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C alifornia Evidence-based Initiative – Partnership Opportunities. June Simmons, CEO Partners in Care Foundation September 29, 2008. Partners in Care Foundation. Non-profit in Los Angeles, CA Focuses on aging issues Changes the way healthcare services are delivered

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c alifornia evidence based initiative partnership opportunities

California Evidence-based Initiative –Partnership Opportunities

June Simmons, CEO

Partners in Care Foundation

September 29, 2008


Partners in Care Foundation

  • Non-profit in Los Angeles, CA
  • Focuses on aging issues
  • Changes the way healthcare services are delivered
  • Develops, evaluates and disseminates innovative programs to improve care
  • www.picf.org

California Evidence-Based Initiative 2006

  • California Departments of Aging and Public Health awarded 3-year grant from Administration on Aging to spread EB self-care
  • Brings evidence- based programming to age-based organizations
  • Partners in Care is the state program office, California Health Innovation Center

The Scope of the Problem

  • Chronic diseases affect the quality of life of 90 million
  • And represent 80% of the health care dollar
  • 1.7 million Americans die of a chronic disease each year- 70% of deaths in U.S.
  • 87% of persons aged 65 and over have at least one chronic condition; 67% have 2 or more – 1.3 million in CA
  • Solution requires vital provider system development AND patient activation – education models have failed. Lifestyle change and self-care stem from internal commitment by the patient
opportunity for impact
Opportunity for Impact
  • 99% of Medicare spending is on behalf of beneficiaries with at least one chronic condition
  • 80% of health care costs go to 20% of patients: those with chronic diseases
target population
Target Population
  • Have at least 1 chronic condition
  • Family members, friends or caregiver of someone with a chronic condition
  • Must have stamina to attend a 2 ½ hour class, plus travel time for 6 weeks
  • Must have cognitive function to participate
  • Diverse seniors in underserved communities

California Evidence-Based Programs

  • **Healthier Living: Managing Ongoing Health Conditions
  • Matter of Balance: Managing Concerns about Falls
  • Healthy Moves for Aging Well
  • Medication Management Improvement System

Evidence-Based Programs

Evidence Based Model

Promising Practice

Best Practice

  • Are supported by extensive research and have been proven to work
  • Clear, structured, detailed description of the program
  • Have measurable outcomes
  • Easier to market the program and engage partners
  • Increases effective use of resources to enhance programming

Healthier Living: Managing Ongoing Health Conditions

  • Developed by Stanford University Patient Education Research Center as a collaborative research project between Stanford and Kaiser Permanente
  • aka Chronic Disease Self-Management Program (CDSMP)
  • Designed to help people better manage chronic health conditions and live a happier, healthier life.
  • Adopted as a benefit for Kaiser patients
chronic conditions
Chronic Conditions
  • Arthritis
  • Chronic lung disease
  • Diabetes
  • Heart condition
  • Cardiovascular disease
  • Chronic pain
  • Depression
  • Cancer
  • Stroke
  • Any ongoing health condition
patient activation vs education
Patient Activation vs. Education
  • Brief physician visit can’t do it all
  • Lifestyle change is challenging – behavior change comes from internal, not external
  • Research has developed new approaches to help people gain insights and new behaviors to promote health and delay the progression of chronic conditions

Goals of a Self-Management Program

  • Participant learns how to identify problems
  • Participant learns how to act on problems
  • Participant learns problem-solving skills related to

chronic conditions

  • Participant learns how to generate short-term action plans
parts of an action plan
Parts of an Action Plan

1. Something YOU want to do

2. Achievable

3. Action-specific

4. Answer the questions:

  • What?
  • How much?
  • When?
  • How often?

5. Confidence level of 7 or more

workshop overview
Workshop Overview
  • Managing symptoms
  • Dealing with difficult emotions (frustration, anger, pain)
  • Personalizing a fitness and exercise program
  • Relaxation techniques
  • Tips for eating well
  • Medication "how to's"
  • Improving communications (family, friends, doctors)
  • Effective problem-solving
  • Setting weekly goals
health care utilization effects
Health Care Utilization Effects
  • Fewer outpatient visits
  • Fewer emergency room (ER) visits
  • Fewer hospitalizations
  • Fewer days in hospital
healthcare utilization effects
Healthcare Utilization Effects
  • Saves enough money through reductions in healthcare expenditures to pay for itself within the first year
  • Results in more appropriate utilization of healthcare resources
    • Healthcare needs addressed in outpatient settings vs. ER visits and hospitalizations
health effects
Health Effects
  • Greater energy/reduced fatigue
  • Increase in exercise
  • Fewer social role limitations
  • Better psychological well-being
  • Enhanced partnerships with physicians
  • Improved health status
  • Reductions in pain symptoms
  • Decrease in depression
  • Decrease in shortness of breath
  • Improved quality of life
  • Greater self-efficacy and empowerment!!
other benefits
Other Benefits
  • Effective across chronic diseases
    • Wide variety of chronic illnesses addressed = Efficiencies of scale
  • Effective across socioeconomic and educational levels
    • Used by various ethnic groups in the US and internationally in England, Denmark, Australia, Japan, China, Norway & Canada
    • Attests to program’s broad reach and appeal
  • Enables participants to manage progressive, debilitating illness
    • Even with worsening disability, no increase in use of healthcare resources
other benefits cont d
Other Benefits (cont’d)
  • Important health benefits persist over time
    • improvements in exercise and social/role limitations can be seen over a 2-year period
  • Supported by decades of federal research
    • Developed through 20 years of grants from NIH, US Agency for Healthcare Research & Quality, and Centers for Disease Control & Prevention
materials multiple languages
Materials- Multiple Languages

Leader’s Manual

  • English
  • Spanish
  • Chinese
  • Japanese
  • Korean
  • Bengali
  • Dutch
  • German

Participant Workbook

  • English
  • Spanish
  • Chinese
  • Japanese
  • Korean
  • Hindi
  • Italian
  • Norwegian
  • Somali
  • Turkish
  • Vietnamese
  • Welsh
  • Arabic

Relaxation CD

  • English
  • Spanish
  • Chinese

Getting Started

  • Certified Master Trainers
  • Certified Lay Leaders
partnership with capg tools
Work with CAPG leadership to identify physician groups to participate

Physician group readiness assessment

Patient screening and referral criteria

Education tools for office/clinical staff

Referral forms

Fax back form for CBO

Partnership with CAPG - Tools
pilot models of delivery
Partnership with Community


Accesses community based network

create min-networks


Santa Cruz

LA Medi-Cal groups

Hosted on Site

Incorporate into health education or case management

Larger groups, some with hospital systems


Healthcare Partners

Sharp Healthcare

Pilot Models of Delivery
taking new model to scale
Taking New Model to Scale
  • Already proven method, the question is how to go to scale
  • Contracted network with economies of scale and capacity for responding to volume, maintaining quality and fidelity and cost-effective
  • Partners in Care Foundation is working to prepare a rollout at this level.
  • Will begin with several pilots
  • Partners in Care Foundation


  • Stanford CDSMP website http://patienteducation.stanford.edu/programs/cdsmp.html
  • Center for Healthy Aging of NCOA


  • June Simmons,CEO

Partners in Care


818-837-3775 ext 117