ASSURING QUALITY IN GERIATRICS PRACTICE-A CHANGING ENVIRONMENT

Georgia GAPNA and Arkansas GECMarch 1, 2013Jennie Chin Hansen, RN, MS, FAAN-CEO

www.americangeriatrics.org#geriatrics #3ormore

Agenda

Current Environment Present Situation of Workforce Public Perception of Need The Health Policy and Payment Environment

Alignment What Innovations are Happening to Improve Care

and their Diffusion The Need, Our Opportunity and New Context

Evolving Directions in Framing Health and Care of Older Adults

There is speed in the momentum of reimbursement and delivery system changes in health care

Focus on improving quality and those areas most expensive has become a new culture

There are more concrete population health initiatives that go beyond the hospital and facility settings

Health care payors and providers are learning to expand their consideration of “patient” to “older adult”

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• Survey designed to understand the health care experience of older patients

• Do you have a regular doctor? Are you satisfied with their clinic and hospital-based care?

• Are your doctors asking you about ADLS, IADLs, medications, falls, mental health problems?

• Are they recommending non-medical resources?

• Do you think better training in geriatrics might help?

“How Does It Feel?”

John A Hartford Foundation 04.12

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• Partnered with Lake Research Partners • National survey of 1,028 adults 65 and

older

• Fielded February 29 through March 3, 2012

• Margin of Error: + 3.1 percentage points

Methodology

John A Hartford Foundation 04.12

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Majority Satisfied with Primary Care

0%

3%

27%

69%

Not at all satisfied

Not very satisfied

Somewhat satisfied

Completely satisfied

How satisfied are you with the care you get from your primary care provider?

(N = 976 who have regular primary care MD)

John A Hartford Foundation 04.12

Yes, 93%

No, 6%

DK, Ref 1%

Do you currently have a primary care doctor you see regularly?

Majority Satisfied with Primary Care

0%

3%

27%

69%

Not at all satisfied

Not very satisfied

Somewhat satisfied

Completely satisfied

How satisfied are you with the care you get from your primary care provider?

(N = 976 who have regular primary care MD)

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Attitudes Toward Geriatric Training

Yes, 93%

No, 6%DK, Ref

1%

All medical students and nursing students must take classes and be trained in caring

for children. Do you think medical and nursing students should also be required to take classes in caring for older people?

John A Hartford Foundation 04.12

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Awareness of Shortage

40% of adults 65+ with a college degree or higher have heard of the shortage.

John A Hartford Foundation 04.12

Finance1. Dependable and fair Social Security

2. Bring back traditional pensions.

3. Higher interest rates

Aging in Place4. Good public transportation

5. Walkable neighborhoods

6. Universal design

Healthcare7. Home-based healthcare

8. More geriatricians

Technology9. Self-driving cars

10. Intuitive Technology products

10 THINGS AGING AMERICANS WANTU.S. NEWS & WORLD REPORT

Source: Moeller, Philip, http://money.usnews.com/money/blogs/the-best-life/2012/08/06/10-things-aging-americans-want U.S. News & World Report August 6, 2012.

From Our Core Knowledge of Geriatrics Syndromes To..

Population Based Segmentation Well Older Adults, Chronic Conditions, Advanced

Illness and Complexity, Frailty Use of Prevention Based Evidence and greater self

care Self Management and Care Coordination Risk Management and Care Transitions Palliative Care Management of Complexity Care and Management of Frailty

The Triple Aimfor the Older Adult

Better Care

Better Health Lower Costs

Maintain best function and engagement in home and community: prevention, self care, coordination

Hospital-Quality and Safety• ACE-Acute Care for Elders• Transitions Programs-

Naylor, Coleman, Boost, Project Red

• NICHE• Value Based Purchasing• Partnership for Patients

Save $$$ for consumer/family, payors, society-Medicare, Medicaid

Examples of Innovative Practices

CMS-Center for Innovations and Other ACA Enabled Efforts Partnership for Patients

Long Term Quality Alliance Coalition example of best practice

Independence at Home ACA Section 3024

Hospital at Home (Johns Hopkins!)

Innovation Center PortfolioLong-Term Care Involvement in Many Areas

Primary Care Transformation● Comprehensive Primary Care Initiative (CPC)● Multi-Payer Advanced Primary Care Practice (MAPCP) Demonstration

● Federally Qualified Health Center (FQHC) Advanced Primary Care Practice Demonstration● Independence at Home Demonstration ● Graduate Nursing Education Demonstration

ACOs● Medicare Shared Savings Program● Pioneer ACO Model● Advance Payment ACO Model

● PGP Transition Demonstration

Bundled Payment for Care Improvement ● Model1: Retrospective Acute Care ● Model 2: Retrospective Acute Care Episode & Post

Acute ● Model 3: Retrospective Post Acute Care ● Model 4: Prospective Acute Care

Capacity to Spread Innovation

● Partnership for Patients ● Community-Based Care

Transitions ● Million Hearts ● Innovation Advisors Program

● Health Care Innovation Challenge

Initiatives Focused on the Medicaid Population

● Medicaid Emergency Psychiatric Demonstration ● Medicaid Incentives for Prevention of Chronic

Diseases● Strong Start Initiative

Dual Eligible Beneficiaries● State Demonstration to Integrate Care for Dual Eligible Individuals

● Financial Models to Support State Efforts to Integrate Care

● Demonstration to Reduce Avoidable Hospitalizations of Nursing Facility Residents

Source: CMMS 2012

Partnership for PatientsTen Priority Areas of Focus

1. Adverse Drug Events2. Catheter-Associated Urinary Tract Infections3. Central Line Associated Blood Stream Infections4. Injuries from Falls and Immobility5. Obstetrical Adverse Events *6. Pressure Ulcers7. Surgical Site Infections8. Venous Thromboembolism9. Ventilator-Associated Pneumonia10. Reducing Readmissions

Source: CMMS 2012* Only area that would not relate to older adults

Community Based Care Transitions Program (CCTP)-Section 3026

Provide Payment for Care Transitions Services to Improve Health and Reduce Readmissions

An Engine & Asset to Connect Hospitals and Communities to Help Patients

47 Sites in Place with Many More on the Way Buttressed by Hospital Engagement Networks,

QIOs, AAAs, ADRCs and Many Other Resources to Reduce ReadmissionsCMS 2012

Frailty Care SettingsHospital-based Services

Clinic-based Services

Geriatrics principles embedded in all services and programsConnected by an integrated, informed, accurate, and available information systemSystem measurement and monitoring across the continuum of care

Status: RobustLinked Services

Status: Progressive FrailtyCoordinated Services

Status: End of LifeFully Integrated Services

Frailty Care Services (at home)

Home and Community-based Services

System Features Enabling Older Adults with Complex Conditions to Live at Home

Warren Wong, MD Kaiser Permanente 2012

Long Term Quality Alliance Initial Best Practices

Cathedral Square Corporation (Housing Corporation)• Evolved from landlord role to advocate monitoring health and

coordinating services help resident stability-• 1 year outcome-22% falls reduction, 19% reduced risk reduction

of those of moderate risk; physically inactive residents reduced by 10%

• July 2011-112 housing projects added• Estimated $40million w health care Savings to Medicare

Independence at Home (IAH) 2009 HB 2560 (Markey) + S 1131 (Wyden) 2010 ACA section 3024 Medically-led interdisciplinary team (MD or NP)

House calls, with technology Portable diagnostics, telemedicine

24-7-365 availability Electronic health record Expertise and experience with model

Keep + use existing Medicare benefits (A,B) Savings (gain-sharing)

First 5% Medicare; then 80% IAH 10,000 beneficiary cap in current demo

Why Independence At Home (IAH)

Immobile, complex population is better served at home Patient and family centered Better insight into illness and needs, better care plan More timely response when getting sick Real opportunity for near term cost savings

Targets highest cost subset with a viable solution that people prefer

Header

Hospital at Home®: Disseminating an Innovative Health Service Delivery Model into Practice Bruce Leff, MD

Professor of MedicineJohns Hopkins University Schools of Medicine & Public Health

Hospitalat Home®23

How Hospital at Home Can Help

Why We Need It How it Helps Spreading Success

Case Studies

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Why We Need It How it Helps Spreading Success

The Future

• 61% chose HAH care• HaH is feasible and efficacious• High-quality care• Fewer complications• Higher satisfaction • Lower costs of careAnn Intern Med. 143:798-808, 2005. J Am Geriatr Soc. 54:1355-1363, 2006. J Am Geriatr Soc. 2008;56(1):117-23. Am J Manag Care. 15:49-56, 2009. J Am Geriatr Soc. 2009;57(2):273-8. Medical Care, 47(9):979-85, 2009.

Less CG stress Better function High provider

satisfaction

Hospitalat Home®

Takeaway themes

Incentives for all are moving in the direction of the “whole person” over time-geriatrics knowledge and quality of care (e.g.transitions of care)

Treating segments of population with the most appropriate health and health care in settings that are most conducive to effectiveness

Consider the whole environment of the person as an asset to health and chronicity maintenance

Engagement and enabling capacity of the person/patient toward health and well being

Enlargement of the caring provider roles-i.e. not just the professionally licensed

Current Heightened Opportunities

Health Systems, Hospitals, Post acute and Community Settings Health Systems-segmentation: focus on most complex ,

at risk Hospitals: reduction of infections and readmissions,

focus on falls, pressure ulcers, medication reconciliation

Post Acute-transfers between hospitals and nursing homes

Community-hospitals working with community orgs

Implications of Our Changing World

Others are Paying Attention-there are specific needs for “older adults”: boomers and those who “show up for care” Traditional: hospitals, post acute and long term care New: e.g ACOs, patient centered medical homes,

convenient care clinics, telehealth, Federally Qualified Health Centers, Naturally Occurring Retirement Communities (NORCs)

Other “Providers” Housing YMCAs Entrepreneurs

Game Changers From Outside Our Usual Players

Mathematicians-using voice technology to help diagnose Parkinson’s disease (10 mins)-implications for neurologists (CNN ”Next” Innovators)

Chronic Disease-Tackled by National Networks (YMCA, OASIS) at 25% of usual cost (adult diabetes)

Aging 2.0-social entrepreneurs

Geriatric Leaders, Catalysts and Facilitators Framing a value that function reigns supreme Person’s (family) goals, confidence and capacity matter

(knowledge, capability and resources) A plan of health, health status and well being is necessary Multiple conditions need competent team management Evidence we have needs to be used Advancing understanding and appreciation of quality of life

while living with disability* Advancing the known “science and best practice” to that of

new inputs that “improve best practice and advance science”

Perceptions of Successful Aging Among Diverse Elders with Late-Life Disability, Romo et al,Gerontologist: Dec 2012

Roles We Can Contribute in Geriatrics Clinical Expert/Care Provider in institutions and home Consultant in Acute, Outpatient, Post Acute, LTC Clinician and Academic Researcher-classic and applying new adaptive models Systems Designer in Various Settings including the

Community

Consultant-a bridge to Those Who “Discover” geriatrics (GEC)

Diffusion Expert of Evidenced Models

Conclusion and Discussion

The need and opportunity for our framing of care, along with our knowledge and skills, is high and will continue to grow Hold to our values of assuring dignity, respect,

voice of our older person and family Assuring the best competency and quality possible

from ourselves and those we enable as teachers, researchers and facilitators

Engage in awareness: Geri-Pal Blog New York Times: New Old Age Blog

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Facebook.com/AmericanGeriatricsSociety

Twitter.com/AmerGeriatrics

www.americangeriatrics.org

Thank you

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