June 2001

Grant Results

SUMMARY

From 1998 to 1999, staff at the Center for the Advancement of Health hosted a series of meetings on medical self-care and the elderly that drew together researchers and representatives from managed care and health professional organizations.

Key Results

  • Project staff hosted three meetings to identify a research agenda on self-care and gaps in the translation of research to practice; and recommend ways to more effectively diffuse medical self-care programs into managed care and clinical practice in general.
    • The first meeting, "How Managed Care Can Help Older Persons Live Well with Chronic Conditions," took place on October 27–28, 1998, in Washington, D.C., and was attended by 57 people.
    • The second meeting, "Interventions to Improve Adherence to Medical Regimens in the Elderly," took place on May 19, 2000, in Washington, D.C., and was attended by 10 people.
    • The third meeting, "Imagining a Behavioral Insurance Benefit for Older Persons," took place on May 26, 2000, in Washington, D.C., and was attended by 24 people.

    Attendees included representatives from research institutions, managed care organizations, government agencies and foundations.

    Project staff also produced reports on each of the meetings.

Funding
The Robert Wood Johnson Foundation (RWJF) supported this project through a grant of $85,760.

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THE PROJECT

Although most chronic care dollars are spent on hospital care and physician services, it is estimated that 80 to 95 percent of all health problems are managed at home through medical self-care. Self-management of chronic health conditions at home means patients learn to carry out the recommendations of their physicians and manage the physical and psychosocial impairment that disease can engender in daily life.

Research suggests that medical self-care has the potential to improve management of chronic disease, create positive outcomes, and reduce health care costs. Increasingly, managed care organizations are offering a variety of innovative programs for managing the health care of the elderly, including self-care and chronic disease management programs.

This grant from RWJF provided partial support for three meetings on medical self-care and the elderly that drew together researchers and representatives of managed care and health professional organizations. The meetings were designed to identify a research agenda on self-care and gaps in the translation of research to practice; and recommend future directions toward more effective diffusion of medical self-care programs in managed care and clinical practice in general. The meetings were convened by two federal government organizations, NIA and HCFA, as well as CAH. The first meeting was also sponsored by the John D. and Catherine T. MacArthur Foundation, the Nathan Cummings Foundation, and HCFA.

The first meeting, "How Managed Care Can Help Older Persons Live Well with Chronic Conditions," was held October 27–28, 1998, in Washington, D.C., and was attended by 57 participants from 41 organizations. Participants included senior scientists, representatives from peer review organizations, and managed care clinicians and decision-makers. Formal presentations were made by 17 speakers. Eleven presentations focused on self-management as seen from a variety of perspectives, including managed care (corporate and clinical), and the scientific perspective (exercise, nutrition, emotional adaptation to illness, and medications management).

The second meeting, "Interventions to Improve Adherence to Medical Regimens in the Elderly," held May 19, 1999 in Washington, D.C., examined a number of interventions that have been shown to increase adherence, including programs that teach self-management techniques; improving the communication of information that patients need to help them adhere to medical regimens; and the use of pagers, telephones, and other technology to prompt patients to adhere. The meeting was attended by 10 participants, including senior scientists from eight organizations, foundations, government agencies, and universities. It featured a discussion format with no formal presentations.

The third meeting, "Imagining a Behavioral Insurance Benefit for Older Persons," held May 26, 1999, Washington, D.C., used smoking cessation and arthritis self-care as examples to explore how behaviorally oriented preventive health services might be incorporated into the federal Medicare program. The meeting was attended by 24 behavioral researchers and government officials from 17 organizations and agencies. It featured a discussion format with no formal presentations.

CAH prepared three reports following the meetings. The first report, How Managed Care Can Help Older Persons Live Well with Chronic Conditions, offers recommendations to improve health for older persons by encouraging self-management in three areas: exercise and nutrition, emotional adaptation to illness, and medications management. The second, Interventions to Improve Adherence to Medical Regimens in the Elderly, outlines interventions such as teaching patients self-management techniques and improving communications to older patients. The third, Imagining a Behavioral Insurance Benefit for Older Persons, uses the examples of smoking cessation treatment and arthritis self-care to illustrate how a behavioral insurance benefit might be integrated into the current federal Medicare program. (See the Bibliography for details.)

Recommendations

  • Managed care must begin to implement effective evidence-based behavioral and psychosocial approaches to improve health and functioning of older persons. At the provider level, physicians and others need better training in these approaches, as well as more incentives to work in partnerships with patients, their families, and communities. Barriers to full integration of self-management approaches need to be prioritized and surmounted. Once implemented, programs need to be better monitored and evaluated to determine how effective they are and under what conditions.
  • The most promising intervention models to improve adherence in the elderly include:
    1. Programs that teach patients self-management techniques.
    2. Approaches that improve communication to older patients by using current research findings on how people best remember information related to their medication regimens.
    3. Use of communications technology, such as computerized calling systems, pagers, and personal data systems, to prompt patients to adhere to medication regimens.

    More research is needed in a number of areas, including:
    1. Successful adherence practices and how to teach them.
    2. How life contexts support or undermine adherence.
    3. People's changing views of medications in their lives.
  • Designing smoking-cessation benefits or other behaviorally oriented preventive health benefits for the elderly is possible. But projects are needed that would demonstrate the feasibility and effectiveness of a stepped-care intervention in the elderly (i.e., a step-by-step routine involving physician advice, counseling, and follow-up). Even with such evidence, the current structure of the Medicare program presents a number of barriers to implementation that must be overcome, including: (1) congressional approval, since HCFA does not have the legislative authority to approve new preventive benefits; and (2) HCFA reimbursement rules, which currently allow for reimbursement for face-to-face counseling, but not telephone help lines (as are used in many model smoking-cessation programs), and which do not allow reimbursement for group sessions led by lay leaders (as are employed in model self-care programs for people with arthritis). It would be possible, however, for the American Medical Association to create a procedure code to allow for reimbursement of group sessions conducted at a doctor's office.

Communications

The three reports were disseminated to all meeting attendees and invitees; medical directors of the 100 largest HMOs; academic departments in geriatrics, gerontology, and others; relevant members of Congress; behavioral and social scientists at the National Institutes of Health (NIH); senior staffers at HCFA and NIA; and members of 24 professional research societies. HCFA distributed 500 additional copies of two reports: How Managed Care Can Help Older Persons Live Well with Chronic Conditions and Imagining a Behavioral Insurance Benefit for Older Persons. NIA distributed 300 additional copies of How Managed Care Can Help Older Persons Live Well with Chronic Conditions and Interventions to Improve Adherence to Medical Regimens in the Elderly.

In addition, 300 copies of Interventions to Improve Adherence were requested by potential applicants to a multi-institute request for applicants (RFA) issued by the NIH Office of Behavioral and Social Science Research. The full text of each report is also available on the CAH Web site, which reaches more than 5,000 health and behavior researchers. (See the Bibliography for details.)

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AFTER THE GRANT

According to the project director, the collaboration between CAH, NIA, and HCFA laid the foundation for further, long-term collaboration between the participants to continue work begun during the meetings. They are discussing adding two other federal agencies to the collaboration — the Administration on Aging and the Centers for Disease Control and Prevention, which are both part of the US Department of Health and Human Services. The goal would be to address the physical activity component of self-care among older persons.

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GRANT DETAILS & CONTACT INFORMATION

Project

Conference on Medical Self-Care and Managed Care for Older Persons

Grantee

Center for the Advancement of Health (Washington,  DC)

  • Amount: $ 85,760
    Dates: September 1998 to June 1999
    ID#:  034298

Contact

Jessie Gruman, Ph.D.
(202) 387-2829
jgruman@cfah.org

Web Site

http://www.cfah.org

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BIBLIOGRAPHY

(Current as of date of this report; as provided by grantee organization; not verified by RWJF; items not available from RWJF.)

Books and Reports

How Managed Care Can Help Older Persons Live Well with Chronic Conditions. Washington, D.C.: Center for the Advancement of Health, 1999. Also appears online.

Imagining a Behavioral Insurance Benefit for Older Persons. Washington, D.C.: Center for the Advancement of Health, 1999. Also appears online.

Interventions to Improve Adherence to Medical Regimens in the Elderly." Washington, D.C.: Center for the Advancement of Health, 1999. Also appears online.

Sponsored Workshops

"How Managed Care Can Help Older Persons Live Well with Chronic Conditions," October 27–28, 1998, Washington, D.C. Attended by 57 participants from 41 organizations, foundations, governmental agencies, and universities. Participants included senior scientists, representatives from peer review organizations, and managed care clinicians and decision-makers.

Presentations

  • Robert G. Harmon and John M. Ludden, "Why Self-Management? The Managed Care Corporate Perspective."
  • John C. Scott, JoAnne Konick-McMahan, and Cheryl Phillips, "Why Self-Management? The Managed Care Clinical Perspective."
  • Russell E. Glasgow and Tom Janisse, "State of Science and Practice: Exercise and Nutrition."
  • David Spiegel and Connie Davis, "State of Science and Practice: Emotional Adaptation to Illness."
  • Judith Garrard and Sandra Harmon-Weiss, "State of Science and Practice: Medications Management."
  • Carol C. Hogue, Halsted Holman, and Lee Sechrest, responding to the formal presentations.
  • Marcia G. Ory, Catherine Gordon, and Jessie C. Gruman, responding as representatives of the sponsoring organizations to the presentations and responses of participants.

"Interventions to Improve Adherence to Medical Regimens in the Elderly," May 19, 1999, Washington, D.C. Attended by 10 participants, primarily senior scientists from 8 organizations, foundations, governmental agencies, and universities. (Discussion format; no formal presentations.)

"Imagining a Behavioral Insurance Benefit for Older Persons," May 26, 1999, Washington, D.C. Attended by 24 behavioral researchers and government officials from 17 organizations and agencies. (Discussion format; no formal presentations.)

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Report prepared by: Jan Hempel
Reviewed by: Richard Camer
Reviewed by: Robert Crum
Program Officer: James R. Knickman

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