October 10-16 marks a weeklong celebration of National Case Management Week, recognizing the contributions and commitments case managers make and the significant work they perform across the health care continuum. The theme for this year is “Case Management Is The Critical Connection To Optimal Health Care”.

It’s a remarkable time to be in healthcare, especially as a case management professional. Changes in health care are happening at an unprecedented rate and include:
• Far-reaching health care reform efforts;
• Innovative new models of health care delivery and reimbursement;
• Public policy mandates to reduce spending while assuring quality outcomes; and
• Significant advancements in implementing patient-centered models of health care.
 
Case managers have often been the unrecognized voice in the health care industry, and the impact of case management has historically been underappreciated. However, with the passage of the Patient Protection and Accountable Care Act (PPACA), case management has taken a giant leap forward. This is because the concepts of care coordination and case management are key components woven throughout the PPACA. At last, case management is being acknowledged for what it is: the “glue” that carefully, creatively, thoughtfully, and successfully holds together the multiple parts and pieces of health care, regardless of the setting or where the patient is along the care continuum.
 
As a direct result of the PPACA¸ we can expect to see more opportunities and more demand for case management. The role of case management will become more highly visible and will be seen as pivotal in effective implementation of new models of care. For example, case managers can step up to leadership roles within Accountable Care Organizations (ACOs) to help design and implement care coordination programs and evaluate the outcomes. Case managers are ready, willing, and able to take on this challenge to help coordinate patient-centered care and ensure successful outcomes in health care quality and practice improvement efforts underway.
 
Health care reform efforts and a renewed focus on improving quality outcomes mean that there will be an increased utilization of case manager professionals throughout a variety of care settings. For example, case management is a central component of the patient-centered medical home (PCMH) model of care delivery. Case managers will be working with health care consumers along all points of the health/illness continuum—from wellness and prevention to complex acute medical care to chronic care self-management.
 
However, as the need for case managers across care settings grows, so too does the responsibility to maintain tight linkages between and among case managers along the various points of the care continuum. It is essential that case managers recognize when silos of care exist and work together to break down these barriers—because successful case management depends on shared efforts united by an ever-present focus on the patient as the center of the total health care experience.
 
Topping the list of public policy and accreditation mandates faced by hospitals is the directive to reduce hospital readmissions and improve patient safety. Case managers offer a significant contribution to meeting these quality goals by focusing on effective care transitions. Care transition programs aim to ensure that care is well-coordinated, well-communicated, continuous, safe, and timely as patients move across care settings, or across levels of care within a setting. Case managers know that improving communication, coordination, and collaboration throughout the care transition process results in better identification and elimination of gaps in care, improved medication adherence, better self-care management and self-care efficacy, and more effective utilization of patient support systems and resources.
 
No one can deny we work in an industry that is ever-changing and being driven by reform efforts aimed at reducing costs, improving access, and assuring quality. Case managers provide the common denominator and the key to success to dealing effectively with these forces of change because:
• Case managers use a patient-centered process of care coordination that includes meaningful, goal-directed communication and interaction with all key stakeholders—the patient, their family and support system, physicians, social workers, other members of the multidisciplinary care team—with the goals of promoting quality, cost-effective outcomes.
• Case managers work hard to promote effective communication across care settings to ensure smooth, coordinated delivery of care and services.
• Case managers believe in the power of advocacy, collaboration, shared-decision-making and education to promote effective patient engagement and adherence with evidence-based care and treatment plans.
 
For these reasons and more, case management truly IS the critical connection to optimal health care. There has never been a time where this has been truer. As we celebrate National Case Management week, let’s take a moment to really recognize and appreciate case managers for the vital role they play in optimizing health care as we journey ahead.


A couple of months ago I went to a play a local playhouse. It was during intermission that I noticed how many men were using walkers and how hunched their shoulders were. I could see that at one time these men were very tall, but inches have been lost along with strength and balance. Indulging in a conversation with a few of them, they seemed resolved that this is the way life is now for them. Henceforth, is why I think men need to know a little more about osteoporosis and bone loss.

Osteoporosis is where bones lose density and fractures are likely to occur. This is put into the woman’s category of conditions, as it is related to women’s hormones and menopause. It is a well known fact that post menopausal women are at high risk and bone density test should be done before a woman is fifty. This is not your grandmother’s disease anymore as over eight million women over fifty will be at risk.
 
But, men beware as you too should worry about bone loss. Roughly two million American men have osteoporosis. Twelve million could be at risk and could be in the early stages of osteopenia. It was a fact that men did not live as long as women, so osteoporosis was considered. Today with modern medicine and healthier lifestyles, men are living longer. Men are generally more physically active over their lives in thus they produce more bone mass and have stronger bones. As the men age though, the physical activity decreases along with the decrease in bone mass, putting men at risk.
 
The key factor to preserving bone mass is weight bearing exercise. Many men spent much of their youth playing sports, so finding an exercise routine doing something they like can be fun and exciting. Exercise will help with bone strength, muscle strength, which will help maintain balance and coordination. Brisk walking, playing tennis, skiing and jogging are examples of low impact exercises, where your foot hits the ground with controlled force. Weight lifting and resistance training at least twice a week is an excellent way to keep bone loss at a minimum. This can be as simple at standing up and down from a chair ten or twenty times, doing push ups on a counter or wall or using soup cans to strengthen your arms. The heavier the resistance the better results you will obtain. I have seen amazing results after designing an exercise program for men. Posture improves along with their daily activity of daily living and activity level increases.
 
According to the National Osteoporosis Foundation the following risk factors are associated with osteoporosis in men:
1. Prolonged exposure to certain medications, such as steroids used to treat asthma or arthritis, anticonvulsants, certain cancer treatments and aluminum-containing antacids
2. Undiagnosed low levels of sex hormone testosterone
3. Lifestyle habits which include smoking, excessive alcohol use, low calcium intake and inadequate physical exercise
4. Heredity
5. Race, white men appear to be at the greatest risk. But men from all ethnic groups develop osteoporosis.
 
As with women, if men notice a loss in height or a change in their posture, which could include back pain, it is important to inform your doctor. Osteoporosis can be treated with lifestyle changes, making sure you take enough calcium, changing unhealthy habits and include exercise in your daily routine. Check with doctor in treating any underlying medical conditions and to identify and evaluate any medications that may be contributing to bone loss. Your bones will thank you.
 
Take charge of your life, no matter what age you are. Good health and fitness is not a destination, but a journey to be continued the rest of your life. Make fitness fun and live life to the fullest, you deserve it. The Golden Years should truly be Golden.


The last century saw remarkable gains in life expectancy—an extraordinary 30 years in the United States and in other developed countries. Whereas improvements in the earlier portion of the century were largely nonmedical (nutrition, sanitation, housing, etc.), those of the second half were clearly due to medical innovation—drugs, devices and procedures. It is therefore not surprising that health care expenditures have grown 2.8% per year more rapidly than the rest of the economy for the past 30 years. At the beginning of the 20th century, only 41% of live births could expect to reach age 65; by the end of the century the percentage doubled. However, these advances are not without their costs. At age 65, 4 out of 5 men and 9 out of 10 women are not in the labor force, and 4 out of ten have a physical or mental disability. Almost half of all hospital beds are filled with patients 65 years of age and older. Therefore, any gains in longevity are likely to be associated with increasing rather than decreasing societal financial burdens.

Since the vast majority of eldercare is financed through federal entitlement programs, the federal government, concerned with the very real potential of a crippling acceleration of national debt, is increasingly faced with the ironic conundrum of greeting each new medical advance/success with suspicion if not outright fear. If internal cardioverter defibrillators are shown (as they have been in large prospective randomized trials) to increase the life expectancy of patients with congestive heart failure who have reduced ventricular systolic function, the potential costs are enormous. Approximately five million Americans suffer from heart failure; approximately half of these have reduced ventricular systolic function. These devices cost upwards of $50,000 each, not counting hospitalization and implantation and care and monitoring expenses. This would amount to a total cost in the billions of dollars. If cardiac resynchronization therapy (placement of sophisticated biventricular pacemakers) is demonstrated to benefit a large portion of this population (as it has), the incremental expense is substantial. If cardiac surgery, once inconceivable in those over 75, is increasingly demonstrated (as recently shown by our studies at the Florida Heart Research Institute) to provide comparable long-term improvements in patient perception of quality of life with operative survival that rivals that of younger patients, how do we weigh the costs with the benefits? Clearly care of these elderly patients is more costly—they are more prone to complications, they tend to have longer hospital stays and a greater need for postoperative support care. What then becomes the metric by which we determine that the benefits warrant the expense??
 
There is a methodology for comparing the expenses of various medical interventions—the Quality-Adjusted Life Years. This methodology applies a cost-utility approach to creating a simple arithmetic model to compare various health-care interventions. It is assumed that one year of life in perfect health has a value of 1.0, death has a value of 0.0, and one year in less than perfect health has a value somewhere in-between. Therefore, one can compare the years of life predicted to result from a treatment, multiplied by the relative quality of life of those years, to arrive at the QALY’s. Unfortunately, there is tremendous subjectivity in the evaluation of life quality, with different values of the same status when assessed by different populations. Moreover, health status is personal—the manner in which one individual views his health status may differ radically from that of the population mean, even if perfect objective testing where available. Even more perplexing, health status is not static, but rather dynamic with time. Let us examine the 80 year old with congestive heart failure from aortic valve stenosis. The progressive shortness of breath and disability will increase with time. On the other hand, the postoperative disability after successful valve replacement surgery, although it may be profound, will dissipate with time. Assessment is likely to be based on perception at the time it is being asked, not over the course of years being evaluated.
 
In short, care of the elderly stands at the forefront of our values as a society—faced with increasing financial pressures, how do we choose to provide care for that sector of society which requires the greatest expense yet is least able to return productivity to the system? The answers are far from clear, but the questions need to be framed in a manner which will enable us to begin to make the decisions. Although we can certainly not be the arbiter of these decisions, we at FHRI are committed to supplying the information necessary to make informed decisions.


The population of Americans aged 55 – 64 numbered 32.6 million in 2008. U.S. longevity statistics indicate that about 90% of those people will live to 65. Almost all of the survivors will become eligible for Medicare at that point. When they get there, unless unhealthy lifestyles are changed substantially, the incidence of hospitalizations, death and the costs of care in Medicare will rise, perhaps substantially. Table 1 shows that the 55 – 64 cohort smokes twice as frequently as does the 65+ age cohort and that the younger cohort is also more overweight/obese, has less adequate nutrition intake and a higher percentage of heavy drinkers.

 

 
 
 
 
 
 
 
 
As to smoking, this situation has been worsening for a decade. Table 2 shows that in the ten year period from 1999 to 2009, smoking among 55 – 64 year olds has declined significantly less than among the 65+ cohort.
 
 
 
 
 
 
 
 
 
 
Smoking costs the U.S. healthcare and economy system an estimated $150 billion per year. At least $20 billion of these expenditures are made by Medicare.
 
Whereas smoking has declined overall, obesity increased by 32% between 1998 and 2006 (which is responsible for 89% of the increased obesity costs in that period – a doubling to perhaps $147 billion per year). 8.5% of Medicare’s expenditures are for obesity. Most of the cost burden difference between obese and non-obese elders is for prescription drugs. Obesity is a major risk factor for hypertension, type 2 diabetes, coronary artery disease, stroke and much else. Prescription drugs for Medicare recipients are about $600 higher than for non-obese Medicare enrollees.
 
Table 3 shows that Floridians in the age cohorts 55 – 64 and 65+ are rather like the national cohorts. The 55 – 64 group in Florida smokes about twice as much as the 65+ group and is modestly higher in overweight/obesity, heavy drinking and lower fruit and vegetable intake. But in Florida, unlike the nation, the 55+ group is less likely than the 65+ group to have regular moderate-to-vigorous physical activity.

 

 

 

 

As to smoking in Florida, both the 55 – 64 group and the 65+ group increased in percentage tobacco use in the 2004 – 2009 time period.

 
 
 
 
 
 

 

Medicare, other public payers, physicians, hospitals, FQHCs, employers, insurers, non-profits and of course, the 55 – 64 year olds themselves, have a role to play in dealing with the issues of late career wellness and of family fitness. The ElderCare Companies are working in several states to be of assistance.



Medical Foster Home (MFH) is a new program at the West Palm Beach VA Medical Center that offers veterans an alternative to nursing homes or assisted living facilities. Medical Foster Home is designed for veterans with a disability due to complex chronic disease or traumatic injury who are no longer able to safely live independently or whose care needs exceed the capabilities of their families.

Veterans pay caregivers directly and the VA provides all of the medical care through the Home Based Primary Care team. The expectation is that this would be a long term commitment where the veteran may live for a few years, often the remainder of his/her life. The individual rates are paid monthly and vary depending on the level of care needed. For example, a veteran who is ambulatory and requires supervision and medication management would pay less for a Medical Foster Home than a veteran who requires total care and may be completely bed bound, or who has skilled sub-acute care needs. Veterans may be eligible for Aid and Attendance in a Medical Foster Home to help defray costs.
 
Medical Foster Homes are different from assisted living facilities and nursing homes in several aspects: the foster homes are rented or owned by the caregiver and the veteran lives with the caregiver; there are no more than 3 residents in a Medical Foster Home; pets are allowed; it is child friendly; and foster home residents are enrolled in Home Based Primary Care and followed closely by home care teams. Medical Foster Home began as a pilot program in Little Rock, Arkansas with 2 additional programs in Tampa and San Juan. As a result of its impressive success and potential as a long term care option for veterans of all ages, it has expanded to 35 VA facilities. Veterans with disabling polytrauma are also receiving care through Medical Foster Homes.
 
West Palm Beach currently has 12 homes available. The Medical Foster Homes are located primarily in Wellington, Riviera Beach, Lake Worth, Royal Palm Beach, the Acreage, Loxahatchee and West Palm Beach. All selected caregivers have cleared FBI background checks and their relief caregivers are also screened.
 
The MFH Coordinator started offering tours of the Medical Foster Homes to veterans and their families in September. The Medical Foster Homes offer private and semi-private rooms, furnished or unfurnished, 24-hour care and supervision, all meals, laundry service and transportation. All of the foster home caregivers have extensive caregiver training and also receive routine training from the VA. Most of the foster home caregivers have nursing backgrounds.