Chronic Disease

Let's zoom in on one aspect of the new report on "The Future of Nursing: Leading Change, Advancing Health" -- nurses' role in primary care aimed at managing chronic disease, particularly in high risk, underserved populations.

The report, the result of a two year initiative from the Robert Wood Johnson Foundation and the Institute of Medicine, will fuel the ongoing fight, federally and in the states, over "scope of practice" - ie letting nurses with post-graduate degrees do more complex care, with less supervision from physicians. People who see Advanced Practice Nurses as part of the solution to the primary care workforce like this; doctors generally don't. (My colleague Meredith Hughes has posted on this topic here, here, and here and Mary Agnes Carey and Andrew Villegas at Kaiser Health News did a really good job of illustrating the crosscurrents.)

Watch out strip mall drugstore. You may have some competition. Natasha Singer reported recently in the New York Times, “The farm stand is becoming the new apothecary, dispensing apples—not to mention artichokes, asparagus and arugula—to fill a novel kind of prescription.”

Wholesome Wave, a nonprofit dedicated to increasing access to healthy foods, announced its “Fruit and Veggie Prescription Program" pilot program where physicians at community clinics can prescribe vouchers for local farmers markets and then monitor the impact of increased fruit and vegetable consumption on a patients’ health. (Watch Dr. Shikha Anand on CNN talk about the program here.) It's being tested in Holyoke, Lawrence and Boston, Mass., and in Portland, Maine.

The Washington Post this weekend had a human interest story in the Metro section -- a 110-year-old woman reunited with her 85-year-old daughter, who had been in a nursing home for the past three years. The mother Eddye Williams is believed to be Washington's oldest citizen. They are able to live together again in their home because of an innovative program by Washington Hospital Center that provides home-based care for sick elderly people, including house-calls by a physician and a home health aide under a Medicaid waiver. It's a touching story, of family, faith and medicine, but what really caught our eye is that it's a wonderful example of what health care can look like under health reform.

Health reform won't just expand coverage. It will also help reduce or eliminate the health disparities and care inequalities that face racial and ethnic minorities. A brief from Families USA , Moving toward Health Equity: Health Reform Creates a Foundation for Eliminating Disparities, highlights the provisions of the Patient Protection and Affordable Care Act that move us toward this goal.

Improving Community-Based Prevention and Public Health. Prevention can play a role in bringing down costs and improving health in the long term. The issue brief argues that racial and ethnic minorities are more likely to face barriers to good health in the form of community-based factors like substandard housing, unemployment, and transportation difficulty. To change this, the law calls for the “community transformation” grants to test strategies for addressing chronic disease and prevention at a local level. Transforming communities to promote public health can be about the little things that go a long way -- for example, one way to combat childhood obesity could be making sure that all children have a safe place to walk and play outdoors, and that all families have access to stores or markets that sell fresh, healthy foods. As we've written before, studies demonstrate that these social determinants of health really do have a significant impact on community health and risk factors for disease. (Read our earlier discussions here and here.)

(This post first appeared on the Altarum Health Policy Forum. In a future post I'll tie it into advanced medical homes and other aspects of health reform  that address the needs of  the chronically ill and the elderly.)

Transitions are one of the weak points in the U.S. health care system. Poor coordination and inadequate communication around transitions is particularly pronounced in the care of frail elderly people with multiple chronic diseases -- or maybe an acute illness or injury on top of a whole big bunch of chronic diseases.

Wishard Memorial Hospital in Indianapolis is a large urban safety net hospital serving largely low-income people, many of whom are “dually eligible” for Medicaid and Medicare. Led by geriatrician Dr. Steve Counsell, the hospital has been developing a multi-pronged strategy to improve care and care coordination for this at-risk population. The programs have a smart approach to the shortage of geriatricians, leveraging the skills of geriatricians and geriatric nurse practitioners to support, not supplant, hospitalists (inpatient) and the primary care doctors (outpatient) caring for at-risk patients.

Yesterday we introduced you to the new edition of our colleague Phil Longman's book on the VA, "Best Care Anywhere." Today we wanted to look at one specific example of VA care, tying in electronic medical records and chronic disease management. The VA's pathfinding use of its VistA health IT system also helps doctors avoid errors, and track treatment. For instance, doctors are able to track a patient on chemo's blood count with a simple click on the screen. In the example we're excerpting here, Dr. Ross Fletcher, "an avuncular white-haired cardiologist," hits a key on his laptop, and pulls up the medical records of an 87-year old veteran living just outside Washington.

Up pops a chart showing a daily record of his fluctuating weight over a several-month period. The data for this chart, Dr. Fletcher explains, flow automatically from a special scale the patient uses in his home that sends a wireless signal to a modem.

Why is the chart important? Because it played a key role, Fletcher explains, in helping him to make a difficult diagnosis.

One in three of the 1.67 million people admitted to hospitals in California in 2005 were readmitted at least once within a year, according to a new report from the California Office of Statewide Health Planning and Development.

One in ten spun around that revolving door within a week.

Not all readmissions are avoidable, of course. Even when sick people get terrific care, they can still get sicker. But experts believe that a large number (estimates vary) of admissions can be prevented. The highest readmission rates in the California were for psychiatric care, which can be hard to treat and control (and community-based care outside the hospital is not always optimal). Other conditions with high readmissions were heart failure, adult pneumonia and joint replacements -- and some hospitals and clinics do a good job of keeping those readmission rates down. In California, rates were uneven across the state: Los Angeles had the highest average number of readmissions.

Senior Writer Joanne Kenen wrote a piece for Miller-McCune this week on one of the lesser known provisions in the health reform law -- the requirement that chain restaurants disclose the nutritional content of their food right smack on the menu. (Section 4205 of the law, for those of you playing along at home.) Menu labeling might not be as big of a deal as, say, the individual mandate to purchase insurance or the creation of a Center for Medicare and Medicaid Innovation, but it has the potential to have a big impact on public health. As Joanne writes,

Picture yourself in a restaurant, trying to decide between two chicken entrees. Equally tempting, equally tasty, equally priced. How to decide? And if you knew that Chicken A had three times as many calories as Chicken B, would you decide differently?

Not even professional nutritionists can accurately estimate calorie counts in restaurant food -- unless the menu tells them.

Picture yourself in a restaurant, trying to decide between two chicken entrees. Equally tempting, equally tasty, equally priced. How to decide? And if you knew that Chicken A had three times as many calories as Chicken B, would you decide differently?

Not even professional nutritionists can accurately estimate calorie counts in restaurant food — unless the menu tells them.

New America's California Health Program recently released the report of The California Task Force on Affordable Care. This group of leaders from the physician, hospital, insurance, business and consumer sectors worked together to develop a plan to save the state $305 billion in health spending during the next decade. This excerpt, the fifth of a series we will post on the blog, focuses on one strategy from the High Value Top Ten, a comprehensive set of proposals to improve value for the patient and bring down costs for Californians.

9. To combat the high morbidity and cost of diabetes and other conditions caused by obesity, California should improve the affordability and accessibility of highly nutritional foods through local tax-incentive programs, revenue-generating disincentives to the consumption of calorically sweetened beverages, and the removal of high-calorie, low-nutrient foods from vending machines and cafeterias in schools, and in healthcare and public facilities.