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January 6, 2011 Volume VII, No. 26

HIN Communications Editor Jessica Papay

Dear Healthcare Intelligence Network Client,

Can a team-based approach to care manage depression and other diseases at the same time? This week's issue explores this approach to care, along with the increased need for hospice care for dementia patients. We also examine the link between obesity risk and alcoholism.

Your colleague in the business of healthcare,
Jessica Papay
Editor, Disease Management Update

This week's DM news:

Table of Contents

  1. Obesity & Alcoholism
  2. Dementia & Hospice Care
  3. Case Managers in Care Continuum
  4. PCPs & Health Coaching
  5. Adherence Assessment Tools
  6. 2010 Obesity Benchmarks
  7. Team-based Depression Management
  8. Healthcare Case Management in 2011

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Risk for Alcoholism Linked to Risk for Obesity

Addiction researchers at Washington University School of Medicine in St. Louis have found that a risk for alcoholism may also put individuals at risk for obesity. The researchers noted that the association between a family history of alcoholism and obesity risk has become more pronounced in recent years. Both men and women with such a family history were more likely to be obese in 2002 than members of that same high-risk group had been in 1992.

Researchers say individuals with a family history of alcoholism, particularly women, have an elevated obesity risk, and this risk seems to be growing. Researchers speculate that that may result from changes in the food people eat and the availability of more foods that interact with the same brain areas as addictive drugs. “Much of what we eat nowadays contains more calories than the food we ate in the 1970s and 1980s, but it also contains the sorts of calories — particularly a combination of sugar, salt and fat — that appeal to what are commonly called the reward centers in the brain,” said the researchers. “Alcohol and drugs affect those same parts of the brain, and our thinking was that because the same brain structures are being stimulated, overconsumption of those foods might be greater in people with a predisposition to addiction.” The researchers hypothesized that as Americans consumed more high-calorie, hyper-palatable foods, those with a genetic risk for addiction would face an elevated risk because of the effects of those foods on the reward centers in the brain.

The researchers looked particularly at family history of alcoholism as a marker of risk. They found that in 2001 and 2002, women with that history were 49 percent more likely to be obese than those without a family history of alcoholism. There was also a relationship in men, but it was not as striking in men as in women. Researchers say that a possible explanation for obesity in those with a family history of alcoholism is that some individuals may substitute one addiction for another. After seeing a close relative deal with alcohol problems, a person may shy away from drinking, but high-calorie, hyper-palatable foods can also stimulate the reward centers in their brains and give them effects similar to what they might experience from alcohol.

According to the researchers, other variables, from smoking to alcohol intake to demographic factors like age and education levels, don’t seem to explain the association between alcoholism risk and obesity. The results suggest that there should be more cross-talk between alcohol and addiction researchers and those who study obesity. There may be some people for whom treating one of those disorders also might aid the other.

Obesity in the United States has doubled in recent decades from 15 percent of the population in the late 1970s to 33 percent in 2004. Obese people — those with a BMI of 30 or more — have an elevated risk for high blood pressure, diabetes, heart disease, stroke and certain cancers.

To learn more about this research, please visit:

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Hospice Care Increasing for Nursing Home Patients with Dementia

A new study of nursing home records shows more residents with dementia are seeking a hospice benefit and using it longer. The study also estimates that 40 percent of nursing home residents die with some degree of dementia. By analyzing data on more than 3.8 million deceased nursing home residents, researchers at Brown University and Hebrew SeniorLife/Deaconess Medical Center in Boston found that the proportion of residents with dementia who benefited from Medicare hospice care nearly tripled — and the duration of care more than doubled — between 1999 and 2006.

Because hospice care provides important medical benefits to patients with dementia, including more attentive assistance with feeding and medication, the increased use of the benefit is good, according to the researchers. But the data need to be considered carefully by policymakers, hospice administrators, physicians and families in the context of efforts to control Medicare costs. This study is the first to estimate the proportion of people who die in nursing homes with mild to moderately severe or an advanced degree of dementia, an important indicator of the prevalence of the condition in nursing homes. It puts the figure at 40.6 percent nationwide in 2006, although that varies widely by state.

Wide state-by-state variations in the length of stay in hospice care were also found, which is a key finding because Medicare requires patients to have a terminal prognosis of six months or less before they can be enrolled for the hospice benefit. Because the prognosis of someone with dementia is hard to determine so precisely, some patients with dementia have remained in hospice care for much longer than six months, said the researchers, and that concerns Medicare officials who must manage costs. While the national average length of stay for nursing home patients with advanced dementia increased from 46 days in 1999 to 118 days in 2006 — still within the six-month time frame — in eight states more than a quarter of such patients retained hospice care for more than six months. Oklahoma had the largest proportion of long-staying patients with 46.6 percent, followed by Alabama, New Mexico, Wyoming, South Carolina, Mississippi, Arizona and North Dakota. The variations revealed in the state-by-state data suggest that very long stays are not just a product of a general uncertainty about prognosis but also of very different practices in different parts of the country.

As Medicare officials consider the cost of the rising use of the hospice benefit, especially with regard to patients with dementia, the researchers hope the officials will not create “perverse financial incentives” that make it harder for patients to get care they really need. For example, physicians should not be discouraged from referring dementia patients for hospice care even though determining an exact prognosis is difficult. Meanwhile, reimbursement should be configured in such a way that it does not unduly favor short hospice stays.

To learn more about this research, please visit:

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Co-Locating Case Managers in the Care Continuum

Co-locating healthcare case managers in care settings can improve communication with patients as they move through the continuum of care, says Jan Van der Mei, regional director of continuum case management for Sutter Health Sacramento Sierra Region. Ms. Van der Mei describes the major issues that case managers face while helping patients navigate the Sutter system, as well as the key role of case managers in reducing hospital readmissions.

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Championing Coaching in Primary Care

Each week, healthcare professionals respond to a reader's query on an industry issue. This week's experts are Dr. Richard Botelho, M.D., professor of family medicine at the University of Rochester Medical Center, and Dr. Edward Phillips, M.D., director of outpatient medical services at Spaulding Rehabilitation Hospital Network and assistant professor of the Department of Physical Medicine and Rehabilitation at Harvard Medical School.

Question: What is the best way to motivate a primary care practice group to collaborate in a health coaching effort?

Response: (Dr. Richard Botelho) Primary healthcare is so resource-depleted that if someone can come along and say, “We can provide a health coach to work in your setting,” that would be a gift. The practice group would need to find an internal champion if they’re going to provide additional resources to deal with the demands of care. They would have to do their strategic work in advance, and it would be odd if a practice would not be accepting of this. Obviously, one would have to work through many logistic issues as well. The whole notion of the seventh principle of the patient-centered medical home (PCMH) states, “How can you change the financial structures to support the work that needs to get done?” Unfortunately, we’re trapped in a visit-based reimbursement system, which does not serve patients well enough. In this case, change the financial structures and supports to integrate these services. That’s the cutting edge.

(Dr. Edward Phillips) The primary care medical director where my organization is setting up a clinic looked at us and said, “This is a done deal. I tell people to lose weight all the time and I’m frustrated. If I could point them down the hallway, you could have them. If you’re any more successful than I am, teach me what you’re doing.” The hospital is looking upon this as a way of saying, “If we need to get a hypertensive patient to take their medication and to walk 30 minutes a day, then let us take the time to do that.” They don’t need to see the doctor in two months to say that they haven’t done that. With the model, the ultimate approach is up to the local insurance companies, who are saying, “Yes, we know that there will be money saved; however, prove it to us.” For the financial structure, we need to set out on multiple levels to say that those that can afford it can engage a one-on-one health coach, in person or on the phone, similar to getting a personal trainer or a financial consultant for their personal life. Second, if there are groups that need to happen, we can do that and charge for it. We’d also like to get the people to be able to spend their health insurance monies from a cafeteria-style program. We’re exploring the financial model for this. Overall, the system will save money. It’s only a matter of taking the first step toward that end.

For more information on health coaching in primary care, please visit:

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Adherence Assessment Tools

Medication adherence programs can improve patient care and lower healthcare costs by more effectively managing chronic medication utilization. We wanted to see which tools are used to assess and monitor medication adherence in individuals.

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2010 Benchmarks in Obesity and Weight Management

This white paper captures the top strategies organizations are implementing to prevent and reduce obesity and related conditions and costs, based on responses from 131 healthcare organizations to the Healthcare Intelligence Network Obesity and Weight Management e-survey.

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Team-based Approach to Care Successful in Managing Depression with Comorbidities

When depression coexists with diabetes, heart disease, or both, health outcomes are often less favorable. In a randomized controlled trial, testing a primary care intervention called TEAMcare, nurses worked with patients and health teams to manage care for depression and physical disease together, using evidence-based guidelines. The result for patients: less depression, and better control of blood sugar, blood pressure and cholesterol, and improved quality of life. Depression is common in patients with diabetes and heart disease, and it has been linked to worse self-management and more complications and deaths. Depression can make people feel helpless and hopeless about managing other chronic diseases. In turn, coping with chronic disease can worsen depression. This tangle of health problems can feel overwhelming — for patients, their families and their healthcare providers.

Researchers at the University of Washington (UW) and Group Health Research Institute focused on 214 Group Health Cooperative patients who were randomly assigned to either standard care or the TEAMcare intervention. In the TEAMcare intervention, a nurse care manager coached each patient, monitored disease control and depression, and worked with the patient’s primary care doctors to make changes in medications and lifestyle when treatment goals were not reached. Working together, the nurse and patient set realistic step-by-step goals: reductions in depression and blood sugar, pressure and cholesterol levels. Patients assigned to standard care did not receive the nurses’ coaching and monitoring services. To reach the goals, the nurse regularly monitored the patient’s mental and physical health. Based on guidelines that promoted incremental improvements, the care team offered recommendations to the patient’s primary care doctor to consider changes to the dose or type of medication used for managing blood pressure, blood sugar, lipids or depression. This process is called “treating to target.” The treating to target approach helped boost patients’ confidence as goals were accomplished. “It reverses what happens when they set overly ambitious goals they don’t reach, which discourages them, their families, and healthcare providers," said the researchers.

At one year — compared with the standard care control group — patients with the TEAMcare intervention were significantly less depressed and also had improved levels of blood glucose, low-density lipoprotein (LDL) cholesterol, and systolic blood pressure. These differences are clinically significant, particularly if achieved in large numbers of patients, researchers said. “Each of these four disease control measures has been linked to higher risks of complications and deaths from diabetes and heart disease,” the researchers added. The researchers have not yet completed their analysis of possible cost savings from the intervention, but they estimated that the two-year TEAMcare intervention cost $1,224 per patient, on average. This is for patients whose medical care costs healthcare systems approximately $10,000 per year.

TEAMcare intervention patients reported enhanced quality of life and satisfaction with care for depression and either diabetes, heart disease or both. Patients were more likely to have timely adjustment of glucose levels, high blood pressure, cholesterol and antidepressant medications. “TEAMcare is a truly patient-centered approach that enhances a primary care team to deliver optimal care for both physical and mental health in a seamless manner,” according to the researchers.

To learn more about this research, please visit:

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Healthcare Case Management in 2011

Targeted case manager interventions across the healthcare continuum are generating significant ROI and positive clinical outcomes resulting from more effective care coordination and reduced health resource consumption. Complete HIN's second annual Survey of the Month on Healthcare Case Management by January 31, 2011 and receive a free executive summary of the compiled results. Your responses will be kept strictly confidential.

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