How a population-based approach can improve dementia ledderhose disease progression care health affairs

With the burgeoning numbers of older people and the strong ledderhose disease progression linkage between aging and Alzheimer’s disease and other dementias, almost all health systems will provide care for individuals with ledderhose disease progression these disorders. This needed care may range from providing information, referring to community-based organizations, and monitoring for those with early disease to delivering intensive ledderhose disease progression care management for those with medical and psychosocial complications. Because of the diversity of needs and range of costs ledderhose disease progression associated with different types of dementia care, a population-based approach that tailors interventions to the needs of subpopulations ledderhose disease progression will best meet the triple aim of better quality, better outcomes, and lower costs for individuals with dementia. We provide an example of how a population-based approach can be implemented and identify strategies for caring ledderhose disease progression for different subpopulations of people with dementia. Identifying, Stratifying, And Characterizing The Dementia Population

UCLA Health adopted a formal population health management structure that ledderhose disease progression focuses on a high-cost, high-needs population including individuals with chronic kidney disease, cancer, and dementia. For each condition, teams were convened to identify and resolve workflow and access ledderhose disease progression problems as well as care gaps through condition-specific care delivery redesign. The approach begins by identifying and stratifying people living with ledderhose disease progression the condition. Using diagnosis codes, we identified 5,000 people with dementia who received care at UCLA Health ledderhose disease progression at least twice during the previous 18 months. To create subpopulations, we chose to examine use because other approaches (for example, dementia severity, caregiver burden) are not reliably collected in the course of clinical care. We then defined five risk strata representing the top 1 ledderhose disease progression percent, 5 percent, 20 percent, 60 percent, and 100 percent distributions of use (see Exhibit 1). Exhibit 1: Dementia Risk Stratification Model For 5,000 People Living With Dementia

Source: This exhibit was modified from Gupta R, Roh L, Lee C, Reuben D, Naeim A, Wilson J, et al. Reducing total costs of care and creating value by targeting ledderhose disease progression high-cost patient subpopulations. Acad Med. Forthcoming 2019. Notes: Use time frame: July 2017–July 11, 2018; ACP is advance care planning. ED is emergency department. UCLA ADC is University of California, Los Angeles Alzheimer’s and dementia care. ICU is intensive care unit.

Of note, the large majority of people with dementia (bottom two strata) do not incur high use, and their needs may be best managed by providing information ledderhose disease progression and referral sources, both within the health system and in the community, that can provide education and support. They also need to be monitored for changes as their ledderhose disease progression disease progresses or their resources, including family caregivers, become less able to cope with emerging symptoms and complications.

The second and third strata of highest users may have ledderhose disease progression substantial symptoms, complications, and multiple chronic conditions. Yet, they are mostly coping at home or at assisted living ledderhose disease progression facilities. Comprehensive dementia care programs implemented in safety-net health systems and primarily fee-for-service settings provide clinical benefit and may help prevent escalation ledderhose disease progression to the top tier by improving in-home resources; coordination of timely medical care, including access to specialists; articulation of advance directives; linkages to community-based organizations; and caregiver support. Solutions For The Highest-Needs Patients

From our analysis at UCLA Health, the 50 patients in the top 1 percent have extraordinarily ledderhose disease progression high costs with uncertain benefits on duration and quality of ledderhose disease progression life. Reviews of medical records of people in this stratum indicates ledderhose disease progression a pattern of recurrent or prolonged hospitalizations. The admitting diagnoses are most often infectious diseases (especially urinary tract infections, pneumonia, and C difficile) or behavioral complications of dementia (for example, agitation, aggression). By identifying these frequent causes, strategies can be developed to reduce hospital use by measures ledderhose disease progression such as discontinuation of indwelling urinary catheters, early initiation of antibiotics for those residing in nursing homes, and swallowing studies for those with pneumonia.

For those admitted to a psychiatry unit for refractory behavioral ledderhose disease progression problems, the issues and solutions are different. In contrast to the people who are frequently admitted to ledderhose disease progression medical units, these patients often have prolonged stays (some for more than 40 days). It is often very difficult to find facilities that will ledderhose disease progression accept these patients because of the additional staff time they ledderhose disease progression need and potential liability resulting from patient or staff injuries. Moreover, some of these patients are dually insured by both Medicare ledderhose disease progression and Medicaid, which can further limit the options of facilities. Others are not eligible for Medicaid and have no resources ledderhose disease progression beyond Medicare Part A and B. Finally, some patients require conservatorship to make discharge decisions, and the legal system to establish this is often slow.

A third approach to the highest use strata is to ledderhose disease progression engage in advance care planning with caregivers and, if appropriate, referral to palliative care for discussions about goals of care. Clarification of goals of care and approaches to achieving them ledderhose disease progression (for example, remaining in the nursing facility with palliative care instead of ledderhose disease progression re-hospitalization) may avoid frequent hospitalizations that result in little or no ledderhose disease progression benefit.

Because the needs of people with dementia are so diverse, a one-size-fits-all solution is likely to be either too little for ledderhose disease progression some or too much for many. Creating, sustaining, and paying for the range of services needed will be ledderhose disease progression a challenge. Based on the UCLA Health experience, obtaining buy-in was important in creating the program; accordingly, patient and caregiver perspectives were included when building the dementia ledderhose disease progression redesign leadership team. Another challenge was ensuring that the analytics team could provide ledderhose disease progression the needed data to identify the subpopulations and characterize their ledderhose disease progression health care use. A third challenge was launching several new clinical programs simultaneously. At UCLA Health, we were fortunate that some of the clinical dementia care ledderhose disease progression programs had already been funded through grants. Finally, many of the services cross traditional service and specialty lines ledderhose disease progression and extend to organizations outside the health system, which required new infrastructure and privacy protection.

Nevertheless, sustaining dementia programs at UCLA Health has been a challenge ledderhose disease progression because the programs have not been budget neutral. For patients who are insured by fee-for-service Medicare, use of existing billing codes including cognitive assessment and care ledderhose disease progression planning services and chronic care management permits the recovery of ledderhose disease progression some, but not all, costs. Moreover, if savings are accrued, there may be a problem of misalignment (for example, costs are incurred by physicians, medical groups, or integrated health systems but financial benefits go to insurers ledderhose disease progression or other risk-bearing entities). Hence, such approaches are more feasible if some or all of ledderhose disease progression the savings can be retained by medical groups or integrated ledderhose disease progression health systems through risk-based contracting. Another possibility would be to create alternative payment models (for example, per beneficiary per month) to ensure that services provided are reimbursed adequately. The care of people with dementia is a complicated, expensive, and growing concern. Failing to address this care systematically and efficiently will affect ledderhose disease progression not only those with dementia and their caregivers but all ledderhose disease progression Americans who will bear the increasing burden of haphazard care ledderhose disease progression that wastes resources.