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Individuals with comorbidity — the presence of more than one disease or health condition at a given time — comprise more than a quarter of the population and account for 65 cents of every U.S. healthcare dollar. When comorbidity is complicated by advanced age and/or the presence of behavioral health conditions, healthcare costs and care challenges can increase exponentially.

Comorbidity Care Models: Integrated Action Plans for Complex Healthcare Needs presents emerging models of care for comorbidity, with a special focus on the needs of aging multi-morbid patients as well as those whose comorbidity encompasses physical and behavioral health conditions.

In this 38-page special report, two industry thought leaders share programs aimed at the co-morbid patient. Chad Boult, M.D., M.P.H., M.B.A., professor of public health, medicine & nursing and director of the Lipitz Center for Integrated Health Care, Johns Hopkins Bloomberg School of Public Health, presents Guided Care, an emerging model of care for older multi-morbid patients that is demonstrating early success in improving quality of life and efficiency of healthcare utilization for this population.

The Guided Care model, which has been in development at Johns Hopkins for several years, depends largely on a Guided Care Nurse (GCN) who collaborates with multiple primary care physicians to provide cost-effective care to their chronically ill patients. In a 2010 study, researchers at the Johns Hopkins Bloomberg School of Public Health found that chronically ill older adults who are closely supported by a nurse-physician primary care team are twice as likely to rate their healthcare as high-quality than those who receive usual care.

Dr. Boult reviews Guided Care Nurse (GCN) roles and responsibilities and offers preliminary results from initial pilots, including the impact of Guided Care on healthcare quality and costs for 904 older patients in the Baltimore-Washington, D.C., area. Previously published data has suggested that, compared to usual care patients, Guided Care patients tended to spend less time in hospitals and skilled nursing facilities and had fewer ER visits and home health episodes, producing an annual net savings for healthcare insurers (after accounting for the costs of Guided Care) of $1,365 (11 percent) per patient or $75,000 per nurse.

Providing perspectives from the Medicaid population, where there is significant behavioral health comorbidity, is Jim Hardy, senior vice president of care management services with McKesson Health Solutions. Hardy describes the growing trend toward closing physical and behavioral healthcare gaps for this population and adopting an integrated, whole-person approach.

These integrated approaches can help reduce the cost of chronic care, which consumes a significant portion of state Medicaid budgets already strained by budget cuts and the failing economy. Also at issue are large numbers of prescriptions for Medicaid beneficiaries written by non-psychiatrists for significant behavioral health issues, a consequence of a lack of care coordination for these individuals.

Hardy offers strategies for overcoming information and care gaps on both the physical and behavioral health sides and describes initiatives underway in Illinois and elsewhere that target the comorbid Medicaid patient, with special attention to behavioral health comorbidity.

This special report also provides details on:

• The real costs of implementing the Guided Care model;
• The eight key responsibilities of the GCN;
• EHR support for Guided Care patient action plan, care reminders, prescription decision support, and more;
• Strategies to empower and motivate the older patient and move them toward self-management;
• Preliminary impact of Guided Care on utilization, quality and efficiency of healthcare for high-risk patients with multi-morbidity;
• Enhanced primary care case management efforts that encompass behavioral health;
• Improvement of information transfer and care coordination across physical and behavioral health systems;
• Early efforts in multidisciplinary approaches in California, Illinois and Pennsylvania;

Table of Contents

• Guided Care: Empowering the Older Multi-Morbid Patient
  • The Cost of Caring for Multiple Morbidities
  • A Nurse-Guided Model of Care
  • Monitoring the Patient Action Plan
  • Smoothing Care Transitions
  • The Role of Caregivers in Guided Care
  • Using Predictive Modeling to Determine Eligibility
  • Highlights from Ongoing Pilot
  • Patient Assessment of Chronic Illness Care
  • The Cost of Guided Care
  • Preliminary Conclusions
• Coordinating Physical and Behavioral Health Comorbidity
  • Behavioral Health Issues in the Chronically Ill
  • Challenges of Integrating Physical and Behavioral Health
  • Illinois Effort Focuses on Medication Adherence
  • Other Enhanced Primary Care Initiatives
• Q&A: Ask the Experts
  • Measuring Impact of Care Improvement
  • Selecting Participants for Illinois Medical Home
  • Measuring Medication Compliance
  • Measuring Impact of Care Improvement
  • Overcoming Patient Resistance
  • The Transient Nature of the Medicaid Patient
  • Paying the Guided Care Nurses
  • Identifying Members for Case Management
  • Overcoming Resistance to Change
  • Licensing and Billing for Home Visits
  • Discharge Planning Strategies
  • Home Visit Details
  • Included Diagnoses
  • Skills and Training for Guided Care Nurses
  • Overcoming Patient Resistance
  • Bringing PCPs on Board for Behavioral Health
  • Empowering the Older Multi-Morbid Patient
  • Assessing the Impact of Guided Care
• Glossary
• For More Information
• About the Presenters