The Changing Faces of Medicare & Medicaid

Friday, May 27, 2011Sheraton Suites

Cuyahoga Falls Ohio

Improving Care through Collaboration: Integration of the Aging Network and

Acute and Post AcuteMedical Care Services

Kyle R. Allen, D.O., Medical Director, Post Acute & Senior Services

Chief, Division of Geriatric Medicine Summa Health Systems

allenk@summahealth.org

The SAGE Project

A 15 year collaboration partnership Multiple initiatives, a “cast of thousands” well, maybe 100s, but

you get the point Common goal to improve the health, well being and functional

status of Akron region frail older adult population Identified major gaps in the continuum and care processes from

each partner Searched and defined mutual benefits Shared mutual threats and concerns Built trust Grew and multiplied to other regional health systems Communication, communication, communication Vision, Vision, Vision, Vision

SAGE Goal

S.A.G.E. Project is an example of how to partner with a community agency:

Acute hospital and medical care services and

A community-based Area Agency on Aging

Goal: To integrate a comprehensive geriatric hospital-based clinical program with the community aging network to improve the health, functional status, and to prevent institutionalization of older adults at risk for nursing home placement.

Area Agency on Aging Programs

Mission: To provide older adults and their caregivers long-term care choices, consumer protection and education so they can achieve the highest possible quality of life.

Aging Resource Center PASSPORT Home Care Medicaid Waiver Assisted Living Medicaid Waiver Community Services Division

Care Coordination Alzheimer’s Respite Program Family Caregiver Support

Elder Rights Division

Who were the partners?Summa Health System

Geriatric Medicine Department 6 Hospital System

2,027 licensed beds 61,800 admissions

Level 1 Trauma 113,059 ED visits

Community Locations 4 outpatient health centers Wellness Institute –

• medically-based fitness

Health Plan 110,000 Covered Lives 16,000 Medicare Risk HMO

Major Teaching Residency and Fellowship Program

Post Acute/Senior Service Line 10 Certified Geriatricians 12 Geriatric Certified APNs

Continuum of Care Acute Care/Acute Rehab/ LTAC/ SNF

Beds Home Care/ Hospice/ Home Infusion/

HME

SummaCare, Inc.

Summa Akron City HospitalSummaSt.ThomasHospital

Summa Western Reserve Hospital

A Comprehensive ApproachSenior and Post Acute Services Existing Services and Programs>>>INSTITUTE

Wagner’s Chronic Illness Model Change that Works

ProductiveInteractions

Improved Functional and Clinical Outcomes

Informed,Activated Patient

Prepared,Proactive Practice Team

Health SystemOrganization of Health Care

Self-Management

Support

Decision Delivery Support System Design

Clinical InformationSystems

Community

Resources and Policies

The S.A.G.E. Project (Summa Health System/Area Agency on Aging, 10B/Geriatric Evaluation Project: A

Successful Health Collaborative(Est. 1995)

Improving Care through Collaboration: Integration of the

Aging Network and Acute and Post Acute Medical Care Services

Key Historical Collaborative Programs

Interdisciplinary Community Aging Network Committee (ICAN) - forms and communication processes. (1995)

Imbedding AAA care managers in clinical sites, i.e., Center for Senior Health and Acute Care for Elders (ACE) Unit. (1998)

Widespread AAoA RN Assessor Program. (2000)

Key Historical Collaborative Programs

Area Agency and ODA Grant: Integrated care planning for Medicare Advantage health plan and AAA case managers. Used Appreciative Inquiry technique to build relationship. (2003)

Care Management Interdisciplinary Team at the AAoA with geriatrician and pharmacist (CMIT). (2006)

Use of Extended Care Information Network (ECIN) between hospital and AAoA case managers. (2008)

Key Historical Collaborative Programs

Integration of AAoA RN assessor and case manager to large rural primary care office. (2008)

AHRQ funded - After Discharge Management of Low Income Frail Elderly (AD-LIFE) RCT Trial. (2005-2009)

NPCRC funded - Promoting Effective Advance Care in the Elderly (PEACE) RCT Pilot Trial. (2009)

The Strength and Frailty of Interdisciplinary Teams“ The healthcare system is poorly organized to

provide care to a population increasingly afflicted by chronic conditions. One remedy, is to provide team-based care to coordinate all aspects of patient treatment, from medical exams to social services”.

-The Institute of Medicine report, Crossing the Quality Chasm: A New Health System for the 21st Century, March 2001

The AD-LIFE Trial

After Discharge Care Management of Low Income Frail Elderly

Kyle R. Allen, DO*Kathy Wright, MSN*Susan Hazelett, MS*

Lynn Clough, MA*Dave Jarjoura, PhD**Eugene Pfister, MD***

Summa Health System*Health Services Research and Education Institute

**The Ohio State University***Akron General Medical Center

Agency for Healthcare Research and QualitySupported by Grant # R01 HS014539

Supported by Summa Foundation

AD-LIFE: A Model of Integrated Care

The AD-LIFE Trial will test the effectiveness of interdisciplinary care management that integrates medical and social care to improve patient’s overall health and well-being.

AD-LIFE: A Model of Integrated Care

The AD-LIFE model was designed to test the effectiveness of interdisciplinary care management that integrates medical and social care to improve patient’s overall health and well-being Initiated at time of acute hospitalization Transitional care components applied after discharge

at time of enrollment Care management intervention for 12 months (six

months focus on health coaching and patient activation for self care)

Key Points

Post-discharge care management of low income frail elderly

Nurse care manager activation of client

Collaboration between a hospital-based interdisciplinary team, Area Agency on Aging, and PCP

Integration of acute and long-term care

Who

> 65 years

Hospitalized with likelihood of returning home

Medicare/Medicaid, PASSPORT, or eligible

CHF, COPD, DM, Stroke, Osteoarthritis, Osteoporosis, HTN, CAD

1 Activity of Daily Living or 2 Instrumental Activities of Daily Living prior to admission

Where, What, How:Post-Discharge Model

Within 48 hrs post-discharge, the AD-LIFE RN Case Manager (RN-CM) will contact patient by phone to ensure immediate transitional care needs are met

Within 1 week of discharge, the Geriatric Clinical Nurse Specialist (CNS) and RN-CM will perform an in-home comprehensive geriatric assessment

Findings from assessment presented to interdisciplinary team (e.g. AD-LIFE CM, geriatrician, pharmacist, AAoA social worker)

Where, What, How:6-12 months care management

Care plan developed and sent to primary care physician (PCP) using Assessing Care of Vulnerable Elders (ACOVE)* guidelines and geriatric principles as framework

RN-CM meets face-to-face PCP to review care plan

AD-LIFE RN CM in collaboration with PCP and other agencies, implement care plan over the next 6 months.

Both groups measured at 6 months and 1 year.

* Assessing Care of Vulnerable Elderly. Ann Intern Med. 2001;135:647-652

Assessing Care of Vulnerable Elders(ACOVE) Quality Indicators Change

Multidisciplinary Consensus panel of the leading experts in geriatrics

Developed first ever set of quality indicators (QI) for older adults and specifically for geriatric conditions, e.g., dementia, falls, incontinence.

Benefits of Office Visit

Patient benefits: A “health coach” to help them navigate the health

system Client then learns to navigate and self-manage Someone to educate them about health care and

chronic conditions

Physician/Office benefits: Assistance with the most complex and labor intensive

patients Decrease office resources and staff time. Support and educational resource for care of complex

patients.

Quality Outcomes

Functional Performance

Institutionalization

Quality of Life

Quality of Medical Management

Quality of Self-Management

AD-LIFE Demographics

Mean age 74.78 (SD 7.42) range 65-96

Percentage Female 83.77%

Living Arrangements Alone 63.40% Relative 32.45% Non-relative 3.96% Assisted living 0.19%

Race African American 27.92% Caucasian 71.32% Other 0.76%

AD-LIFE Demographics

Marital Status: Married 11.32% Widowed 39.80% Divorced 38.11% Single 10.19%

Enrolled in Passport 68.3%

Mean LOS for enrollment hospitalization 4.5 days (SD 3.6)

Enrolled in traditional Medicare/Medicaid 67.7%

9.1% are Medicaid only, 2.8% traditional Medicare only, 20.2% Medicare Advantage Plans with or without Medicaid

Keys for Success

Working collaboratively with PCP

Goal setting with the patient ~ Emphasis on Chronic Disease Self Management principles

Keeping care local and within established network and aging network resources and coordinated linkages

Integrated health care system

Willingness to participate and provide feedback

Kyle R. Allen, DO*Steven Radwany, MD*

Susan Hazelett, MS, RN*Denise Ertle, MSN, RN, CNS* *

Susan Fosnight, RPh, CGP, BCPS* Pamela Moore, PharmD, BCPS*

Patricia Purcell, MSN, RN, CNS * * *Barbara Palmisano, MA * * * *

Ruth Ludwick, PhD, RN.C, CNS* * * * *

* Summa Health System, Health Services Research and Education Institute * * Area Agency on Aging 10B, Inc. * * * The University of Akron

* * * * Northeastern Ohio Universities Colleges of Medicine and Pharmacy * * * * * Summa Affiliate, Robinson Memorial Hospital

The PEACE Trial is supported by The National Palliative Care Research Center

& the Summa Foundation

Area Agency on Aging, 10B, Inc. | Summa Health System | NEOUCOM Kent State University | The University of Akron

PEACE TRIALPromoting Effective Advanced

Care for Elders

Purpose of the PEACE Pilot Study

This randomized pilot study will determine the feasibility of a fully powered study to test the effectiveness of an in-home interdisciplinary geriatric- palliative care management intervention to improve the quality of palliative care for consumers of Ohio’s community-based long-term care Medicaid waiver program, PASSPORT.

Health Care Utilization Experience for Patients with Chronic Conditions: Current Health Care System

Hospitalization prompting advance care decisions

(often by the family)

Community-dwelling chronically ill patient with poor symptom

control and coordination of care whose advance care wishes are

rarely documented

Exacerbation of chronic illness

Palliative Care and Advance Care Planning

  Independent Management HospiceAdvance Care Planning

Symptom Management

Disease Management

Diagnosis Death

Patient Centered Care

Frailty

Advanced Organ Failure

Dementia

Chronic Critical Illness

Cancer

Stroke

Well Older Adults

Osteoporosis

Geriatric syndromes

Peri-operative care

Stable chronic dx

Preventive care

Gait DisordersAIDS

Cancer (<65)

TBI

Cystic Fibrosis

Genetic/ Developmental

Disorders

Pediatric Oncology

Morrison , Sean NPCRC

Target Population PEACE Pilot Study

New PASSPORT enrollees >60 years old with one of the

following diseases and the corresponding level of severity will

be eligible for inclusion:

CHF and being actively treated (AHA class C) COPD and on home O2 or nebulizer treatments

Diabetes with renal disease, neuropathy, visual problems, or CAD

End-stage liver disease, cirrhosis Cancer (active, not history of) except skin cancer Renal disease on dialysis ALS with history of aspiration Pulmonary hypertension Parkinson’s disease (stages 3 and 4)

Unique Features/ Successes

Strong working relationship and commitment by the AAoA

Addressing advance care planning and activation for self management at time of “change in support needs” e.g. independent to LTC needs

Culture sensitivity and knowledge between aging network and acute care sector- “becoming bilingual”

Outgrowths of other educational projects, additional funding for PC research, and bridging the community network and acute sector

A success story

60 y/o female, caregiver for two chronically mentally ill sons

COPD, CHF, Depression and Pain Difficulty breathing with walking, on chronic oxygen

now. State goal: “I want to go back to work” PEACE team meeting

Most disturbing symptoms Medication changes per pharmacist Pain better controlled

Outcome with PEACE intervention Outcome without PEACE intervention????

Additional PEACE Related Projects:

A survey of knowledge and attitudes about ACP and PC sent to all area PCPs. Funded by the Summa Foundation.

A statewide survey of all care managers at all AAoA that will examine knowledge and attitudes regarding ACP and PC. Funded by Northeastern Ohio Universities Colleges of Medicine and Pharmacy.

An video on-line educational program to teach AAoA care managers how to bring PC upstream in the disease process. Funded by the First Merit Foundation.

Transitions of CareAD-LIFE, PEACE, and Bridge to Home

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Post-discharge care management of low income frail elderly

Nurse care manager activation of client

Collaboration between a hospital-based interdisciplinary team, Area Agency on Aging, and PCP

Integration of acute and long-term care

Transitional care to reduce readmissions

AD-LIFE trial is supported by the Agency for Healthcare Research and Quality Grant # R01 HS014539. PEACE is funded by the National Palliative Care Research Center. Both are supported by the Summa Foundation.

Bridge to Home is funded by SummaCare.

The Primary Care Physician• Medical model

• Limited time with patient

The Center for Senior Health and Senior

Services• Consult and support across the continuum

including outpatient, inpatient, house calls and

skilled/long- term care• Addresses medical and

psychosocial

The Area Agency on Aging • Social service model but now

becoming more integrated

• Care management and services for long-term care

• Limited interaction with PCP

• Addresses functional abilities/geriatric syndromes but challenged with high risk enrollees with multiple chronic illnesses

AD-LIFE, PEACE, &

SummaCare’s Bridge to

Home

Key Points

No single organization can tackle complex social, community, human service problems in a silo.

Working in effective collaboration can overcome many obstacles and barriers that lie beyond the scope of any single entity through sharing and combining talents and creative solutions.

When done effectively “the whole is more than sum of the parts”.

Outputs are greaterSynergy buildsEnergy builds

Effective collaboration is a team sport between two or more organizations.