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Friday, November 14, 2003 - Page updated at 04:01 P.M.
Stakes high to help those with chronic diseases
By Sandi Doughton
Lois Stolle wasn't aging well.
Not even 60 years old, the Seattle woman had twice collapsed in a diabetic coma, saved from death only by timely visits from friends and relatives. At high risk of blindness, stroke and heart attack because she couldn't keep her blood sugar under control, Stolle shuttled in and out of hospitals. When the ravages of her diabetes and congestive heart failure left her unable to walk or care for herself, she wound up in a nursing home.
"I woke up screaming: 'Get me out of here!' " recalled Stolle, whose mother languished in a nursing home for two decades after a series of strokes. "I didn't want the same thing to happen to me."
Society doesn't want it, either.
On the cusp of an unprecedented age boom, America can't afford its elderly to be as sick as Stolle was.
"The stakes are really quite high," said Dr. Ed Wagner, director of Group Health Cooperative's W.A. MacColl Institute for Healthcare Innovation.
"Don't spend the last 15 years of your life blind, or as an amputee, because your diabetes wasn't managed properly. Don't die young from congestive heart failure, because it wasn't managed properly," said health-care consultant John Fiorillo, author of a Robert Wood Johnson Foundation report on chronic illness in America. "The goal of chronic-disease management is to keep us as healthy as possible, with as good a quality of life as we possibly can have, until the day we die."
But few seniors today get the coordinated care required to control chronic diseases, which primarily afflict the elderly and consume 75 percent of the national health-care budget.
"We have a health-care system that's pretty good if you have an acute problem, like a broken arm or pneumonia," Wagner said. "But it's not set up to deal with these lifelong illnesses."
More than half of the people who suffer from chronic diseases are not getting the tests and treatments that are considered state-of-the-art medical care, he said. A 70-year-old with multiple health problems may bounce between four or five specialists, who never confer with each other. The patient is left with a bewildering array of drugs, conflicting advice and little real guidance.
The costs both in dollars and quality of life are already staggering and are certain to escalate as the number of Americans 65 and older doubles by 2030, Wagner said.
More than 80 percent of seniors suffer from at least one chronic ailment, and 25 percent have four or more.
For diabetes, that translates into a cost of more than $32 billion a year. Without improvements in health care, analysts project the total medical bill for the nation's elderly will at least double, and possibly quadruple, over the next few decades, conceivably reaching $1.3 trillion a year by 2020.
Better care, lower cost
Stolle's experience is testament to the power of coordinated health care to reduce human misery while also saving money.
Now 61, she's back in her own apartment. Every morning, a home-health aide helps her check her blood sugar and take the proper dose of insulin, along with nine other drugs for everything from high blood pressure to bloating.
Twice a week, she shuttles to an adult day center in South Seattle run by Providence ElderPlace, a government-funded program that provides comprehensive care for 176 people age 55 and older all of whom would otherwise be living in nursing homes.
Because of the physical therapy she receives at the center, Stolle can walk short distances with a walker. She has lost nearly 75 pounds, thanks largely to the dietitian who helps plan her menus and the healthful meals served at the center. She gets regular physical exams from the program's in-house geriatrician, Dr. Assad Kazemi.
"We know everyone's history and background here," he said. "We don't wait for things to get so bad that people wind up in the hospital."
For Stolle, the most tangible benefits are being able to live on her own again, and feeling well enough to socialize with her sister and girlfriends.
"I'm so much better since I've been here," she said.
For Medicare and Medicaid, the federal and state programs that pay for the ElderPlace program, the benefit is a savings of up to 15 percent compared with what it would cost to keep Stolle in a nursing home.
Prevention is key
In the traditional approach to medicine, people with chronic diseases usually visit the doctor only when there's a specific problem. Someone with heart disease might come in complaining of fluid retention and painfully swollen legs. An asthmatic might go to the emergency room when he can't breathe.
The doctor deals with the crisis at hand but has little time to address the underlying reasons the disease is out of control. She might admonish the patient to lose weight and hand over a pamphlet on exercise.
Then, three months later, the patient is back, with the same problems or worse.
"It's frustrating for everyone," Wagner said.
Chronic care turns the system upside down, placing the emphasis on regularly scheduled checkups. Nurses call patients at home to see if they're taking their medications or eating properly. Doctors use computer programs to identify patients with specific conditions and to see, at a glance, their treatment histories. That also helps to ensure each patient receives all the recommended tests and the most effective medications.
"I don't have to spend my time flipping through all the sheets of paper in the chart," said Dr. Kevin Martin, an Auburn family-practice physician who switched to the chronic-care model three years ago. "I can listen to patients tell me what's going on in their lives."
Financially, the new approach is a wash.
"I can't say that I'm getting paid any better," Martin said. "My own belief is that it makes us more efficient; we're giving better care, and it makes the patients happier."
Keeping patients happy and being aware of what else is going on in their lives is crucial, because people who live with lifelong diseases must take the lead in managing their health.
Under the chronic-care model, doctors, nurses and educators work with patients to figure out what's keeping them from taking their drugs regularly, losing weight or eating healthfully. The team then works to remove those barriers and helps the patient set achievable goals.
At Highpoint Medical Clinic, a low-income clinic in West Seattle, Dr. Jane Baird gives her hypertension patients blood-pressure cuffs so they can see for themselves when their disease is edging into the danger zone.
"They quickly realize: If I eat a bag of Lay's potato chips, my blood pressure is going to be higher," Baird said. "That has much more of an impact than me wagging my finger at them and saying: 'You need to lose 10 pounds.' "
Baird often schedules diabetic patients for group visits, where everyone gets their eyes, feet and blood sugar checked, while sharing health tips and learning more about the condition they all share. Social workers, dietitians, nurses and doctors work together to coordinate each patient's care.
"Everybody talks to everybody else," said Jayne Nelson, a clinic patient who lives in Lake City. "If I was a race car, I couldn't be any more well-taken-care of."
Under Baird's guidance, Nelson gave up the weekend drinking parties that aggravated her diabetes and can control the condition with diet alone. She exercises and keeps careful records of her blood sugar.
"They make me feel like it's worth taking care of myself," Nelson said.
And at the age of 41, Nelson understands that managing chronic disease isn't only important for the elderly.
"If you want to prolong your life, you've got to do things differently," she said.
A slow change
As leaders of a national program of the Robert Wood Johnson Foundation called "Improving Chronic Illness Care," Wagner and his colleagues have trained more than 1,000 doctors, medical groups and clinic staffs across the country in the chronic-care model. The Washington Department of Health also is spreading the word through an award-winning program focused on diabetes.
Even the state's poorest residents are benefiting from a scaled-down version of chronic care. More than 27,000 Medicaid patients with asthma, kidney disease, diabetes and heart disease get regular calls from a network of contract nurses who check their status, remind them to take medications and answer questions.
Health officials estimate that the program already has saved the state $2 million as a result of reduced hospitalizations and fewer costly complications.
Other success stories are starting to accumulate.
At Group Health in Seattle, diabetes patients treated under the chronic-care model had fewer hospital admissions and emergency-room visits and cost $700 to $950 a year less to treat. Another study of elderly patients with congestive heart failure found a nearly 60 percent drop in hospital admissions and higher quality-of-life scores among patients who received more comprehensive care.
Though it often requires more work and money up front to change systems and adjust to a new way of working, doctors who have embraced the model are uniformly enthusiastic. Most also believe the new approach is more cost-efficient and engenders patient loyalty.
"I firmly believe the better you take care of people, the cheaper it is in the long run," Baird said.
But many obstacles remain, particularly the traditional payment system used by most insurance companies and Medicare, the program that pays for most seniors' health care. Medical practices usually don't get reimbursed for patient education, a mainstay of chronic-care systems, nor do many insurers cover phone consultations by nurses or blood-pressure monitors and other home equipment for patients, Wagner said.
The Medicare reforms being debated in Congress offer few incentives to promote chronic care. But as the shadow of the coming age wave stretches across the country, policymakers soon might be overwhelmed by the sheer numbers and the growing discontent of the millions of Americans who want to age well, despite their chronic illnesses.
"The way we deal with the chronic patient and the chronic elderly patient is the bellwether for our health system," said Fiorillo, the health-care consultant. "If the system can't deal with the chronically ill by providing high-quality, affordable care, the system is not going to succeed."
Sandi Doughton: 206-464-2491 or firstname.lastname@example.org
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