You’ve got the power: programs teach, coach and coordinate to help people better manage their own health

Tuesday, August 13, 2013


If you have one or more chronic health conditions such as diabetes, high blood pressure or heart disease, you know the day-to-day work of managing your symptoms can be a grueling task. You may be tired all the time, confused about your medications, and worried about your out-of-pocket medical costs. Your chronic condition(s) may have landed you in the hospital or emergency room.

If this sounds familiar, Healthy U and other local programs may be able to help.

Healthy U is for adults of any age with any type of chronic health condition (diabetes, high blood pressure, heart disease, fibromyalgia, arthritis, sickle cell and others). It is an evidence-based program that focuses on problem solving and building self-confidence to help people maintain their health by managing their chronic health conditions.

Healthy U participants meet in small groups for six weeks. With the help of a facilitator, an easy-to-read workbook, and the support of their peers, participants brainstorm ways to overcome barriers to healthy living, set goals, and report on their progress each week. Caregivers are also invited to participate.

The program is available through community organizations across the country, including more than 170 here in Ohio. Locally, Council on Aging has been offering workshops and training leaders to make the program more widely available. New workshops will start this fall. The program appealed to Council on Aging because empowering people to better manage their health helps to keep them in their homes and out of nursing facilities and hospitals.

According to the National Council on Aging, about 91 percent of older adults have a least one chronic condition, and 73 percent have at least two. Chronic conditions seriously compromise the quality of life of older adults, often forcing them to give up their independence too soon.

Increasingly, Healthy U is seen as a program that not only helps improve quality of life for those with chronic conditions, but also as a way to help bring down the cost of chronic care – costs that totaled nearly $3 trillion in 2011.

Insurance companies – and even organizations that represent and provide benefits to retirees – are looking for ways to bring down those costs. In Ohio, the Ohio Public Employee Retirement System (OPERS) has thrown its support behind Healthy U.  OPERS recently offered a Healthy U workshop just for its members in the Montgomery area.  Now, OPERS is notifying all its members of Healthy U workshops scheduled to start near their home zip codes. 

Changes brought on by the Affordable Care Act, including penalties for unnecessary hospital readmissions, and a focus on patient-centered care, have led to the development of a number of programs and initiatives aimed at empowering patients to be more involved in their health care, while driving down the cost of chronic care.

In addition to Healthy U, local examples of these efforts include:

  • Care Transitions – a health coaching and intervention program for older adults who have been hospitalized for serious and usually chronic conditions, such as heart failure and diabetes. According to a 2010 report from the Robert Wood Johnson Foundation, people with chronic health conditions account for 79% of inpatient stays. Hospitals now face penalties for high readmission rates among Medicare beneficiaries with certain diagnoses.

    Care Transitions is led by Council on Aging with the goal of preventing unnecessary hospital readmissions and helping patients access the most appropriate post-acute medical care as well as home and community-based services.

  • Care Coordination – According to the Robert Wood Johnson report, people with chronic conditions are getting services, but those services are not necessarily coordinated with one another, and they are not always the right ones needed to maintain health and functioning. The report also notes that 98 percent of Medicare expenditures are for beneficiaries with two or more chronic conditions. 

    National health policy organizations are offering a number of programs and incentives to physician practices and other community organizations to better coordinate patient care and bring down health care costs.

    Locally, 75 primary care physician practices are participating in Medicare’s Comprehensive Primary Care (CPC) Initiative. Participating practices are eligible for bonus payments and receive resources to better coordinate primary care for their Medicare patients. For example, a CPC practice might learn that a referral to Council on Aging can help a patient who does not have access to transportation or good nutrition.

    In Downtown Cincinnati, Crossroad Health Center and Council on Aging have partnered to better coordinate the care of the center’s older patients. A COA care manager is stationed at the center with the goal of connecting older patients to home and community-based services that can help them live independently, improve their health and enhance their overall quality of life.

  • Make the Right Call – a community awareness campaign aimed at reducing inappropriate emergency rooms visits by helping Greater Cincinnatians make better, more informed decisions about their health care so that they can get the kind of care they need when they need it. The campaign uses the Your Health Matters web site to help people find a primary care physician who is committed to quality care. Council on Aging is one of several local organizations participating in the campaign.