Advisory Council August 2016 Meeting Presentation: Indiana University Dissemination of the Aging Brain Care Program

Monday, August 1, 2016

Indiana University Dissemination of the Aging Brain Care Program

Malaz Boustani, MD, MPH
Founding Director, Chief Innovation & Implementation Officer,
Sandra Eskenazi Center For Brain Care Innovation
Indiana University Center for Health Innovation and Implementation Science

IU Team

• Mentors & peers
  • Chris Callahan
  • Greg Sachs
  • Mary Austrom
  • Siu Hui
  • Daniel Clark
  • Su Gao
  • Lisa Harris
  • Patrick Monahan
  • Wanzhu Tu
  • Anthony Perkins
• Mentees:
  • Noll Campbell
  • Babar Khan
  • Nicole Fowler
  • Michael LaMantia
  • Richard Holden
  • Daniel Bateman
  • Sophia Wong
  • Ashley Overlay
  • Nadia Adams
  • Cathy Alder
  • Ben Zarzour

 

• Potential Conflict of Interest in the past 12 months
  • Hold equity in a preferred population health management (PPHM), LLC. PPHM is the distributing network for the IU ABC program.
  • Member of the Beacon Advisory Board for Astra-Zneca.

 

• Source of Funding:
  • For Brain Care Discovery:
    • K23AG026770; R01AG029884; R01AG040220; R01AG034205; P30AG024967; R01HS019818; and R01HS10884.
  • For Brain Care Delivery:
    • R24MH080827; 1C1CMS331000-01-00; 1L1CMS331444-01-00; and Eskenazi Health Foundation.

Objectives

• Describe the structure, the tools, the staffing models, and effectiveness of the IU Aging Brain Care model.

Indiana University Reaction

• Developed the Aging Brain Care Model (ABC beta ) (2000-2001).
• Evaluated the model in RCT* (2001-2006).
• Translated the model into a local clinical program (ABC 1.0) (2007).
• Served 1,000 patients in Indianapolis (2012).
• Developed a scalable version (ABC 2.0) (2012).
• Served 5,000 patients in Indiana (2015).
• Active distribution of the ABC 2.0 (2015)
• Developing an advanced scalable version (ABC 3.0) (2016)

*RCT: Randomized Controlled Trial

The Aging Brain Care Model (ABC beta)

• Primary Care Clinician (Hospitalists):
  • detect and treat delirium
  • detect and treat BPSD
  • Enhance cholinergic system by
    • Prescribe ChEIs
    • Discontinue Anticholinergic
• Caregiver Focus:
  • Problem solving skills
  • Counseling
  • Respite care
  • Support group
• Expert Team:
  • Geriatrician
  • Social Psychologist
  • GeroPsychiatrist
• General Environmental Modification:
  • Medication adherence support
  • Home safety assessment

BPSD: Behavioral and psychological symptoms
ChEIs: Cholinesterase inhibitors

Callahan et al, JAMA 2006; Austrom et al, Gerontologist 2004; Boustani et al, JCIA 2006

Work Force for ABC Model from 1.0 to 3.0

Today ABC 2.0: : M-F 8-5 p.m. about $ 100 p.m.p.m., focusing on dementia / depression
Future ABC 3.0: 24/7 about $ 50 p.m.p.m., almost all brain conditions

• ABC 1.0 -- MD; RN & SW
• ABC 2.0 -- MD; RN & SW; CCA
• ABC 3.0 -- MD; RN & SW; CCA; Patients and informal caregivers

p.m.p.m.=per member per month; MD=medical doctor; RN=registered nurse; SW=social worker; CCA=care coordinator assistant; eMR ABC=electronic medical record ageing brain care (a specialized software application for the model)

IT Support of ABC Model from 1.0 to 3.0

• ABC 1.0 -- MD, eMR-ABC; RN / SW + eMR-ABC
• ABC 2.0 -- MD, eMR-ABC; RN / SW + eMR-ABC; Care Coordinator Assistants + eMR-ABC
• ABC 3.0 -- MD, eMR-ABC; RN / SW + eMR-ABC; Care Coordinator Assistants + eMR-ABC; Informal Caregiver + AVATAR

Standardized Minimum ABC 2.0 Care

1. Check Hospital & ER Alerts every day
2. Coordinate with Inpatient services
   • Alert hospital team of presence of cognitive or mood problems
   • Medications conciliation
   • Connect with family caregiver
   • Request Geriatric consult (If available)
   • Coordinate post discharge transition
3. Post discharge care
   • Home visit within 72 hours of discharge
   • Medication reconciliation
   • Coordinate Home Care visit
   • Coordinate post hospital orders
   • Deliver Delirium protocol and handout
4. Ongoing Aging Brain Care
   • Manage Depression
     • Problem Solving Therapy
     • Pharmacotherapy
     • Cognitive behavioral Therapy
   • Manage Cognitive Impairment
     • Cholinesterase inhibitors (if needed)
     • D/C medications with adverse cognitive effects (Anticholinergics, Histamine 2 antagonists, Benzodiazepines)
     • Caregiver problem solving coaching
     • Medication adherence support

Callahan et al, Aging & Mental Health 2011; Boustani et al, Aging & Mental Health 2011; LaMantia et al, JAGS 2015

The Current Tools of ABC 2.0

• Mobile office
• HABC Monitor for both self and Caregiver report
• eMR-ABC population management software
• Mobile HABC App for Informal Caregiver
• ABC Replication Manual
• ABC Caregiver Booklet
• Anticholinergic Cognitive Burden Scale

LaMantia et al JAGS 2015; Frame et al eGEMS 2013; Monahan et al, JCIA 2010; Monahan et al JCIA 2012; Boustani et al, JCIA 2009

The ABC beta version Efficacy

• NNT = 3.7
• 7 NPI point improvement
• Each 1 point decline in NPI = $250-$400 in health care expenses
• Potential saving 1750-$2800 per patient
• Improvement in family stress

Callahan, Boustani et al, JAMA 2006

NNT: Number Need to Treat; NPI: Neuropsychiatric Inventory; CG: Caregiver

ABC 1.0 Performance

The Acute Care Service Utility Domain	ABC	PCC
% patients with at least one ER visit	28%	49%
Total number of ER visits	124	1143
% patients with at least one hospitalization	13%	26%
Total number of hospitalizations	45	438
Mean/Median length of hospital stay	5 / 4	7 / 4
ABC; Aging Brain Care patients; PCC: primary care center patients Boustani et al, Aging & Mental Health 2011

 

The Quality of Care Indicator Domain	ABC	PCC
% seen at ER again within one week	14%	15%
% re-hospitalized within 30 days of discharge	11%	20%
% with at least one order of definite anticholinergics	19%	40%
% with at least one order of neuroleptics	5%	5%
% with at least one order of anti-dementia drugs	55%	13%
% with at least one order of antidepressant drugs	68%	48%
% with at least one order of definite anticholinergics and anti-dementia drugs	16%	32%
% with at least one LDL order	82%	72%
% of patients with LDL < 130	45%	23%
% with at least one HbA1c order	78%	62%
% of patients with HbA1c < 8	78%	51%
% with last systolic BP < 160	27%	24%
ABC; Aging Brain Care patients; PCC: primary care center patients Boustani et al, Aging & Mental Health 2011

ABC 1.0 Annual Cost Savings Per Patient

Total Cost Savings Per Patient	Low	Mid	High
	$2,885	$3,474	$4,227

ABC 2.0 Performance

Health Outcomes
Full Dementia Care Giver Responders at 12 months	66%
Full Major Depression Patients Responders at 12 months	51%
LaMantia et al, JAGS 2015

ABC DistributionPreferred Population Health Management, LLC

• On-boarding of scalable and existing workforce within the AAAs. (multiple Mini Interview)
• Training and ongoing management and support of the scalable workforce (combined experiential adult learning based coaching)
• Ongoing Zoom-in & Zoom-out monitoring of the performance of the entire population to allow both complex case management and comprehensive resource allocation for the entire population at Risk (Population Health Logistic software)
• Evidence-based clinical pathway to mange the complex cognitive, functional, behavioral and psychological needs of both the client (member suffering from the disease) and their family caregiver.