community programs to address heart failure - … disability, veterans services division department...
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Aging, Disability, Veterans Services Division
Department of County Human ServicesRevised 05.17.1016
Community Programs to Address
Heart Failure
www.ADRCofOregon.org
Community
Services
Adult Care
Home
Long Term
Care
Adult
Protective
Services
Public
Guardian &
Conservator
Continuum of CareN
um
be
r o
f P
eo
ple
Se
rve
d
More Costly &
More Serious Impairments
$$$$Most Costly &
Restrictive
Less Costly
$$$$
Aging & Disability Resource
Connections
Community Access & Safety Net� 24/7 access Helpline - (Aging
Resource Connection-ADRC)
� Gatekeeper
� Medicare insurance counseling
� Partnerships with district senior centers
� Family caregiver support
� Foster grandparent
� Case Management / In-home services (MPI & OPI)
� Veterans services
� Nutrition services
� Culturally specific services
� Evidence based health promotion & chronic disease management
� Transportation
� Legal services
� Safety Net / Emergency Services (housing, Rx, medical & dental)
Health Care Transformation – ADVSD
role
• Care Coordination – ADRC; Case Management;
Options Counseling; Benefits Counseling (SHIBA &
Medicare Medical Assistance ), and interdisciplinary
care conferences.
• Chronic care self-management – Evidence based
disease prevention and health promotion.
• Care Transition – History of nursing facility transitions;
pilot with healthcare system of transition from
hospital to community and the CCTP funding
application.
Regional Interdisciplinary Care
Coordination Model
• AAAs/APD offices work with health system partners to identify highest need mutual clients/members e.g. those with high emergency department and/or inpatient utilization
• Our approach is a wrap around, person-centered, individualized model with uniform procedures agreed to by participating health plans
• Offered regularly through CareOregon, FamilyCare, and Providence; as needed through Kaiser, Tuality, and for open-card Medicaid members
Evidence-based Health Promotion
Programs Available Currently
•Chronic Disease Self Management
•Physical Activity & Falls Prevention
•Medication Management
•Depression & Mental Health
•Alzheimer’s and care-giving
•Care Transitions
http://www.oregon.gov/dhs/spwpd/sua/docs/evd-bsd-pract.pdf
Chronic Disease Self Management
•Living Well with Chronic Conditions,
including in Spanish
•Diabetes Self-Management Program,
including in Spanish
•Diabetes Prevention Program (DPP)
•PEARLS
Multnomah County
EBHP Program Providers
•African American Health Coalition, Inc.
•Asian Health & Service Center
•YWCA/Impact NW/East District Senior Center
•El Programa Hispano/Catholic Charities
•Friendly House/SAGE Metro
•Immigrant & Refugee Community Organization/Mid District Senior Center
•Native American Youth & Family Center
•Hollywood Senior Center/N/NE District Senior Center
•Impact NW/SE District Senior Center
•Urban League of Portland
•Neighborhood House/W District Senior Center
Last year: 1000+particpated in Falls Prevention & 540 participated in
Chronic Disease Self-Management classe
The High Cost of Readmission
• The 2014 average cost per inpatient stay in Oregon hospitals was $13,376.
• Adults aged 45-64 were the most costly to treat, followed by adults aged 65-84.
• Chronic condition hospitalization cost an average of $6,000 more than acute conditions.
• In Oregon, readmission rates for fourth quarter 2013 averaged 13.6% for heart attack, 18.8% for CHF, 16.1% for chronic obstructive pulmonary disease, and 15.4% for pneumonia.
• Among admission diagnoses tracked nationally for the QIO project, Oregon’s highest readmission rates were for patients with a principal diagnosis of diabetes, averaging 29.4% statewide in fourth quarter 2013. Readmissions for septicemia are also common and expensive.
Community Care Transitions Program
• Our model is the Coleman Transitions
Intervention plus wrap-around services
• 2,950 Medicare fee- for-service patients
with chronic illness were served
between April 2014 and June 2015
across a 4 county area through a
contract with the Center for Medicare
Services (CMS).
• The CMS- funded program was active in
6 area hospitals.
Coleman Transition Intervention
plus Wrap Around– One home visit within 72 hours of discharge
– Coach and empower participants to
• Develop their Personal Health Record
• Identify important personal goals
• Make and keep doctors appointments
• Manage their medication(s)
• Understand warning signs and how to respond
– Three follow-up phone calls within 30 days of
discharge.
• Review items covered at home visit
• Follow up on additional needs
Plus Wrap Around Services
Linking Participants to other Community Services they may need:
• Home-delivered meals
• In-home assistance with personal care, activities of daily living, house-keeping, and more
• Options Counseling
• Behavioral health support services, Supplemental Nutrition Assistance benefits (SNAP/food stamps), family caregiver support services, transportation services, State Medicaid medical benefits, and many more.
OUR OUTCOMES
• A majority of patients visited in hospital accept services offered
• Almost 90% complete the intervention, with one home visit and three follow up phone calls
• Hospital re-admission rate within 30 days of discharge reduced by 58% for those who participate compared to those who decline services (data review of 270 patients between Dec. 2014 and Feb. 2015)
• Decrease in overall hospital readmission rate amongst program participants is greater than 50%
• Fewer than 12% of program participants re-admit to hospital
CURRENT TARGET POPULATION
• MEDICARE and/or MEDICAID
Beneficiaries, including dual
eligibles
• Age 18 or older
• CHRONIC HEALTH CONDITIONS, not
including active substance abuse
disorder and/or acute mental health
condition(s)
• Second in-patient admission
Contact Information
Jan McManus
LTC Innovator Agent for Multomah,
Clackamas, and Washington
counties
503-988-2853