The document discusses strategies for community-based chronic illness management to reduce costs and improve outcomes. It outlines several programs that have shown promise, including transitional care programs and house call programs. Transitional care programs of varying intensity use nurses and nurse practitioners to coach patients after hospital discharge. House call programs provide primary care to high-risk elderly patients in their homes through visits from physicians and nurse practitioners. Evaluation of these programs has found reduced utilization, lower costs, and improved outcomes and quality of life.

1. Community-based Chronic Illness Management: Strategies and Tools to Reduce Costs and Improve Outcomes Steve H. Landers MD, MPH Director, Cleveland Clinic Center for Home Care and Community Rehabilitation [email_address] April 5, 2010 Brent T. Feorene, MBA President, House Call Solutions [email_address]

3. Powerful Trends Impact Medical Practice Aging Population Chronic Illness Economic Pressures Consumer Expectations Technology

4. Demographic Imperative Administration on Aging. A Profile of Older Americans: 2007. Accessed at www.aoa.gov

5. Activity Limitations Administration on Aging. A Profile of Older Americans: 2007. Accessed at www.aoa.gov

6. Chronic Illness Epidemic Johns Hopkins University, Partnership for Solutions. Chronic Conditions: Making the Case for Ongoing Care, A Chartbook. September 2004 Update

7. Aging + Chronic Illness Johns Hopkins University, Partnership for Solutions. Chronic Conditions: Making the Case for Ongoing Care, A Chartbook. September 2004 Update

8. Costly Congressional Budget Office

9. “High Risk” 2005 MCR FFS stats from MedPAC DataBook June 2008 Johns Hopkins University, Partnership for Solutions. Chronic Conditions: Making the Case for Ongoing Care, A Chartbook. September 2004 Update

10. Jencks SF et al. N Engl J Med 2009;360:1418-1428 Readmissions Half of Medicare Patients Rehospitalized Without Seeing Doctor After Discharge ~60% of Rehospitalized HF patients hospitalized due to another problem

19. “Secret Weapons” Enhances view of patient and caregivers Reduces barriers to care Strengthens patient relationships Avoids hazards of hospitalization Costs less Desired more Enabling technology emerging

25. Rates of Rehospitalization within 30 Days after Hospital Discharge Jencks SF et al. N Engl J Med 2009;360:1418-1428

40. House Calls Montefiore Medical Center Results for Medicare Advantage Enrollees