A Primer on Managed Care: Multiple Chronic Conditions SPRING 2019 supplement 3

Journal of the American Society on Aging


A Primer onManaged Care: Multiple Chronic Conditions



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A Primer on Managed Care: Multiple Chronic Conditions

ASA Executive Committee Chair, Board of Directors Karyne Jones, Washington, DC Chair-Elect Michael Adams, New York, NY Secretary Jean Accius, Washington, DC Treasurer Lisa Gables, Alexandria, VA

GENERATIONS STAFF Publisher Robert G. Stein Editor

Alison Hood Senior Editor Alison Biggar Typography & Production Michael Zipkin | Lucid Design, Berkeley, California Generations cover and book design by Lisa Rosowsky, Blue Studio. Front cover image ©Getty Images/ filo © 2019 American Society on Aging

ASA Board of Directors Ginna Baik, San Diego, CA Connie Benton-Wolfe, Fort Wayne, IN Richard Browdie, Cleveland, OH Yanira Cruz, Washington, DC Paul Downey, San Diego, CA Brian M. Duke, Radnor, PA Robert Espinoza, Bronx, NY Maria Henke, Los Angeles, CA Brooke A. Hollister, San Francisco, CA Karen N. Kolb Flude, Chicago, IL Daniel Lai, Hong Kong Rebecca C. Morgan, Gulfport, FL Scott Peifer, San Francisco, CA Kevin Prindiville, Oakland, CA Deborah Royster, Washington, DC Phil Stafford, Bloomington, IA Joyce Walker, Richmond Heights, OH President and CEO Robert G. Stein, San Francisco, CA

Union Bug

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A Primer on Managed Care: Multiple Chronic Conditions

inside generations field guide supplement 3 A Primer on Managed Care: Multiple Chronic Conditions

chronic conditions, social determinants, and Medicare Advantage Managing Chronic Disease in an Evolving Healthcare Environment By Erin Westphal 3

47 How Will LTSS and Medical Care Integrate to Provide Community-Based Care? By Anne Montgomery and Sarah Slocum 53 New Reimbursement Mechanisms Are Driving New Levels of Competition By Lori Peterson 57 CBO’s Role in Addressing Malnutrition in Community-Dwelling Older Adults By Brenda Schmitthenner, Andrea Morris, Jessa K. Engelberg, Amy Herr, and Cheryl Hassoldt


Chronic Conditions, from A to Z By Kathleen A. Cameron

12 The Role of Social Determinants and Why Community-Based Programming Works By Karen D. Lincoln 18 Medicare Advantage: Modernizing Medicare Through Innovation in Financing and Care Delivery By Allyson Y. Schwartz 23 New Strategies for Condition Management Within Value-Based Care By Robert Fields 27 The CHRONIC Care Act: Expanding Access, Extending Medicare’s Focus By G. Lawrence Atkins and Andrew L. MacPherson supporting Medicare Advantage clients in the community Partners in Care Foundation: A Change Agent in Community-Based Care By June Simmons and Sandy Atkins 35 Successful Chronic Disease Programming: The Important Role of Community Health Workers By Carl H. Rush 42 Healthcare Providers Can Help to Connect Family Caregivers to Resources and Supports By Donna Benton and Kylie Meyer 31

highlighting innovations in dementia care, in the community


The UCLA Alzheimer’s and Dementia Care Program

By David B. Reuben, Leslie Chang Evertson, Michelle Panlilio, Mihae Kim, Kelsey Stander, and Zaldy S. Tan 67 A Profile in Population Health Management: The Sandra Eskenazi Center for Brain Care Innovation By Malaz Boustani, Lindsey Yourman, Richard J. Holden, Peter S. Pang, and Craig A. Solid 72 The Dementia Cal MediConnect Project By Brooke A. Hollister, Jarmin Yeh, Leslie Ross, Jennifer Schlesinger, and Debra Cherry 78 An Advance Directive for Dementia By Barak Gaster 82 Improving Care for People with

Chronic Conditions By Katherine Hayes

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GENERATIONS – Journal of the American Society on Aging

Managing Chronic Disease in an Evolving Healthcare Environment By Erin Westphal

Community-based organizations increasingly are addressing social determinants of health, and preventing more expensive medical interventions.

O ver the past 100 years, great advances have been made in medicine. These have resulted in increased human longevity, however, people are living longer with chronic conditions, as shown in Figure 1 (see page 4). A chronic condition can be a physical condition, such as chronic obstruc- tive pulmonary disease (COPD), or a mental health condition, such as Alzheimer’s disease or other dementias. These conditions persist for more than one year and result in functional limitations. Heart disease, cancer, stroke, COPD, and diabetes account for more than two-thirds of deaths and 75 percent, or $1.5 trillion, of health- care spending (Wullianallur and Raghupathi, 2018). The systems providing care and payment policies have not kept pace with these medical advancements. Medicare, the nation’s largest payer for healthcare, provides coverage to nearly 90 mil- lion people. Twenty percent of those people are dually eligible, meaning they also have Medi­ caid, the insurance for low-income individuals (Rudowitz and Garfield, 2018). Fourteen percent

of these beneficiaries have six or more chronic conditions, and 55 percent have between two and five (Better Medicare Alliance, 2017). When peo- ple have both functional limitations and chronic conditions, their use of healthcare services and the attendant costs increase drastically. A per- son who needs help with one or more activities of daily living costs twice as much to the Medicare The CHRONIC Care Act advances integrated, person-centered care for Medicare beneficiaries and dual eligibles. program as does someone with no functional limitations. Figure 2 (see page 4) illustrates this point (Tumlinson and Johnson, 2018). The Changing Landscape of Care Provision and Reimbursement In response to the older adult population living longer with chronic conditions and functional

abstract Now, more than ever before, people are living longer with chronic conditions. More than half of Medicare beneficiaries have two to five chronic conditions. In addition to managing their clini- cal conditions, many are dealing with social determinants of health. Beginning with the advent of the Affordable Care Act, the healthcare sector has seen a shift to value-based care and an increased focus on outcomes. As it has taken on more risk, the healthcare sector has recognized it must address the patient as a whole person and not merely focus on clinical conditions. | key words: chronic conditions, social determinants of health, community-based organizations

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to food, must be considered before providers can expect people to eat healthily and exercise. In a specific situation, such as transitioning from hospital to home after a case of pneumonia, the needs are more limited. These may be solved via 30-day interventions. These may be more clinical, but social interventions also are needed, such as transportation to follow-up appoint- ments, and to pick up medications. In some cases, the needs can be determined as medi- cally necessary, with some possibility of payment fromMedicare and ongoing support through Medicaid waiver programs. The impacts of policy shift Since the 2010 passage of the Patient Protec- tion and Affordable Care Act (ACA), we have seen a shift in policies that defines how care is provided. There has been increased attention Figure 2. Moderate Functional Impairment Associated with High Medical Costs

Figure 1. Life Expectancy Has Changed Dramatically

Source: National Center for Health Statistics–National Vital Statistics Service Reports, 2010.

limitations, and the shifting payment environ- ment, the healthcare sector and community- based organizations (CBO) have begun partnering to integrate care and more effectively address the social determinants of health and functional limi- tations. CBOs for decades have been addressing social determinants of health: they know first- hand the value of meeting the person where they are, and addressing all of their needs. The impacts of social determinants of health There is now a greater understanding for how social determinants of health impact a person’s health, function, and quality of life. Social deter- minants include social and economic status, health, education level, and the community in which a person lives, and are realized as access to affordable housing, transportation, services to support daily needs, access to healthcare, and residing in a safe and accessible environment (Office of Disease Prevention and Health Pro­ motion, 2018). Older adults’ healthcare needs can be ongoing and-or time-limited. In both cases, a healthcare intervention, or a response to those needs, often requires a mix of medical and social interven- tions. It has been accepted practice that before a healthcare organization can address a person’s chronic conditions, it must address his or her immediate and ongoing needs. Basic needs, such as paying for rent or utilities and having access

Source: The SCAN Foundation, 2018.

to value-based purchasing, especially in the hospital setting (Centers for Medicare & Med- icaid Services [CMS], and Medicare Learning Network, 2017). There has been a move toward services integration through the Financial Align- ment Initiative, which is focused on dual eligible beneficiaries, who have both Medicare and Med- icaid (CMS, 2018a). And new approaches to care delivery are being tested through entities such as Accountable Care Organizations (ACO) (CMS, 2018b) for Medicare Fee-for-Service.

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In 2018, The Bipartisan Budget Act was signed into law, which incorporated the Creat- ing High-Quality Results and Outcomes Neces­ sary to Improve Care (CHRONIC) Care Act (2017). The new law significantly advances pol- icies related to providing integrated, person- centered care for Medicare beneficiaries and for those who are dually eligible for Medicare and Medicaid. The Act provides an opportunity for Medicare Advantage to provide supplemental Heart disease, cancer, stroke, COPD, and diabetes account for 75 percent of healthcare spending. benefits to cover the costs of some non-medi- cal needs for high-need, high-cost beneficiaries. This also applies to those in permanently autho- rized Special Needs Plans (D-SNP; for dual eli- gibles), Chronic Condition Special Needs Plans (C-SNP; for people with chronic disabling condi- tions), Institutional Special Needs Plans (I-SNP; for institutionalized individuals), and provides greater flexibility to ACOs. A focus on population health management With these opportunities, the healthcare sector has focused on population health management and social determinants of health. Population health management typically uses data to iden- tify at-risk individuals and apply interventions to manage their health needs; and the healthcare sector employs diagnosis and claims data to tar- get the highest utilizers. These are retrospective data, which means the healthcare sector begins the intervention after a person already has used healthcare services. For some providers, this means that the individual’s needs are harder to address and support. There has been much dis- cussion and early work to predict which patients might be future high utilizers, in order to antici- pate needs and deploy an intervention before healthcare utilization begins (Figueroa et al., 2017; Joynt et al., 2017). Healthcare entities are

still working out how to do this in a meaningful and cost-effective way. Diagnosis and claims data provide only one picture of an older adult’s health. Functional status is another major indicator of healthcare services use. Assessing an individual’s func- tional status and acting upon that information is an effective strategy for identifying people who are high-risk and high-cost. Those provid- ers participating in the Financial Alignment Initiative are required to conduct health risk assessments of their members. These assess- ments take into account all aspects of indivi­ duals’ medical, biological, and psychosocial needs. To this end, the California Department of Health Care Services, in 2018, required plans to add ten questions specific to function to the health risk assessment (The SCAN Founda- tion, 2018). Additionally, in the 2019 Call Letter (CMS, 2018c), CMS recognized the importance of why a health risk assessment should include a functional assessment. Healthcare Environment Continues to Evolve The shift from volume to outcomes in health- care continues to grow. There are several partnerships that have moved from pilots to ongoing sustainable collaborations for both parties. These early adopters have seen the benefits in improved quality of life for older adults but also in savings. Savings and ben- efits result from delaying institutionalization, reducing readmissions to hospitals, shortening hospital lengths of stay, and reducing emer- gency department visits. CBOs have made these benefits and savings possible through providing short-term and ongoing care management and care transitions, providing nutrition and trans- portation services, and linking older adults to other programs that offer housing, energy ‘The shift from volume to outcomes in healthcare continues to grow.’

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assistance, home modifications, and many other types of assistance. The challenge continues to be how to expand the flexibility of healthcare dollars to cover the costs of community services. A community inter- vention often costs a fraction of a medical inter- vention. Health and social service sectors will need to continue to show that these interventions result in the same or better outcomes at a lower cost. Meeting the person where they are, under-

standing what they define as their greatest need, and responding to that need sounds easy concep- tually but, in practice, the current system is not designed to support this approach to care. Erin Westphal is a program officer for The SCAN Foundation in Long Beach, California. Her work focuses on building the business case for person- centered care models and integrating the care and financing for medical and social services.

References Better Medicare Alliance. 2017. “Understanding Risk Adjustment in Medicare Advantage.” tinyurl. com/ya3k92xf. Retrieved October 22, 2018. Centers for Medicare & Medicaid Services (CMS), and Medicare Learning Network. 2017. “Hospital Value-based Purchasing.” tinyurl. com/lfed3dt. Retrieved October 22, 2018. CMS. 2018a. “Financial Alignment Initiative.” Retrieved October 22, 2018. CMS. 2018b. “Accountable Care Organizations.” pn3wfcw. Retrieved October 22, 2018. CMS. 2018c. “NOTE TO: Medicare Advantage Organizations, Pre- scription Drug Plan Sponsors, and Other Interested Parties.” tinyurl. com/ycak6kl2. Retrieved October 22, 2018.

Creating High-Quality Results and Outcomes Necessary to Improve Chronic (CHRONIC) Care Act of 2017. 2017. S. 870. 115th Cong. Retrieved October 22, 2018. Figueroa, J. F., et al. 2017. “Concen- tration of Potentially Preventable Spending Among High-cost Medi- care Subpopulations: An Obser- vational Study.” Annals of Internal Medicine 167(10): 706–13. Joynt, K. E., et al. 2017. “Segment- ing High-cost Medicare Patients into Potentially Actionable Co­ horts.” Healthcare 5(1–2): 62–7. Office of Disease Prevention and Health Promotion. 2018. “Social Determinants of Health.” tinyurl. com/z32yfnv. Retrieved October 22, 2018.

Rudowitz, R., and Garfield, R. 2018. “10 Things to Know About Med- icaid: Setting the Facts Straight.” Henry J. Kaiser Family Foun- dation. Retrieved October 22, 2018. The SCAN Foundation. 2018. “Ten Questions to Better Understand and Serve Your Complex Care Pop- ulation.” Retrieved October 22, 2018. Tumlinson, A., and Johnson, M. 2018. “CHRONIC Care Act: Mak- ing the Case for LTSS in Medicare Advantage Supplemental Benefits.” The SCAN Foundation. tinyurl. com/ybrx6wtz. Retrieved October 22, 2018. Wullianallur, R., and Raghupathi, V. 2018. “An Empirical Study of Chronic Diseases in the United States: A Visual Analytics Approach to Public Health.” International Journal of Environmental Research and Public Health 15(3): 431.

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GENERATIONS – Journal of the American Society on Aging

Chronic Conditions, from A to Z By Kathleen A. Cameron

Life expectancy is lower in America than in other developed nations, mainly due to the toll of chronic conditions, many of which are preventable.

L ife expectancy has increased notably since the beginning of the twentieth century, due to improvements in public health, nutrition, and medical technology. Today, the 10,000 baby boomers turning age 65 every day can expect to live another eighteen years (for men) to twenty years (for women) (Organisation for Economic Co-operation and Development, 2018). However, the United States falls behind many countries in life expectancy, including Japan, Canada, most European and Scandinavian coun- tries, and Australia. Millions of older adults in America struggle daily with challenges associ- ated with chronic conditions, which are the lead- ing causes of disability and death in the nation; these conditions explain, in large part, the dif- ferences in life expectancy between America and other countries (Heron, 2018). Good health is essential to ensuring longev- ity, as are independence, connectedness, sense of ‘The United States falls behind many countries in life expectancy.’

purpose, and security. Prevention and manage- ment of chronic conditions are key to maximiz- ing health, well-being, and longevity. Facts About Chronic Conditions Among Older Adults Chronic conditions are defined broadly as con- ditions that last one year or more and require ongoing medical attention, limit activities of daily living, or both. As shown in Figure 1 (see page 8), the top three conditions with the highest prevalence rates are hypertension (59 percent), hyperlipidemia (46 percent), and rheumatoid- osteoarthritis (33 percent). Nearly 30 percent of older adults has a diagnosis of ischemic heart disease (28 percent) and-or diabetes (28 percent). Anemia, chronic kidney disease, and depression each are present in about 20 percent of the Medi- care population (Centers for Medicare & Medi­ caid Services [CMS], 2016). Due to advances in treatment, certain can- cers such as ovarian, chronic leukemias, and some lymphomas, as well as HIV/AIDS, are now considered chronic conditions (American Cancer Society, 2018; Siddigi et al., 2016). Alzheimer’s

abstract This article lays out what is known about the common chronic conditions in older adults, which segments of this population are most affected, and causation of conditions. The top three conditions in older adults are hypertension, hyperlipidemia, and arthritis. Chronic conditions, which have significant personal impacts on those affected, are the primary drivers of healthcare spending in the United States. Racial-ethnic, geographic, and socioeconomic groups are disproportionately impact- ed by chronic disease with causation tied to behaviors, socioeconomics, genetics, healthcare access and quality, and the environment. | key words: chronic conditions, older adults, hypertension, hyperlipidemia, arthritis, prevention

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and Botoseneanu, 2016). This study also found that the com- bination of arthritis, hyperten- sion, and depression resulted in the highest level of people’s limitations in activities of daily living (ADL) and instrumental activities of daily living (IADL) compared to healthy partici- pants or participants with a single disease. Physical health and men- tal health conditions are fun- damentally linked. People living with mental illness are at a higher risk of experienc- ing a wide range of chronic physical conditions. Conversely,

Figure 1. Medicare: CCW Condition Period Prevalence, 2016

Source: CMS. 2016. “Chronic Conditions Warehouse.” Retrieved October 10, 2018.

disease is a chronic condition because an indi- vidual with this condition typically lives three to ten years after diagnosis, depending upon age at diagnosis (Brookmeyer et al., 2002). Behavioral health conditions, such as clinical depression, schizophrenia, bipolar disorder, and substance use disorders, also are chronic in nature. Adults older than age 65 are disproportionally affected by multiple chronic conditions (MCC), with MCC prevalence increasing dramatically with age. Eighty percent of older adults have MCC, while only about half of all people ages 45 to 64 experience MCC (Gerteis et al., 2014). A recent study identified the following most prev- alent two-condition combinations among inpa- tient older adult populations: hyperlipidemia and hypertension; hypertension and ischemic heart disease; diabetes and hypertension; chronic kidney disease and hypertension; anemia and hypertension; and hyperlipidemia and ischemic heart disease (He et al., 2018). Another study showed that the three most prevalent combinations among non-institution- alized older adults are the following: hyper- tension and arthritis; hypertension, arthritis, and cardiovascular disease; and hypertension, arthritis, and diabetes (Quiñones, Markwardt,

people living with chronic physical health con- ditions experience higher rates of mental health conditions than does the general older adult population. For example, depression is found to co-occur in 17 percent of cardiovascular cases, in 23 percent of cerebrovascular cases, in 27 percent of diabetes patients, and more than 40 percent co-occurs in individuals who have cancer (Cen- ters for Disease Control and Prevention [CDC], 2012). The association between depression and chronic disease appears attributable to depres- sive disorders precipitating chronic disease and to chronic disease exacerbating symptoms of depression (Chapman, Perry, and Strine, 2005). Causes of Chronic Conditions Most chronic conditions are caused by multiple factors, and premature death resulting from chronic conditions and poor health are influ- enced by determinants in the following five main areas: behavioral patterns (40 percent), socio­ economics (15 percent), genetic predisposition (10 percent), healthcare access and quality (10 percent), and environmental exposures (5 per­ cent) (Schroeder, 2007). The single greatest opportunity to improve health, prevent and manage chronic conditions,

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and reduce premature deaths is through healthy behaviors. Obesity, physical inactivity, and smoking are the leading causes of many chronic conditions, such as hypertension, heart disease, and diabetes. Other behavioral factors are poor nutrition, including diets low in fruits, vegeta- bles, and whole grains, high in sodium and sat- urated fats, and in alcohol or other drug use. Eating healthily and performing regular physi- cal activity help to prevent, delay, and manage heart disease, diabetes, and other chronic dis- eases. Older adults should aim for moderate physical activity (e.g., brisk walking) for at least 150 minutes a week, and should include exer- cises that build endurance, strength, balance, and flexibility. Smoking and excessive alcohol use also are associated with higher rates of chronic illness. Stopping smoking (or never starting) lowers the risk of serious health problems, such as car- diovascular disease, cancer, type 2 diabetes, and chronic obstructive pulmonary disease, as well as premature death. Over time, exces- sive drinking can lead to high blood pressure, many cancers, heart disease, stroke, and liver disease. By following drinking guidelines or not drinking at all, these health risks can be avoided. People with lower socioeconomic status (SES) experience more chronic illness than those with higher SES. Factors related to SES are income, total wealth, education, employ- ment, and neighborhood; these factors are tied to access and quality of care and people’s health behaviors. For example, experiencing a dearth of venues for purchasing healthy foods (e.g., food deserts), lacking opportunities for recreation and physical activity, and being exposed to toxic environmental conditions, such as lead paint, polluted air and water, unsafe neighborhoods ‘Physical health and mental health conditions are fundamentally linked.’

with few outlets for physical activity, all con- tribute to the development of chronic conditions and premature death. People with lower SES have greater exposure to these conditions, which directly influence their health. Also to consider is genetic predisposition, or family history of a chronic disease, which may make people more likely to develop diseases such as sickle cell anemia, Alzheimer’s disease, or cer- tain types of cancer. Thus, knowing about one’s family history is important to prevent condi- tions, or to identify and treat them early on. Chronic Conditions and Health Disparities Differences in health status or access to health- care among racial, ethnic, geographic, and socioeconomic groups are referred to as health disparities. Health disparities exist in all age groups, including in the older adult cohort. Disparities in the burden of illness and death associated with chronic diseases experienced by African Americans, Hispanics, American Indians/Alaska Natives, and Asian Americans/ Pacific Islanders, compared to the U.S. popula- tion at large, continue to be a problem. Examples include the following: Hypertension : The disparity in hyperten- sion and associated poor outcomes has been recognized for decades in African Americans compared to whites. African Americans experi- ence an earlier onset of the condition and lower rates of control leading to higher rates of stroke, kidney disease, and congestive heart failure (Lackland, 2014). Diabetes : The percentage of the U.S. adult population with diabetes varies significantly by race-ethnicity: American Indians/Alaskan Natives at 15.1 percent, Hispanics at 12.7 percent, and African Americans at 12.1 percent compared to whites at 7.4 percent (CDC, 2017). Cancer : Overall, the United States has expe- rienced declining cancer incidence and mor- tality rates due to reductions in tobacco use, greater uptake of prevention measures, adoption of early detection methods, and improved treat-

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ments. However, African Americans and indi- viduals living in rural areas continue to have the higher cancer mortality rates and shorter survival times than other population groups in the nation (O’Keefe, Meltzer, and Bethea, 2015; Henley et al., 2017). Alzheimer’s disease : Consistent and adverse disparities exist among African Americans and Hispanics, compared to non-Hispanic whites, in the incidence of Alzheimer’s disease, and related Despite overall declining cancer incidence and mortality rates, African American and rural American mortality rates are higher. mortality. In addition, disparities exist in these two groups’ participation in clinical trials, use of medications and long-term services and sup- ports, healthcare expenditures, and quality of care received. More African Americans than Caucasians care for relatives with dementia, and they are less likely to ask for support. Caring for a loved one is considered a responsibility, not a burden (Alzheimer’s Association, 2004). There- fore, the impact of caregiving may be greater for this population. Demographic shifts that are taking place and leading to a more racially and ethnically diverse older adult population will magnify the impor- tance of addressing disparities in the develop- ment of chronic conditions. Chronic conditions are the leading causes of frailty, disability, and death in the United States. They lead to declines in ADLs and IADLs, caus- ing individuals affected to lose their indepen- dence, and resulting in the need for help from family and-or paid caregivers, and-or requiring use of other long-term services and supports. Many people with chronic diseases restrict their The Personal and Financial Impacts of Chronic Conditions

social engagement with family, friends, and com- munities (Meek et al., 2018). As the number of chronic conditions in peo- ple increases, complications associated with care are more common. Due to America’s frag- mented healthcare system, there occur more instances of unnecessary and often avoidable hospitalizations, duplicative and-or contrain- dicated medication prescribing, and scenar- ios in which patients receive conflicting advice from physicians and other healthcare provid- ers. Functional limitations often complicate access to healthcare and interfere with self- management, which leads to elevated reliance upon caregivers (U.S. Department of Health and Human Services, Office of the Assistant Secre- tary for Health, 2015). Also, chronic conditions are leading drivers of our nation’s $3.3 trillion in annual healthcare costs. They account for 71 percent of all health- care costs (Gerteis et al., 2014) and 93 percent of Medicare fee-for-service spending (CMS, 2012). Medicare beneficiaries with multiple chronic conditions are the highest utilizers of health- care services, such as physician and emergency department visits, hospitalizations, home health care, and prescription drugs. In addition, indi- viduals with multiple chronic conditions face substantial out-of-pocket costs for their care, including more co-pays and higher costs for pre- scription medication. Conclusion Due to the heightened levels of chronic illness in the United States, along with the tremendous personal and financial costs associated with such illness, integrated approaches among clini- cal providers and community-based organiza- tions are critically needed. Also, important to prevent further progression of chronic disease and onset of new conditions are broad-based implementation and payment mechanisms for self-management and engagement programs for those afflicted with chronic illness. Targeting racial-ethnic, geographic, and socioeconomic

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groups disproportionately affected by chronic disease with culturally appropriate prevention and management services and programs must be a priority in order to stem the tide of chronic illness in America.

Kathleen A. Cameron, M.P.H., is a pharmacist, an aging and public health advocate, and is senior director of the Center for Healthy Aging at the National Council on Aging in Arlington, Virginia. She can be contacted at .

References Alzheimer’s Association, 2004. “Serving African American Fami- lies: Home and Community-based Services for People with Dementia and Their Caregivers.” RTI Inter- national. Retrieved December 10, 2018. American Cancer Society. 2018. “Managing Cancer as a Chronic Illness.” Retrieved October 10, 2018. Brookmeyer, R., et al. 2002. “Sur- vival Following a Diagnosis of Alzheimer’s Disease.” Archives of Neurology 59(11): 1764–7. Centers for Disease Control and Prevention (CDC). 2012. “Men- tal Health and Chronic Diseases” (Issue Brief 2). cqp. Retrieved October 10, 2018. CDC. 2017. “Addressing Health Disparities in Diabetes.” tinyurl. com/ydd4hlcb. Retrieved October 10, 2018. Centers for Medicare & Medicaid Services (CMS). 2012. Chronic Con- ditions Among Medicare Beneficia- ries, Chart Book 2012. Baltimore, MD: CMS. CMS. 2016. “Chronic Conditions Warehouse.” Retrieved October 10, 2018. Chapman, D. P., Perry G. S., and Strine, T. W. 2005. “The Vital Link Between Chronic Disease and Depressive Disorders.” Preventing Chronic Disease 2(1): A14.

Gerteis, J., et al. 2014. Multiple Chronic Conditions Chartbook: 2010 Medical Expenditure Survey Data (AHRQ Publication No. Q14-0038). Rockville, MD: Agency for Health- care Research and Quality. He, Z., et al. 2018. “Prevalence of Multiple Chronic Conditions Among Older Adults in Florida and the United States: Comparative Analysis of the OneFlorida Data Trust and National Inpatient Sam- ple.” Journal of Medical Internet Research 20(4): e137. Henley, S. J., et al. 2017. “Invasive Cancer Incidence, 2004–2013, and Deaths, 2006–2015, in Non-met- ropolitan and Metropolitan Coun- ties—United States.” Morbidity and Mortality Weekly Report Surveil- lance Summary 66(No. SS-14): 1–13. Heron, M. 2018. “Deaths: Lead- ing Causes for 2016.” National Vital Statistics Reports 67(6). Atlanta, GA: CDC. Lackland, D. T. 2014. “Racial Dif- ferences in Hypertension: Impli- cations for High Blood Pressure Management.” American Journal of the Medical Sciences 348(2): 135–8. Meek, K. P., et al. 2018. “Restricted Social Engagement Among Adults Living with Chronic Conditions.” International Journal of Environ- mental Research and Public Health 15(1): 158.

O’Keefe, E. B., Meltzer, J. P., and Bethea, T. N. 2015. “Health Dispar- ities and Cancer: Racial Disparities in Cancer Mortality in the United States, 2000–2010.” Frontiers in Public Health 3(51). Organisation for Economic Co- operation and Development. 2018. “Life Expectancy at Age 65.” Retrieved October 10, 2018. Quiñones, A. R., Markwardt, S., and Botoseneaunu, A. 2016. “Multi- morbidity Combinations and Dis- ability in Older Adults.” The Jour- nals of Gerontology, Series A: Biological Sciences and Medical Sciences 71(6): 823–30. Schroeder, S. A. 2007. “We Can Do Better—Improving the Health of the American People.” New England Journal of Medicine 357(2): 1221–8 . Siddigi, A., et al. 2016. “Population- based Estimates of Life Expec- tancy After HIV Diagnosis: United States, 2008–2011.” Journal of Acquired Immune Deficiency Syn- dromes 72(2): 230–6. U.S. Department of Health and Human Services, Office of the Assistant Secretary for Health. 2015. “HHS Initiative on Multi- ple Chronic Conditions: Optimum Health and Quality of Life for Indi- viduals with Multiple Chronic Conditions . ” Retrieved October 10, 2018.

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The Role of Social Determinants and Why Community-Based Programming Works By Karen D. Lincoln

Social needs often are not met during healthcare visits, but HCBS can fill that gap.

H ealth spending in the United States is pro- jected to rise to $3.5 trillion in 2018, a 5.3 per­ cent increase from 2017. Primary drivers of the increased spending include the aging population and growing prevalence of chronic conditions, which are difficult to treat and responsible for 85 percent of healthcare costs. Three in four Ameri- cans older than age 65 have two or more chronic health conditions, such as diabetes, hypertension, arthritis, or cancer. These individuals may strug- gle to manage their health in ways that allow them to maintain wellness and independence. Despite the increasing costs associated with treating chronic conditions, individuals with chronic illness often do not make significant progress with their health conditions. Nearly one in five Medicare beneficiaries are readmit- ted to the hospital within thirty days of an ini- tial discharge, and many more end up in the emergency department (Brennan, 2014). It is estimated that readmissions for Medicare ben-

eficiaries cost $26 billion a year, of which an estimated $17 billion comes from potentially preventable re-hospitalizations. Findings reported by the University of Wis- consin Population Health Institute indicated that many of the largest drivers of healthcare costs fall outside the clinical care environment (Uni- versity of Wisconsin Population Health Institute, 2014). Only 20 percent of the modifiable variation in health outcomes is due to clinical care, whereas 40 percent is due to social and economic determi- nants, 30 percent to health behaviors, and 10 per­ cent to the physical environment. This report came out just a few years after the Robert Wood Johnson Foundation’s report called Health Care’s Blind Side , which showed that 85 percent of pri- mary care physicians and pediatricians indicated that unmet social needs—e.g., access to nutritious food, reliable transportation, and adequate hous- ing—were leading to worse health for all Ameri- cans (Robert Wood Johnson Foundation, 2011).

abstract Social determinants of health—income, education, social inequality, living conditions, food security, environmental factors, and health behaviors—account for 80 percent of modifiable variations in health outcomes. They are key to improving health outcomes and optimizing healthcare resources. Unmet social needs are not typically detected or addressed by clinicians during healthcare visits; this increases risk of chronic conditions, reduces the ability to manage health conditions, and increases risk for morbidity, mortality, and institutionalization. Home- and community-based services fill the gap left by the healthcare system by addressing these needs. | key words: social determinants of health, commu- nity-based programs, chronic conditions

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GENERATIONS – Journal of the American Society on Aging

‘Individuals with chronic illness often do not make significant progress with their health conditions.’ during typical healthcare-related visits, thus increasing the risk of developing chronic condi- tions and reducing an individual’s ability to man- age these conditions, all resulting in increased healthcare utilization and costs. Many health systems lack the infrastructure and incentives to develop systematic screening and referral protocols, or to build relationships with existing community service providers. Findings from Hidden Hazards: Closing the Care Gap Between Physicians and Patients with Multi- ple Chronic Conditions , a report from Quest Diag- nostics (2018), showed that providers feel they are unable to address patients’ comprehensive needs. Providers cite limited time, while patients’ professed satisfaction with their care may mask social and behavioral risks and needs. These findings suggest that the traditional medical care model of an annual provider visit may be insuffi- cient for those with multiple chronic conditions. Findings from this study also indicated that 85 percent of providers say they were too pressed for time to address complex clinical issues, and 66 percent indicated that they do not have time to address social and behavioral issues, such as financial concerns or loneliness, that could affect their patients’ health. More than four in ten pa­ In 2016, the Affordable Health Communi- ties initiative by the U.S. Department of Health and Human Services (HHS) announced that it was awarding $157 million dollars for projects that integrated social services with healthcare. The initiative’s goal was to test whether screen- ing beneficiaries for unmet health-related social needs, and increasing their awareness about and access to community-based services, would improve quality and affordability in Medicare and Medicaid. HHS recognized that over time, unmet social needs are not detected or addressed

tients (42 percent) thought that seeing their phy- sician only one to two times per year to manage multiple conditions was “just not enough.” Social Determinants of Health Social determinants of health are “the conditions in which people are born, grow, work, live, and age, and the set of forces and systems shaping the conditions of daily life,” according to the World Health Organization (Allen et al., 2017). Social determinants of health are indexed by factors outside of the individual, beyond genetic predis- positions and individual behaviors. They are the contexts in which individual behaviors arise. According to the National Research Coun- cil and the Institute of Medicine, the most im­ portant social factors determining health are income, accumulated wealth, education, occupa- tional characteristics, and social inequality based on race and ethnic group membership (Woolf and Laudan, 2013). These variables have direct effects on other social determinants of health such as living conditions, food security, levels of stresses and strains, social disadvantages over the life course, environmental factors that influ- ence unhealthy and healthy lifestyles, high- or low-risk health behaviors, biological outcomes through gene expression, and other connections to chronic diseases. Regarding gene expression, epigenetics refers to external modifications to DNA that turn genes “on” or “off.” Epigenetic change is a regular and natural occurrence, but also can be influenced by several factors including the environment, lifestyle, and disease state. A wide variety of ill- nesses, behaviors, and other health indicators have some level of evidence linking them with epigenetic changes, including cancer, cognitive dysfunction, and respiratory, cardiovascular, reproductive, autoimmune, and neurobehavioral illnesses (Weinhold, 2006). The social context of a person’s life, origi- nating in childhood and accumulating over the life course, determines their risk of exposure, degree of susceptibility, and the course and out-

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A Primer on Managed Care: Multiple Chronic Conditions

come of a disease. A life-course perspective con- siders social determinants of health factors as flexible pathways determining health outcomes over time. Consequently, social determinants can initiate the onset of pathology and thus serve as a direct cause for a host of chronic conditions (Cockerham, Hamby, and Oates, 2017; Holtz et al., 2008). The recognition that social determinants of health may be key to improving health outcomes and optimizing the use of healthcare resources has led to interest in creating strategies to man- age the relevant material need insecurities of individuals (Doran, Misa, and Shah, 2014; Egg- leston and Finkelstein, 2014; Garg, Jack, and Zuckerman, 2013). However, the knowledge base for this approach within healthcare systems remains limited. One study provides some evidence of a link between social determinants of health and healthcare utilization. Berkowitz and colleagues (2015) examined the association between social determinants of health factors and dia- betes control and healthcare utilization among 411 patients. Findings indicated that all mate-

rial need insecurities had some association with poor clinical control or increased utiliza- tion. For example, food insecurity was associ- ated with poor diabetes control and increased outpatient visits, while cost-related medica- tion underuse was associated with poor diabe- tes, cholesterol, and blood pressure control, and emergency department and inpatient care utili- zation. Moreover, housing instability and energy insecurity were both associated with increased outpatient utilization. Home- and Community-Based Services Home- and community-based services (HCBS) are designed to help community-dwelling older adults remain safely in their homes and com- munities and delay or prevent entering long- term-care facilities. Between 2002 and 2012, the number of Medicaid HCBS participants increased from 2.3 to 3.2 million (Ng et al. , 2015). The growing demand for HCBS stems in part from the increasing size of the older population, older adults’ desire to “age in place,” and increased federal pressure on states, most recently from the Affordable Care Act of 2010,

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GENERATIONS – Journal of the American Society on Aging

to provide HCBS options that may help reduce spending on nursing homes. HCBS address many social determinants of health factors by providing resources for older adults and their caregivers, such as wellness and nutrition programs, supportive services (e.g., shopping, money management, house and yard work, meal preparation, toileting, dressing, bath- ing, and medication management), job training, senior centers, transportation, health promotion, and family caregiver support programs. HBCS also provide opportunities for community and civic engagement through various volunteer pro- ‘Social determinants can initiate the onset of pathology and serve as a direct cause for a host of chronic conditions.’ grams (National Association of Area Agencies on Aging, 2011). More than 20 percent of adults ages 60 and older receive HCBS (Greenlee, 2013). More than 90 percent of these service users have multiple chronic conditions (Kleinman and Foster, 2011) and related functional impairment (Barrett and Schimmel, 2010). With the rapid aging of the U.S. population, and the growing diversity of older adults (many of whom are Medicaid ben- eficiaries and have multiple chronic conditions), the number of individuals who could benefit from HCBS is expected to increase dramatically during the next two decades. Costs and con- sumer preference have led to a shift from skilled nursing facilities as the primary long-term-care option to HCBS. AARP research shows that 90 percent of people would like to age in their home and community (Farber et al., 2012), and they expect professional care to be provided in communities rather than only in institu- tional settings. Few studies examine the outcomes of HCBS. Those studies that do are focused on the cost- effectiveness of HCBS compared to nursing

homes (Doty, 2000). Findings from these stud- ies revealed that expanding access to HCBS increased aggregate long-term-care expen- ditures (that is, total long-term-care spend- ing, including spending for nursing homes and spending for HCBS combined). More specifically, these demonstration projects showed a substan- tial increase in HCBS use and a modest decrease in nursing home use. However, demonstration projects that targeted services to individuals who had both high levels of functional impair- ment and high risk of nursing home placement saw reductions in cost. If HCBS programs must be “budget neu- tral” to be deemed successful, they will fail the test. Budget neutrality is not the metric for suc- cess when it comes to Medicaid hospital pay- ments or expenditures for physician services. Rather, success should be defined by other mea- sures, including analysis of broader social crite- ria, to determine if the good HCBS programs do outweigh their cost by more than the good that could be obtained by spending the same amount of money in alternative ways. One study examined the effects of commu- nity-based services on the subjective well-being, probability of institutionalization, and mortal- ity of underserved community-dwelling older adults (Shapiro and Taylor, 2002). Findings indi- cated that early provision of in-home social ser- vices was positively associated with older adults’ subjective well-being and negatively associated with permanent nursing home placement and mortality. In addition, participants who received early provision of in-home social services were significantly less depressed, had a greater sense of satisfaction with their lives overall and with their social relationships, had a greater degree of mastery of over their environment, and were less likely to die or experience permanent nursing home placement than those who did not receive these services. My work demonstrates the importance of community-based programs for older African Americans. In the report, New Research High-

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A Primer on Managed Care: Multiple Chronic Conditions

HCBS are important prevention and inter- vention strategies that can reduce the impact of social determinants of health upon the health and well-being of older adults. This is especially the case for poor and minority older adults, who have an increased risk of being placed in low- quality skilled nursing facilities for care that they could otherwise receive at home or in the community (Lincoln, 2014, 2015b). Conclusion The United States spends far more money per capita on medical services than do other nations, while spending less on social services (Tran, Zimmerman, and Fielding, 2017). Residents of nations that have higher ratios of spending on social services to spending on healthcare ser- vices have better health and live longer (Brad- ley et al., 2016) than do residents of the United States. More investment in addressing social determinants of health would, in contrast to cur- rent policies, achieve better population health, lessen inequality, and lower healthcare costs. Such an investment could expand programs, improve quality, and increase access to cultur- ally relevant, coordinated services for older adults—elevating their and their families’ quality of life and significantly reducing healthcare costs by helping them remain in their homes and com- munities for as long as possible. Karen D. Lincoln, Ph.D., M.S.W., is associate professor and director at the University of Southern California, Suzanne Dworak-Peck School of Social Work, in Los Angeles. She can be contacted at .

lights the Benefits of Community Programs for Older African Americans in Los Angeles County , findings indicated that participation in programs and services for older adults was associated with higher quality of life, less loneliness and isola- tion, and less food insufficiency (Lincoln, 2015a). One of the most significant service-related fac- Residents of nations with higher ratios of spending on social services versus healthcare have better health and live longer. tors associated with the health and well-being of African American older adults was whether they felt that services were missing from their neigh- borhood. African American older adults who felt that services were missing, such as home-deliv- ered meals, transportation, In-Home Supportive Services, and adult daycare, were more likely to report fair or poor mental health, a lower qual- ity of life, more loneliness and isolation, food insufficiency, and poor medication adherence compared to those who had services in their neighborhood. The effectiveness of HCBS for older adults and their families cannot be captured solely with measures of cost-effectiveness. However, if cost is the primary measure, then the cost reductions associated with improved subjective well-being and quality of life, less loneliness and isolation, less depression and food insufficiency, bet- ter medication adherence, and lower mortality should be taken into account.

References Allen, J., et al. 2017. “Social Deter- minants of Health.” International Review of Psychiatry 26(4): 392– 407.

Barrett, A., and Schimmel, J. 2010. OAA Title III Services Tar- get the Most Vulnerable Elderly in the United States. Washington, DC: Administration on Aging.

Berkowitz, S. A., et al. 2015. “Mate- rial Need Insecurities, Control of Diabetes Mellitus, and Use of Health Care Resources Results of the Measuring Economic Inse- curity in Diabetes Study.” JAMA Internal Medicine 175(2): 257–65.

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