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Overcoming Health Disparities in Aging: Strategies for Better Care

Explore evidence-based programs for self-management, physical activity, medication management, and more to improve care for the elderly. Learn the importance of addressing social determinants of health and the imperative of care coordination. Join us in transforming aging services for a healthier future.

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Overcoming Health Disparities in Aging: Strategies for Better Care

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  1. Transforming Aging Services:Promise and Threats Under Health Reform RCMAR Conference W. June Simmons, CEO Partners in Care Foundation March 31, 2014

  2. Gallant MP. The influence of social support on chronic illness self-management: a review and directions for research. Health Educ Behav. 2003;30(2):170-95.; DiMatteo MR. Social support and patient adherence to medical treatment: a meta-analysis. Health Psychol. 2004;23(2):207-18.; Krieger J, Higgins DL. Housing and health: time again for public health action. Am J Public Health. 2002;92(5):758-68.; American Public Health Association. The hidden health costs of transportation. http://www.apha.org/NR/rdonlyres/A8FAB489-BE92-4F37-BD5D-5954935D55C9/0/APHAHiddenHealthCosts_Long.pdf. Published February 2010. Accessed January 10, 2012.; Centers for Disease Control and Prevention. CDC health disparities and inequalities report – U.S. 2011. Atlanta, GA: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, 2011.; Robert Wood Johnson Foundation. Overcoming obstacles to health care. www.commissiononhealth.org/PDF/ObstaclesToHealth-Highlights.pdf. Published February 2008. Accessed January 10, 2012.; Shi L, Singh D. The Nation’s Health. 8th ed. Sudbury, MA: Jones and Bartlett Learning, LLC; 2011. Social Factors and Health Outcomes Societal-level social determinants have individual-level impact

  3. 1% spend 21% 5% spend 50% The Upstream Approach: What would happen if we were to spend more addressing social & environmental causes of poor health?

  4. The Expanded Chronic Care Model: Integrating Population Health Promotion

  5. Most of Costliest 5% have Functional Limitations http://www.cahpf.org/docuserfiles/georgetown_trnsfrming_care.pdf

  6. Concentration of Risk • Functional Limitation • Dementia • Frailty • Serious illness(es)

  7. Dementia and Total Spend • 2010: $215 billion/yr • By comparison: heart disease $102 billion; cancer $77 billion • 2040 estimates> $375 billion/yr Source: Hurd MD et al. NEJM 2013;368:1326-34.

  8. The Burden of Chronic Disease

  9. Because of the Concentration of Risk and Spending, Home and Community Care Principles and Practices are Central to Improving Quality and Reducing Cost

  10. Predisposition 30% Behavioral Patterns 40% Social Circumstances 15% Health Care 10% Environmental Exposure 5% Determinants of Health & Contribution to Premature Death Source: Stephen A. Schroeder, MD. We Can Do Better. NEJM 357:12

  11. Dual Eligibles – The Ultimate Case Study: Age + Poverty = Worse Health, Higher Cost Sources: Centers for Medicare and Medicaid Services; Kaiser Family Foundation, Medicare Payment Advisory Commission

  12. Targeted Patient Population Management with Increasing Disease/Disability Home Palliative Care Hot Spotters! Post Acute and Long Term Supports and Services Evidence Based Self-Management, Home Assessment and HomeMeds

  13. Targeting Home & Community-Based Services in Active Population Health Management Examples: Hospice & home palliative care Examples: SNF diversion, Respite Care, Home Modifications, home monitoring, daily meals, assisted transportation Examples: Coaching & Patient Activation, Home-delivered Meals; Referral to Self-Management Classes Examples : Stanford Healthier Living; Diabetes Self-Management; Matter of Balance Examples: Activity programs & education @ senior center

  14. Building Our New Care Model: Focus Areas

  15. Some Leading Evidence-Based Programs SELF-MANAGEMENT • Chronic Disease Self-Management • Tomando Control de suSalud • Chronic Pain Self-Management • Diabetes Self-Management Program PHYSICAL ACTIVITY • Enhanced Fitness & Enhanced Wellness • Healthy Moves • Fit & Strong • Arthritis Foundation Exercise Program • Arthritis Foundation Walk With Ease Program • Active Start • Active Living Every Day MEDICATION MANAGEMENT • HomeMeds FALL RISK REDUCTION • Stepping On • Tai Chi Moving for Better Balance • Matter of Balance DEPRESSION MANAGEMENT • Healthy Ideas • PEARLS CAREGIVER PROGRAMS • Powerful Tools for Caregivers • Savvy Caregiver NUTRITION • Healthy Eating DRUG AND ALCOHOL • Prevention & Management of Alcohol Problems

  16. The Imperative • Critical to invest in solutions: • The social determinants of health • Prevention • Care coordination • It takes a village • Need interorganizational teams to meet the needs of increasingly complex, older patient populations • Responsibility cannot solely reside with the physician • To meet this imperative, we must partner

  17. Visit our Website • This presentation and others are posted • June Simmons, MSW • WWW.PICF.ORG • jsimmons@picf.org

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