Looking Forward: Looking Forward: Imagining New Models of CareImagining New Models of Care

Eric A. Coleman, MD, MPHAssociate ProfessorDivisions of Geriatric Medicine and Health Care Policy and ResearchUniversity of Colorado Health Sciences Center

Frame the DiscussionFrame the Discussion

Focus is on the interface between new models that improve geriatric care and strategies that overcome the aging workforce shortage

DisclaimerDisclaimer

lConceptual rather than evidence-based approachl Illustrative examples will be offered of

models under development

Assertions:Assertions:

l Business as usual will not sufficel Need a fundamental shift to promote changel Defenders of the status quo are powerfull The distinguished IOM platform is needed

to chart a course for meaningful change

Pipeline or Funnel?Pipeline or Funnel?

Resources committed to conduct study

Good ideas

Reached study recruitment goals

Rigorous evaluation approach

Positive results

Results appeal to decision makers

Adopted in “real world”

Looking Into Our Crystal BallLooking Into Our Crystal Ball……

Strategic PartnershipsStrategic Partnerships……

Model End Adopters:Model End Adopters:A Moving TargetA Moving Target

l Attracted to “cutting edge” technologyl Reliance on evidence-based practice variesl Expect a short turnaround to achieve ROIl Recognize benefits do not always accrue to

those who make the investment in the model

Partnerships Between Model Partnerships Between Model Developers and EndDevelopers and End--AdoptersAdopters

lToo often operate in isolationlNo formal mechanism to foster collaboration

Need for a Collaborative TriadNeed for a Collaborative Triad

Funders

Model Developers

End Adopters

Variation On A ThemeVariation On A Theme

Payors

Model Developers

End Adopters

Medicare Chronic Care Medicare Chronic Care Practice Research NetworkPractice Research Network

l Led by Cheryl Schraeder, RN, PhD Carle Clinicl Legislation sponsors: Sen Obama and Sen Derbinl Fundamental changes to CMS’ research approach

Limitations of the Current CMS Limitations of the Current CMS Demonstration MechanismDemonstration Mechanism

1) A mismatch between project duration and rate at which benefits accrue to different populations

2) Delayed feedback about program performance makes midstream project adjustments impossible

3) Insufficient means to validate care management best practices to ensure replicability & scalability

Goals of the NetworkGoals of the Network

1) To improve our understanding of which care management interventions achieve the greatest benefit at the lowest possible cost

2) To provide a reproducible, reliable and scalable framework to implement effective standardized care management services nationwide

3) To implement a comprehensive evaluation to assess the impact of care management that has implications for current and future policy

Network ActivitiesNetwork Activities

1) Collaboration between CMS and select group of care providers (Medicare Care Coord Demos)

2) To function as “laboratories” to develop, test, adjust, and re-test new approaches

3) To rigorously assess coordinated care management interventions

4) To enable feedback loops between local organizations and policy makers to accelerate practice and policy refinements

The The AnemicAnemic Aging WorkforceAging Workforce

The Anemic Aging WorkforceThe Anemic Aging Workforce

1. Inadequate red blood cells produced in the “factory” (i.e., health professional schools)

2. Loss of red blood cells (i.e., leaving the field or retirement)

3. Sequestration of red blood cells (i.e., workers’ roles leave them unavailable to effectively care for older adults)

Sequestration: Sequestration: The Spleen of Health Care DeliveryThe Spleen of Health Care Delivery

‘‘All Assessed Up and No Where to GoAll Assessed Up and No Where to Go ‘‘

l Assessment often over-emphasized relative to need for execution of care plan

l Enormous drain on health professionals’ time and providers’ resources

l Ties into IOM goals for greater efficiencyl Need to decrease both the number of assessments

and the length of assessments

Let the Punishment Fit the CrimeLet the Punishment Fit the Crime

DoAssess

DoAssess

Current Division

Ideal Division

Process MappingProcess Mapping

l Led by Jane Brock, MD, Medical Director of Colorado Foundation for Medical Care

l CMS Special Study to CFMC and UCHSCl Applied principles of lean thinking to intake

and discharge processes for hospital, skilled nursing facilities, and home health care

DisclaimerDisclaimer

Disclaimer: “This material was prepared by CFMC PM-415-076 CO 2007, the Medicare Quality Improvement Organization for Colorado, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The contents presented do not necessarily reflect CMS policy.

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n o te s c o p ie s t of a c i li t ie s o ra g e n c ie s

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Transfer callto Intake Dept

Assess abilityto takepatient

Home Health IntakeTOC CFMC

Thursday, April 05, 2007

Take Patient?ReceptionReceives call

Write on “ReferralTriage” Log

Receive faxinfo fromreferringfacility

Fill outIntake Form

Checkcomputer(Scan) for

MD & patientinfo

ScheduleRN staff

Print mapfrom

Mapquest

Manuallywrite caseon Intake

Log

Make copies of Intake Packet:1) Field RN

2) Insurance Dept (face sheet)3) Intake Tracking slot system

Place #1packet in HH

RN Box*

Fax packet toHH RN if

necessary(RN can’t pick

up packet

Take #2 Copy (facesheet only) to

Insurance Dept forverification of

insurance*

Verify MDsigned order

for HHSignal Found?

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slot*

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NO

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for entry into“Active Roster”

and notify PCP (ifPCP is known)*

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4) Team Leader5) HomMed

6) MM (med info mgt)

* separate processes not represented on this map because they have not yet been observed

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appropriateness oftelemonitor*

No

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Yes

Yes

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What If We ReWhat If We Re--Invested the Time Invested the Time and Resources Dedicated to: and Resources Dedicated to:

l Joint Commission AccreditationlMDS/OASIS/IRF-PAIlHIPAA Compliance

Continuity Assessment Record Continuity Assessment Record and Evaluation (CARE) and Evaluation (CARE)

l CMS tasked to create under Deficit Reduction Actl Cross-setting assessment tool initiated upon

hospital discharge to post-acute carel Three primary purposes:

– Improve information transfer– Longitudinal outcomes assessment– Promote payment reform

CMS contracted awarded to RTI to develop

Sequestration ContinuedSequestration Continued……

Hospital

HomeAmbulatory Care Clinic

Skilled Nursing Facility

SNF

Rehabilitation Facility Disease Manager

Adding More Care Managers Won’t Fix It!

PolyPoly--Management SyndromeManagement Syndrome

l Physicians deal with multiple care managers– Health plan– Disease category

l Patients deal with multiple care managers– Provider-based– Disease-based– Special programs

Attribution to Cheryl Phillips, MD, CMD

Affect on Older AdultsAffect on Older Adults

l Confused by multiple case/disease managers l Cannot identify their case managerl Become more passive or disengage

Too Many CooksToo Many Cooks……..

Need a care manager for the care managers!

A Solution: Sutter Health SystemA Solution: Sutter Health System

l Formal mechanism for cross referral between health plan and provider programs

l Designate one care manager (ideally with a continuous relationship) to serve as lead, obtaining input of other mangers to create a single plan of care with patient and family

Attribution to Cheryl Phillips, MD, CMD

Returning to Our Analogy Returning to Our Analogy Workforce = Red Blood CellsWorkforce = Red Blood Cells

Need for ChampionsNeed for Champions……

Geriatric Resource NursesGeriatric Resource Nurses

l Nurses Improving Care for Health System Eldersl RNs with enhanced skills in care of older adults l Valuable resource on geriatric best practicesl Improve management of pain, incontinencel Reduce readmission rates

John A. Hartford Foundation Institute for Geriatric Nursing

One Patient, Many Places:

Managing Health Care Transitions

A Report from the HMO Care Management Workgroup

Supported by the Robert Wood Johnson Foundation

Practice Change FellowsPractice Change Fellows

l Build leadership capacity among health care professionals with operational responsibility for aging programs & geriatric service lines

l 10 selected each yearl Nurses, Physicians, Social Workersl Foster national network and platform for change

Supported by Atlantic Philanthropies & John A. Hartford Foundation

eGeriatricianeGeriatrician and ACE Trackerand ACE Trackerl Cannot build and/or staff

enough ACE unitsl Incorporate principles

into all programsl Reach seniors in urban

and rural settings

Michael L. Malone, MD

Aurora Sinai, Milwaukee WI

ACE TrackerACE Tracker-- PurposePurpose

l To identify vulnerable hospitalized seniors

l To provide focus for interdisciplinary rounds

l To promote care planning

Michael L. Malone, MD

ACE TrackerACE Tracker-- DescriptionDescriptionl Who? Team members

enter data into EMRl What? Daily reportsl Where? 12 hospitalsl Why? Focus on reducing

complications

Michael L. Malone, MD

eGeriatricianeGeriatricianl Urban and rural hospitals

connect via conference call with the “e-Geriatrician”.

Michael L. Malone, MD

GeriatricizeGeriatricize Other DisciplinesOther Disciplines

l “Hospitalists are geriatricians in denial”– Eric Segal, MD Madison Wisconsin

l John A. Hartford Foundation is supporting Society for Hospital Medicine to improve care transitions for older adults

l Develop toolkits to foster adoption amongst hospitalists across the country

Advanced Care Medical HomeAdvanced Care Medical Home

l ACP White Paper: Re-invigorate primary carelMedicare Medical Home Demonstration

– 3 years duration– Urban/rural/underserved areas– Small physician practice encouraged

Components of a Medical HomeComponents of a Medical Home

l Advocates for and provides ongoing support, oversight, and guidance to implement a care plan

l Uses clinical decision support toolsl Develop a health assessment tooll Uses health information technologyl Provides support for self-managementl Promote patient access to health information

Will Physician Practices Join the Party?Will Physician Practices Join the Party?

l External entity would certify medical homesl Amount of compensation to practice unclearl Specialists could qualify to be medical homel Patients choose their medical home

Models That Elicit and Honor Models That Elicit and Honor Patient PreferencesPatient Preferences

Advanced Illness Coordinated Care Advanced Illness Coordinated Care (AICC) Program(AICC) Program

l Developed by Dan Tobin MD (Albany VA) and Dale Larson PhD (UC Santa Clara)

l Approach used for people with advanced illness in all settings

l Continuity across hospital, home based and office based care

Conducted in partnership with SUNY Albany and the Life Institute in Albany with support from the Garfield Memorial Trust

MethodologyMethodology

l Targeted people with heart failure, renal failure, or chronic obstructive lung disease

l Patients identified with “surprise question”l Referred to AICC social worker or RN

AICC Program DescriptionAICC Program Description

l Social worker guides patients with advanced illness as they transition into end-of-life

l AICC program evaluates the patient's ability to confront diagnosis and fears

l Focuses on practical issues such as legal planning and completion of advance directives

AICC: 6 SessionsAICC: 6 Sessions

1. Understand perspective in terms of curative, uncertain, or palliative

2. Assess understanding of condition and prognosis3. Inquire about fears, worries, concerns4. Elicit values, goals and preferences5. Planning for the future 6. Coordinate and support per care plan

Preliminary OutcomesPreliminary Outcomes

l Psycho-social outcomes positivel Cost and utilization will be complete by Fall 2007

– Fewer ICU days– Less intensive care

Hebrew Senior Life Center Hebrew Senior Life Center Green House Green House

l Green House founded as a social model l HSL recognize a subgroup whose move was

prompted by a change in health status and need for more support with chronic illness care

lWeave in elements of a medical model but try to make invisible or at the very least, non intrusive

Attributed to Robert Schreiber, MD

HSL Green HouseHSL Green House

l Integrated medical model into environment in non-obtrusive manner-- “behind the scenes”

l CNA driven model with less visible RN & MDl Home visits using cart with wireless EMR

Attributed to Robert Schreiber, MD

HSL Green House: HSL Green House: Preliminary Findings:Preliminary Findings:

lWeight gain among persons losing weight l Reduced number of medications takenl Fewer fallsl Improved depression scoresl Escaped nosocomial Norwalk virus epidemicl High satisfaction among residents

Attributed to Robert Schreiber, MD

HSL Green House: HSL Green House: Impact on WorkforceImpact on Workforce

l Higher satisfaction and retentionl Career ladder for CNA’s

– Support to obtain English equivalency– Paid during pursuit of LPN degree– Nurse mentor program

l New campus opens 2009--all units will adopt approachl Rigorous measurement strategy to capture outcomes

Attributed to Robert Schreiber, MD

Aliens Did Aliens Did NotNot Build The PyramidsBuild The Pyramids……

And Case Managers Do And Case Managers Do NotNot PerformPerformThe Majority of Care CoordinationThe Majority of Care Coordination……

Family Caregivers As Formal Members Family Caregivers As Formal Members of the Interdisciplinary Team of the Interdisciplinary Team

l Silent partners/care coordinatorsl Tremendous financial offset on health care costsl Role not recognized (i.e., not part of JCAHO

hospital surveys)

Expanding EvidenceExpanding Evidence

l Coordination between formal providers and caregivers improves caregiver preparation to provide care

l Positively associated with patients’ pain control, functional status, and mental health.

D. Weinberg et al., “Coordination Between Formal Providers and Informal Caregivers” . Health Care Manage Rev 2007 32(2) 1-10.

United Health Care United Health Care Caregiver CollegeCaregiver College

l Six 2.5 hour seminars led by professionalsl Held at community based organizationsl Respite dollars available

Attribution to Danielle Butin, OTR and Kathy Alsgaard, RN

UHC Caregiver College:UHC Caregiver College:ObjectivesObjectives

1. To increase caregiver efficacy 2. To increase services and community support3. To increase understanding of benefit plans4. Decrease caregiver burden5. Decrease unnecessary healthcare utilization

Attribution to Danielle Butin, OTR and Kathy Alsgaard, RN

UHC Caregiver College:UHC Caregiver College:Core TopicsCore Topics

l Symptom managementl Self-care managementlMedication managementl Emergency managementl Emotional copingl End of life planning

Attribution to Danielle Butin, OTR and Kathy Alsgaard, RN

One Final Look at SequestrationOne Final Look at Sequestration

Electronic Health Electronic Health Information ExchangeInformation Exchange

l Interoperability is a worthy goall Adoption of HIT particularly low among

nursing homes and home health care agenciesl Lack of data standards for physical and

cognitive function, roles of family caregivers

Health Information Exchange Across Health Information Exchange Across Acute, PostAcute, Post--Acute, & LongAcute, & Long--Term CareTerm Care

l Business case needs to be more compellinglWorkflow concerns as challenging as technologyl Use of national data standards not a high priority

Supported by the Office of the Assistant Secretary of Planning and Evaluation, Department of Health and Human Services

State of Indiana: State of Indiana: Docs4DocsDocs4Docs

l Facilitators:– Unique patient identifier– Statewide e-prescribing– Leadership and financing of hospitals

l Information available:– Laboratory and radiology reports– Pharmacy data– Discharge summaries

Standardize Communication For Standardize Communication For Family Caregiver Role (s)Family Caregiver Role (s)

T= Primary Tumor Description

N= Nodal Involvement

M= Metastasis

F= Financial

A= Advocacy

C= Care Coordination

E= Emotional Support

D= Direct Care Provision