2014 Implementation Actions by HHS Agencies

Office of the Assistant Secretary for Health (OASH)

• In conjunction with CMS, provided Medicare data on comorbidities to health care professional organizations that develop clinical practice guidelines to assist in increasing guidelines’ attentiveness to comorbidities of index condition.
• Continued collaboration with HRSA to implement an evaluation project to develop an interprofessional curriculum for MCC education and training of the health care workforce to improve the health of persons with MCC.
• Funded a three-year initiative, through a collaboration between the Office of Women’s Health and the Administration on Community Living, entitled Creating the Foundation for National Replication of Community-Based Oral Health Programs for Older Adults – to promote low-cost, community-based oral health services for older adults that may attenuate MCC in this population through effects on oral disease and on chronic conditions for which oral disease is a precursor.
• Integrated MCC elements within the HHS Strategic Plan for 2014-2018.

Administration on Community Living (ACL)

• Awarded final funding for the three-year project involving 22 state grantees that deliver evidence-based self-management programs that serve individuals with MCC (to date, over 240,000 individuals have participated in chronic disease self-management education programs with results including improved health, quality of life, and physician communications, and decreased emergency room visits and hospitalizations).
• Began a new falls prevention program by awarding grants to 10 state and non-profit agencies and 4 tribes with goals of increasing the number of older adults and adults with disabilities, including those with MCC, who participate in evidence-based falls prevention programs, and to improve the sustainability of these programs.

Agency for Healthcare Research and Quality (AHRQ)

• Disseminated important results through the publication of “Advancing the Field: Results from the AHRQ Multiple Chronic Conditions Research Network”, a supplement of the journal Medical Care that includes 14 original research articles, a new conceptual model on the role of complexity in the care of people with MCC, and a commentary on future research needs.
• Invested over $4 million and awarded 14 new research grants that use existing large data sets to explore new research questions about the care of, and that will develop and test new methods for improving research about, people with MCC (results from these grants are expected in 2016). 
• Expanded the National Healthcare Disparities Report to include for the first time measures focusing on people living with MCC.

Assistant Secretary for Planning and Evaluation (ASPE)

• Published results of a project that identified promising data, methods, and topics for research on health disparities in MCC populations and that assessed the potential utility of existing data systems and datasets for MCC disparities research.

Centers for Disease Control and Prevention (CDC)

• Lead initiation of an interagency collaborative – including HHS agencies, the Department of Veterans Affairs, and the Social Security Agency – to use national-level federal data for analyzing MCC.
• Initiated an IOM consensus study on “Public Health Approaches to Reduce Vision Impairment and Promote Eye Health” which includes a major MCC component on identifying comorbid conditions and characterizing their impact.
• Lead planning for an MCC theme for the 2014 Focus on Eye Health National Summit.
• Completed project on Expanding Information about Dementia and Co-Occurring Chronic Conditions among Older Adults that resulted in publications, including a report on existing datasets to support studies of dementia or significant cognitive impairment and comorbid chronic conditions.
• Initiated an MCC project that will examine functional limitations and receipt of care across groups that vary by severity of cognitive impairment.
• Advanced understanding of the importance of relation between MCC and cancer survivorship through co-sponsorship of the 7^th Biennial Cancer Survivorship Research Conference that included sessions highlighting MCC in cancer survivors.
• In collaboration with NIH, initiated data analysis and examination of MCC in a unique cohort of breast cancer survivors.

Centers for Medicare and Medicaid Services (CMS)

Federal Health Care Programs

• In partnership with other HHS organizational units – including ACL, ASPE, and SAMHSA – initiated work with the National Quality Forum on performance measurement of home and community-based services to support independence for people with MCC and elderly and disabled persons.
• Submitted five post-acute care readmission measures for National Quality Forum endorsement that should encompass many people with MCC.
• Summarized Final Chronic Care Management (CCM) Scope of Service Elements and Billing Requirements for CY 2015.
• Proposed an All-cause Unplanned Admissions quality measure for people with MCC in the Medicare Shared Savings Program.
• Included recommendations in a proposed rule for revisions to the Physician Fee Schedule for a measure subset to address MCC, permit qualified registries to report on a proposed 18 cross-cutting measure set, and, in the Physician Quality Reporting System, ask that eligible professionals/group practices report on at least two cross-cutting measures.
• Began work on the Improving Medicare Post-Acute Care Transformation Act of 2014, which requires standardized beneficiary assessment data to enable quality care and coordination across settings (nearly 70 percent of all Medicare beneficiaries have two or more chronic conditions).
• Reorganized the Medicare Quality Improvement Organization Program into a regional structure to better help beneficiaries – many with MCC – by implementing data-driven quality improvements throughout the care spectrum.
• Announced two initiatives to improve the quality of post-acute care for people with MCC and others through strengthening the five-star quality rating system for nursing homes, and proposed modernization of Medicare’s home health agency rules.
• Began the “Coverage to Care” initiative to help people with MCC and others with new health coverage to understand their benefits and connect to healthcare services.

Federal-State Initiatives

• Entered into agreements with three additional states (Texas, Colorado, Michigan) to provide integrated, coordinated care for Medicare-Medicaid beneficiaries, nearly 77 percent of whom have MCC; in addition, in 2014, four states (California, Illinois, Ohio, Virginia) that previously had signed agreements began serving beneficiaries in demonstration plans.
• Issued guidance to states on Medicaid autism services that extend to some children with Autism Spectrum Disorder, many with under-recognized MCCs.
• Announced the Medicaid Innovation Accelerator Program to assist states in helping people with substance use disorders, including people who have mental illness and other chronic conditions.
• Issued a final regulation on home and community-based services settings and person-centered planning that will benefit people with MCC who receive supports.

Innovative Models and Activities

• Released updated public-use data resources on MCC, including interactive dashboards on MCC prevalence, health care utilization, and costs among Medicare beneficiaries at the state, county, and hospital referral region levels, and more information on co-morbidity at the county and HHS regions levels.
• Leadership co-authored an Annals of Internal Medicine supplement report, “Opportunities for Quality Measurement to Improve the Value of Care for Patients with Multiple Chronic Conditions,” built on the HHS MCC Framework.
• Sponsored and participated in “Patient Goal-Directed Care for Older Adults With Multiple and Complex Conditions,” a Medscape Continuing Medical Education presentation focused on MCC.
• Announced new models, and continued development and testing of care models, that improve health, care, and lower cost for people with MCC, including the Transforming Clinical Practice Initiative.

Food and Drug Administration (FDA)

• Implemented the late 2013 Good Review Practice (GRP) document addressing the need for increased attention to unnecessary exclusions from clinical trials, including increased attention to participation of people from all demographic subgroups, including the elderly (in addition, consequences of the 2012 addition to the International Conference on Harmonization (ICH) E-7 Guidance on the Elderly are expected to influence newly starting clinical trials).

Health Resources and Services Administration (HRSA)

• Awarded approximately $18 million to fund 27 new and 27 continuation advanced nursing education grants to integrate the care of individuals with MCC into interprofessional education for advanced nursing education students.
• Provided 125 continuation Geriatrics program grants to sustain the education of health professions students, faculty, providers, direct service workers, and lay and family caregivers on the care on individuals with MCC.

Indian Health Services (IHS)

• Began the fifth cycle of the Improving Patient Care (IPC) collaborative which now has engaged 172 Indian Health Service, Tribal, and Urban Indian Health programs in building the medical home capability required to provide high-quality, team-based care for persons with MCC.
• Through the annual IHS Diabetes Care and Outcomes Audit, assessed prevalence of 5 co-morbid conditions (CVD, CKD, HTN, dyslipidemia, and depression) in nearly 116,000 AI/AN patients with diabetes, and key elements of diabetes-related treatment and education.
• Implemented the 2014 ONC-certified electronic health record, with an integrated problem list supporting improved care planning and management of chronic conditions and MCC.

National Institutes of Health (NIH)

• Through the Health Systems Collaboratory (supported by NIH Common Fund and focused on strengthening national capacity in research partnerships with health care delivery organizations), made three new awards for MCC-related research totaling up to $19.4 million over five years:  1) PROVEN: Pragmatic Trial of Video Education in Nursing Homes; 2) Improving Chronic Disease Management with PIECES (ICD-PIECES), and 3) A Policy Relevant U.S. Trauma Care System Pragmatic Trial for Posttraumatic Stress Disorder and Comorbidity.
• Through the National Institute on Aging in collaboration with other institutes, published a funding opportunity on investigating intervention strategies that promote self-management across MCC.
• Funded a grant for $2.8 million over 4 years to enable collaboration between the HMO Research Network and the Claude D. Pepper Older Americans Independence Centers to create and advance an interdisciplinary research agenda focused on older adults with MCC.
• Through National Heart, Lung and Blood Institute, published funding announcements for MCC clinical and basic research in the pathogenesis of HIV-related heart, lung, and blood diseases in adults and children.
• Through National Cancer Institute, published the Request for Proposals on the Systematic Reviews to Inform Research and Treatment of Multi-Morbidities to address gaps in knowledge and prioritize future research opportunities in MCC, including assessing the frequency with which randomized controlled trials of behavioral and psychosocial interventions have included participants with MCC.
• Through the National Institute of Mental Health, funded 5 grants totaling $12 million to test innovative services interventions for reducing the prevalence of common modifiable health risk factors and co-morbid medical conditions related to shortened lifespan in people with severe mental illness.
• Through the National Institute for Nursing Research, in partnership with other institutes, solicited research applications to develop Mobile Health tools to promote effective patient-provider communications, adherence to treatment, and self-management of MCC in underserved populations.

Substance Abuse and Mental Health Services Administration (SAMHSA)

• Expanded the Primary and Behavioral Health Care Integration project to serve over 30,000 individuals with serious mental illnesses and additional MCC in 127 communities across the nation (program outcomes include improvements in cholesterol, diabetes and hypertension).
• Collaborated again with HRSA to jointly support the Center for Integrated Health Solutions to provide technical assistance on effective practices in providing whole health care to people with behavioral and physical health problems.