – a long period of good function, followed by a relatively short period of losing weight, taking to bed, and dying “on time.”  This is the classic course of many patients with cancer, in which the average patient is still holding her own just two months before death.  Once the cancer becomes overwhelming, the losses in function and well-being are obvious each week and death becomes fairly predictable.  This is the course that gave rise to hospice, and good primary care in a cancer center or a physician’s office, meshed with good hospice care, would probably serve these patients well.

## Second “end of life” trajectory

- Time

- Function

**Death**

**High**

**Low**

**Begin to use hospital often, self-care becomes difficult**

**~ 2-5 years, but death usually seems “sudden”**

**(mostly heart and lung failure)**

**Notes:**
However, more of us face an end of life that is shaped by heart and lung failure.  The patient has long-term limitations on function with intermittent exacerbations, each one met by rescue treatment and followed by nearly the prior functions status.  Eventually, though, one of the complications will be lethal.  Since it is not possible in advance to know which one, the current hospice program is mostly unavailable.  Death in this course is usually experienced as sudden and unexpected for each patient, even thought the survival time for a large group of people with these conditions can be predicted quite accurately.  Good care for this population requires implementing self-care and prevention in order to limit exacerbations, advance care planning to ensure thoughtful decisions about treatments and the end of life, and availability of competent help around-the-clock to ensure effective treatment and reliable implementation of advance care plans.
Building upon work with three-dozen programs in a collaborative quality improvement program in 1999, our research group here has recently started a demonstration program.  Four hospice programs will provide at their own expense excellent comprehensive care for 75 patients with advanced heart or lung failure.  A grant from The Archstone Foundation allows us to collect evaluation data from the study patients and a comparison group with the same conditions in the same geographic area.  This project will teach about the clinical implementation of comprehensive services for this population and whether those services make a difference in the lives of patients and in the costs.

## Third “end of life” Trajectory

**Onset could be deficits in ADL, speech, ambulation**

**Quite variable -**
**up to 6-8 years**

**Death**

**High**

**Low**

**Third “end of life” Trajectory**

**Function**

- Mostly Multifactorial Frailty, half with dementia

**Notes:**
Those who avoid cancer and keep a strong heart and lungs ordinarily have a third course to death – one marked by severe degenerative conditions, including dementia, and overall failure of physiological reserve which is sometimes called “frailty.” In this course, the patient is quite disabled for a long time, and death comes from what might otherwise be a minor intercurrent illness.  Good care for these patients relies upon assistance for daily activities, support for family or paid caregivers, and prudent use of medical interventions.
Patients in the last phase of life may usefully be grouped into three trajectories, each with a characteristic time frame and key services. 

## “Esther” in Health Care Planning

- Esther with colon cancer
- Esther with heart failure
- Esther with dementia
- All of us can count on good care at the end of life if Esther can

## Managing Marriott....

- Would you build just one kind of hotel?
- Would you wait to design the hotel until a sleepy person showed up looking for a room?
- No – the trick is to design hotels around the priorities of the most likely populations, then customize for individuals as needed
- And the same thinking works for health care

## Clinics, hospitals, EMS

- Stable, disabled

## Slide 13

| Population | Number | 
$/person/yr | Total $ billion/yr |
| --- | --- | --- | --- |
| 1. Healthy  | ~170 million | ~$700 | ~$120  |
| 2. Moms and babies | ~6 million babies, moms | ~$10,000  | ~$60  |
| 3. Acutely ill | ~60 million | ~$10,000 | ~$600  |
| 4. Chronic | ~50 million | ~$7000 | ~$350 |
| 5. Serious disability | ~7 million | ~$35,000 | ~$250 |
| 6. EOL, Short decline | ~1⁄2 million | ~$40,000 | ~$20  |
| 7. Erratic & sudden death | ~1 million | ~$45,000 | ~$50  |
| 8. Long dwindling  | ~5 million | ~$50,000 | ~$250  |
| 
TOTALS -  | 
300 million |  | 
$1.7 trillion |

## Institute of Medicine “Quality Chasm” Aims for Care

- Safe
- Effective
- Efficient
- Patient Centered
- Timely
- Equitable

## Chronic Conditions:  50 Million

| Aim | Interpretation | HIT Opportunities |
| --- | --- | --- |
| Safe | No medication errors; safe devices,  | PHR with CDS, EHRs |
| Effective | Secondary prevention, RX to goals | Reminder systems, EHRs |
| Efficient | Coordinated DX services, successful RXs, no admin bur | EHRs, patient centric PMS, care communities |
| Patient Centric | Individual careplans attentive to circumstance, ability to self-manage | PHRs, shared careplan management, monitoring device |
| Timely | Access to care from remote settings | E-visits, e-prescribing, e-scheduling |
| Equitable | Respect for cultural differences, geography | Multi-lingual, telecommunications |

## Organ System Failure 1 Million

| Aim | Interpretation | HIT Opportunities |
| --- | --- | --- |
| Safe | No preventable ADEs, safe environment, safe devices | Interoperable EHR/PHR, monitoring of care |
| Effective | Aggressive evidence based RX to prevent exacerbations | Home monitoring devices. Patient ed; coordinate regional services |
| Efficient | No screenings or treatments for conditions beyond lifespan | Shared decision support information for intervention |
| Patient Centric | Clarity about RX options and value, careplans, life closure planning | Electronically accessible care plans. Interactive decision aids |
| Timely | Rapid response to change,  | E-visits. Regional delivery coord |
| Equitable | Available to all | Multi-lingual, telecommunications |

## Common Themes for HIT

- Decreased administrative burden
- Remote access to care: e-visits and monitoring
- Reliable 24/7 communication
- Portable health information
- Patient/Consumer control and focus
- Continuity of care across settings
- Informed patient engagement
- Protections from preventable ADEs
- Regionalization of records, coverage, and services

## Outstanding Issues

- Governance – who controls data flow
- Financing – for sustainability
- Privacy and Security
- Standards and interoperability
- Prioritization
- System redundancy and backup

## Orbis Terrarum, 1675 by Visscher

**Orbis Terrarum, 1675 by Visscher**