1. Developing a Program to
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 an innovative model is needed
• Model implementation from a community
perspective: Who, What, Where, How
• Keys for success
• Questions and Discussion
5. “The most common chronic condition experienced
by adults is multimorbidity, the coexistence of
multiple chronic diseases or conditions.”
Tinetti et al, JAMA, 2012
6. 6
• Poor communication among 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 RWJF survey 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 Death Ritual
• 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 Complex and 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
11. Eyes on the Top Users
10% of Beneficiaries 57% of Costs
Medicare FFS:
12. Determinants of Health and
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 Care Palliative 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
Complex Care
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
17. Many reasons….
• Our Mission: 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
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19. Riverside Primary Care
Riverside Callao 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 Health Concerns
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
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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 Certified in 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
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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
30.
31. Outcome Measures
Financial Measures
Financial Performance (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
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34. Clear Measures
• Pick 3 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
39. Geriatric & Palliative Care 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 you are 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