ElderPAC: Sewing a “Program of ElderPAC: Sewing a “Program of All-Inclusive Care for the Elderly” All-Inclusive Care for the Elderly”

Quilt from Community-Based Quilt from Community-Based PatchesPatches

University of PennsylvaniaUniversity of PennsylvaniaJean Yudin, CRNP, Jeanette Gallagher, MSWJean Yudin, CRNP, Jeanette Gallagher, MSW

Philadelphia Corporation for Aging (PCA)Philadelphia Corporation for Aging (PCA)Susan Meyer, MSW, Wendi Botnick, MSWSusan Meyer, MSW, Wendi Botnick, MSW

Campaign for Better Care WebinarCampaign for Better Care Webinar

June 30, 2010June 30, 2010

Long Term Care: Long Term Care: Deconstructing a Nursing HomeDeconstructing a Nursing Home

Complex Health ManagementComplex Health Management

Independence at Independence at HomeHome

HCBC waiversHCBC waivers

Supportive Living Services Housing Supportive Living Services Housing

Elder PAC: Elder Partnership for Elder PAC: Elder Partnership for All-Inclusive CareAll-Inclusive Care

Combines community-based Long Term Care (CB-LTC) Combines community-based Long Term Care (CB-LTC) services (through Philadelphia Corporation on Aging), services (through Philadelphia Corporation on Aging), the local Area Agency on Aging (AAA) with medical the local Area Agency on Aging (AAA) with medical care (In-Home Primary Care Program) in an integrated care (In-Home Primary Care Program) in an integrated academic health system. academic health system.

Links to Home Health Agency services through both AAA Links to Home Health Agency services through both AAA and CMS fundingand CMS funding

Now includes the Waiver, Options,Family Caregiver Now includes the Waiver, Options,Family Caregiver Support, and Bridge programsSupport, and Bridge programs

Service Bundle varies by program– from $14,000-Service Bundle varies by program– from $14,000-$34,000 /year as caps– average is $23,000/year $34,000 /year as caps– average is $23,000/year

Pre-Elder PACPre-Elder PAC

3 Nurse Practitioners 39 Case 3 Nurse Practitioners 39 Case ManagersManagers

180 patients 180 patients at PCAat PCA

Case ManagerCase Manager60 PCA consumers 50 60 PCA consumers 50 providersproviders

Elder-PACElder-PAC

Elder

Caregivers

Philadelphia Corporationfor Aging

Home HealthAgencies

Senior Centers

In-Home PrimaryCare Program

Integrated Service DeliveryIntegrated Service Delivery

Primary CarePrimary Care Acute, Rehab, LTCAcute, Rehab, LTC Home Health ServicesHome Health Services AAA / Aging NetworkAAA / Aging Network Care ManagementCare Management

UPHS In-Home Primary Care UPHS In-Home Primary Care Program Program

Active census of 130 homebound elderly patients in In-Active census of 130 homebound elderly patients in In-Home Program; 19 homebound elderly patients in Home Program; 19 homebound elderly patients in Medicare AdvantageMedicare Advantage

Primary Care provided by NP/SW/MD teams Primary Care provided by NP/SW/MD teams Majority of patients receiving PCA services when they Majority of patients receiving PCA services when they

enter the In-Home Program enter the In-Home Program Majority of patients receiving skilled home health Majority of patients receiving skilled home health

services, including chronic care coordination.services, including chronic care coordination.

ElderPAC Team MembersElderPAC Team Members

Case Manager from the Options/Waiver Case Manager from the Options/Waiver Programs of the Philadelphia Corporation Programs of the Philadelphia Corporation for Agingfor Aging

Social worker from Geriatrics Social worker from Geriatrics Geriatric Nurse Practitioners (GNP)Geriatric Nurse Practitioners (GNP) Physicians from Geriatric MedicinePhysicians from Geriatric Medicine

Home Visit ActivityHome Visit Activity

Social WorkerSocial Worker -- Makes initial contact-- Makes initial contact -- Social/service map-- Social/service map -- Usually bi-weekly contact -- Usually bi-weekly contact NP-Physician teamsNP-Physician teams

- see patients every 6-8 weeks (6 NP/2 MD visits/yr) see patients every 6-8 weeks (6 NP/2 MD visits/yr) - Physical exams, diagnostic studiesPhysical exams, diagnostic studies- Home environmental modificationsHome environmental modifications- Evaluate and strengthen social supportsEvaluate and strengthen social supports- Ensure contact with appropriate community agencies Ensure contact with appropriate community agencies

-- CONSUMER CHOICE (sort of)-- CONSUMER CHOICE (sort of)- Weekly team meeting /monthly with community Weekly team meeting /monthly with community

agenciesagencies2009 average 7.5 visits/pt (6 NP:1 MD)2009 average 7.5 visits/pt (6 NP:1 MD)

Supportive Living Service IntegrationSupportive Living Service Integration EnvironmentEnvironment

Information for modification and repair Information for modification and repair programsprograms

Durable medical equipmentDurable medical equipment StairglidesStairglides

TransportationTransportation Shared Ride SLS Shared Ride SLS Non-Emergency AmbulanceNon-Emergency Ambulance MA / WheelsMA / Wheels

SocializationSocialization Information, lists and application process for:Information, lists and application process for:

• Senior CentersSenior Centers• Adult Day CareAdult Day Care• Senior CompanionSenior Companion• Friendly VisitingFriendly Visiting

Counseling / Mental HealthCounseling / Mental Health Community Mental Health Center / Base Service UnitsCommunity Mental Health Center / Base Service Units

Home Health Aides / Personal Care AidesHome Health Aides / Personal Care Aides SafetySafety

Emergency Response SystemsEmergency Response Systems Locks / Windows ProgramLocks / Windows Program Financial ManagementFinancial Management Older Adult Protective ServicesOlder Adult Protective Services

Medical / Health:Medical / Health:Switching between AAA and CMSSwitching between AAA and CMS

Home Health AgenciesHome Health Agencies Registered NurseRegistered Nurse Physical TherapistPhysical Therapist Occupational TherapistOccupational Therapist Speech TherapistSpeech Therapist Home Health AideHome Health Aide Incontinence SpecialistsIncontinence Specialists

JW JW 78 yo AA woman,78 yo AA woman, Lives independently in Lives independently in

neighborhood for past 50 yearsneighborhood for past 50 years 2-story row home2-story row home Son involved but lived 20 miles Son involved but lived 20 miles

awayaway Oxygen dependentOxygen dependent Held and personally catered Held and personally catered

annual block partyannual block party Multiple cats with fleasMultiple cats with fleas Medicare risk score 4.6Medicare risk score 4.6 Personal goal to survive to 80Personal goal to survive to 80thth

birthday birthday

491.21 COPD491.21 COPD 518.83 Resp Fail 02518.83 Resp Fail 02 327.3 Sleep Apnea327.3 Sleep Apnea 440.2 PVD440.2 PVD 585.3 CKD585.3 CKD 404.11 HTN c CKD and HF404.11 HTN c CKD and HF 416.8 Pulmonary Htn416.8 Pulmonary Htn 428.3 Diastolic CHF428.3 Diastolic CHF 427.89 SVT427.89 SVT 358.8 Neuropathy358.8 Neuropathy 274.0 gout274.0 gout 285.29 anemia 285.29 anemia 721.9 Cervical spondylosis721.9 Cervical spondylosis 366.9 cataract366.9 cataract 530.81 GERD530.81 GERD 389.9 Hearing loss389.9 Hearing loss

JW Hospitalizations Pre/Post JW Hospitalizations Pre/Post Housecall ManagementHousecall Management

2004 2005 2006 2007 2008 2004 2005 2006 2007 2008 20092009

COPD

COPD/ICUCOPD/ICU

COPD/ICU

COPD/ICU

COPD

Start Housecall

ED 80th birthday

ConclusionsConclusions

All-Inclusive management of medically All-Inclusive management of medically complex, homebound patients can result complex, homebound patients can result in substantial savings compared to similarin substantial savings compared to similar

Medicare beneficiaries.Medicare beneficiaries. Independence At Home can provide Independence At Home can provide

funding for housecall practices caring for funding for housecall practices caring for medically complex patients by medically complex patients by guaranteeing a share in those savings.guaranteeing a share in those savings.