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Complex needs in older adults_Riverside
- 1. Developing a Programto Address Complex Needs in Older Adults 2016 Governor’s Conference on Aging Kyle R. Allen DO AGSF VP Clinical Integration Esther Desimini, RN, MSN, BC, APRN VP Riverside Tappahannock Hospital Carol Wilson , MHA Director of Advance Care Planning and Palliative Care Services Riverside Health System
- 2. Takeaways • Why aninnovative model is needed • Model implementation from a community perspective: Who, What, Where, How • Keys for success • Questions and Discussion
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- 5. “The most commonchronic condition experienced by adults is multimorbidity, the coexistence of multiple chronic diseases or conditions.” Tinetti et al, JAMA, 2012
- 6. 6 • Poor communicationamong primary providers, specialists, health and community providers, patients, and families • Failure to catch problems early • Failure to address psychosocial issues • Lack of coordinated, longitudinal care management • Ineffective transitional care management • Insufficient management of multiple medications • Deviations from evidence-based care Fragmented Care Has Driven High Costs and Resulted in Poor Outcomes Source: Academy Health 2012
- 7. • 2011 RWJFsurvey of 1,000 primary care physicians – 85%: Social needs directly contribute to poor health – 4 out of 5 not confident can meet social needs, hurting their ability to quality care – 85% of physicians say patients’ social needs are as important to address as their medical conditions – 95% of physicians serving patients in low income, urban – 76% wish the health system would cover the costs associated with connecting patients to services that met their social needs – 1 in 7 prescriptions would be for social needs – Psychosocial issues treated as physical concerns Healthcare’s Blind Side
- 8. The Modern DeathRitual • Half of older Americans visited ED in last month of life and 75% did so in their last 6 months of life. • 70% of people wish to die at home • Only about 25% reach this goal • Hospice use is increasing but we are still challenged with length of time under Hospice care Smith AK et al. Health Affairs 2012;31:1277-85. 8
- 9. Characteristics of Complexand Seriously Ill Patients First, this population is not easily defined and is definitely not defined by prognosis. ▪ Functional limitation ▪ Dementia ▪ Frailty ▪ Serious illness(es) ➢Cancer, Severe Heart Conditions, etc. ▪ Family and social support needs 9
- 10. Reframing Person-Centered Care From“what is the matter with you” To “what matters to you”
- 11. Eyes on theTop Users 10% of Beneficiaries 57% of Costs Medicare FFS:
- 12. Determinants of Healthand Their Contribudon to Premature Death Health Care 10% Environmental Exposure 5% Social Circumstances 15% Genedc Predisposidon 30% Behavioral Paeer 40% Linkage Across Providers With Connection to Health System and Community Supports and Providers Source: Schroeder, S. We Can Do Better. N Engl J Med 2007;357 12 • Engage primary care in discharge planning and placement • Refer patients to system resources and programs − Intentionally connect patients with appropriate medical homes or disease specific programs for long- term follow-through
- 13. Serious or complex illness Functional impairment Geriatric CarePalliative Care Foster Independence/control over life Increase quality of life Collaborative Care Model Reduce suffering Improve quality of life Interdisciplinary Team model Criteria is not necessarily related to age or diagnosis
- 14. Evidence Based Models •GRACE – Geriatric Resources for Assessment an Care Of The Elderly Project http://graceteamcare.indiana.edu/case-for-grace.html • Sutter Advanced Illness Management ( AIM) ® $13,000,000 CMS Health Care Innovation Award http://www.sutterhealth.org/quality/focus/advanced-illness-management.html • Guided Care http://www.guidedcare.org/ • Independence at Home (IAH) https://www.cms.gov/Medicare/Demonstration-Projects/ DemoProjectsEvalRpts/Medicare-Demonstrations-Items/CMS1240082.html 14
- 15. Behavioral Health Adult Day Care ComplexCare Clinic Home Care, Private Duty & DME Skilled Nursing Facility/ ALF Patient-Centered Health Care Neighborhood Palliative Care Clinic/ Hospice Telemedicine/ Telemonitoring Geriatric Assessment & Consultation Area Agency on Aging & Other Community Agencies House Calls A “Health Care Neighborhood” For Those with Advanced and Chronic Illness
- 16. Administrator’s Perspective Esther Muscari Desimini,RN, MSN, BC, APRN 16
- 17. Many reasons…. • OurMission: Care for Those as You Would Care for Those You Love • Multiple non-acute care settings in our network and region • We are the main hospital w/many services in a rural like region • Hospital and Nursing Home quality is exceptional, recognized nationally for the past three years • Predominantly older population • It’s the right thing to do 17
- 18. Tappahannock and NorthernNeck Market Region 18
- 19. Riverside Primary Care RiversideCallao Medical Arts Riverside Warsaw Medical Arts Tappahannock Family Practice, Riverside White Stone Family Practice Riverside King William Medical Center Tappahannock Urgent Care
- 20. Demographic Overview 20 2013 Population:63,234 Projected 5 Yr Growth Rate: 3.2% Median Age: 46.6 Median Household Income: $49,648 Per Capita Income: $25,980 Community Health Profile ■The whole market has MUA designation ■Uninsured Estimate of Non Elderly: 16%
- 21. Psychographic Overview • 26%lower middle income African American multigenerational families living in small towns. • 25% white, middle class families who embrace a rural life of fishing, hunting and family. • 10% white, fixed income seniors- many retired veterans. • 9% empty nesting couples & singles with disposable income often spent on travel and outdoor activities. 21
- 22. Identified Community HealthConcerns Primary Care • COPD • Diabetes • Heart Disease & Stroke • Obesity • Mental Health • Substance Abuse Cause of Death • Cancer 22
- 23. Our Strengths &Challenges Challenges • Primarily Medicare Payer (59%) • Minimal public transportation for services • Non-existent growth in our community • We are the largest employer in our region • Financially healthy, but narrow margins Strengths • Low re-admission rates because of collaborations w/community groups & care navigation • Experienced with comprehensive nurse navigation • Bay Rivers Telehealth Alliance • Engaged, outstanding, largely employed physician group 23
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- 25. Program Design • Consultants •Established goals • Conducted Community Needs Assessment • Population Eligibility Criteria • Investigated evidence based models • Established Scope and Structure • Assessed Financial Performance • Final Presentation • Hand-off for Implementation 25
- 26. Riverside Leadership Team •Acute, Outpatient, Home Health, Hospice, Case Management; Clinical and administrative • High level of commitment • Biweekly meetings • Clear roles and authority 26
- 27. Adaptability • Board Certifiedin Geriatrics and Palliative Care • Launch of system-wide Care Management initiative • Adjustments: • Expanded to include palliative care • Changed patient criteria • Added complexity to collaborative care delivery 27
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- 29. Ambulato ry Geriatric and Palliative Care Consultati on • Short, Moore RTH Geriatric and Palliative Care Consultati on • Desimin i, Dudley Orchard Geriatrics and Palliative Care Consultati on •Doshier, Im Home Health Palliative Care; Hospice • Morgan , Jims PCMH Identificat ion and referral • Sibley, Damero n House Calls Northern Neck Steering Committee Desimini, Dudley, Short, Doshier, Boggs, Morgan, Sibley, Allen, Wilson, Russo, Hall, Fletcher, Miller, Livengood, Williams, Im Advanced Illness Management (ACP, PC) – Wilson, Cunnington, Im Geriatrics – Allen, Im Care Management, Care Transitions – Russo, Hall, Livengood NICHE – Fletcher, Miller IT/Telemedicine – Kipp, Hebert, Foss Quality – Martin, Lim, Comer, Sheikh Community – As You Wish, EVCTP, LTC Collaborative, CSB, Bay Aging, etc. Short, Moore, Im Complex Care Local Governance Education – Garcia, Hence, Sutton, patient education Pharmacy - Williams
- 31. Outcome Measures Financial Measures FinancialPerformance (Consults, staff, overhead) Savings/Efficiency (ED, Unwanted Tx) Downstream revenue (PCP, Hospice) Process Measures Documented Advance Care Plans Acute utilization Evidence of Advance Care Plan Outcome Measures 30 day readmission rate Mortality: Hospice days PCP access/utilization 31 Patient Outcomes Quality of Life (SF8/12) Patient Satisfaction Caregiver Satisfaction + bereaved families Condition-specific outcomes ** Diabetes control ** Hypertension control **ACOVE indicators Advance Directive ACP Discussion Patient Goals identified Patient's goals -degree to which we have met Where did people die Resource Utilization Other ways to capture "avoidance" dollars? ED utilization 30 day readmission rate Home Health Utilization Hospice Utilization (admissions, LOS)* PCP utilization Specialty Consult Utilization Palliative Consult Utilization Hospitalizations in last 6 months of life* Hospital days in last 6 months of life* Hospital days, terminal hospitalization* ICU admissions in last month of life* ICU utilization in terminal hospital stay* Chemotherapy in last two weeks of life* Operations Number of patients enrolled ** Geriatric assessment ** Discharge clinic ** Palliative consultation (AIM) ** Housecalls **Comanagement ALOS in the program for each service Referrals to community resources Use of decision support tools/risk assessments Documentation timeliness Referring Physician trends Referring Physician satisfaction Telemed Utilization Remote Monitoring Referrals from AIM Assisted Living referrals from AIM DME referrals from AIM Hospice Referals fromAIM HH Referrals from AIM Financial Clinic financial performance vs. Budget Housecalls financial performance vs. Budget Downstream Revenues: Home health revenue generated and Cont Margin Hospice revenue generated and Cont Margin Payor mix reports New to Riverside patients Ancillary charge by practice providers
- 32. Challenges • Leadership changes •Breaking down silos • Identifying patients • For referral • For outcome measures • Developing metrics • Using current systems for health care of the future • Outreach • Finding simple language to present an unfamiliar model 32
- 33. Keys to Success KyleAllen, D.O. 33
- 34. Clear Measures • Pick3 process • Pick 3 financial • Pick 3 outcomes • For the person who can’t help themselves have 1 bonus metric • Challenge of data sources and who is “Oz”
- 35. Measuring the Value •The ROI might not be to a single cost center or entity • The “investment” and “ return” will need to be measured for the whole region • Reduce ED but increase PCP and Homecare • Reduce risk for value based purchasing penalties e.g. Medicare Spend per Beneficiary • Investing for model that might have value that can leverage into enhanced premium payments from MCO , e.g. Managed Long Term Services and Supports MA
- 36. CHANGE MANAGEMENT: WHATEVERY HEALTHCARE LEADER NEEDS TO KNOW HOW TO DO 36
- 37. ADGAP Leadership Pre- Conference#AGS14 The 8 “Physics Laws” of Change May 14, 2014
- 38. Share Victory, ShareDefeat
- 39. Geriatric & PalliativeCare Medicine Capability Success in geriatric and palliative care medicine occurs when: • Patients don’t get care they don’t want. • Patients don’t get care which can’t benefit them. • Patients suffer fewer adverse events. • Patients experience fewer transitions. • And cost of marginal care is reduced.
- 40. Changing Culture “If youare going to change something you’ve got to live on vision, before you live on reality. You have to be so inspired by the vision, that you keep telling everybody until it gets in them, and they start living it with you.” Father President Michael Scanlan, Franciscan University of Steubenville