Transcript Shirley*s slides

Shirley Weaver LOTR, MSOL
Director of Community Based Services for Seniors
Joy M. Marotto MS, CMC
Director of Senior Care Partners Program
In 1966, TIME magazine declared that “the Generation
Twenty-Five and Under” would be its “Persons of
the Year.”
Population Trends
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2012: 11.8 million or 28% of non-institutionalized older
persons live alone
Median income in 2012 was $27,612 for males and
$16,040 for females
Households headed by persons 65+ median income
$48,957
2012: 9.1% was the poverty rate for people 65+
◦ Note: 8.7% in 2011
Source: Administration on Aging: Profile of Older Americans: 2013
https://www.census.gov/hhes/www/poverty/about/overview/
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2010: 45% of seniors live at or below 200% of poverty
level
2010: 36% of seniors are 75+
2003: Second among 23 US cities in population of
residents 65 and older
Increasing age 2025:
◦ 85+: 18% increase
◦ 75 to 84: 22% decline
◦ 65 to 74: 28% Increase
Source: PCA Area Plan 2012-2016
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Number of older adults continues to grow
Increase age results in increased chronic disease
Management of chronic disease places increased
demands on healthcare system
Management of chronic disease places increased
financial demands on the individual
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Older adults express a desire to remain in their
homes and communities
Seniors also desire to stay in a particular residential
setting as long as possible
Remaining in the community is less costly than
institutionalization
Managing Chronic
Disease
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30 day hospital readmission rate
◦ Approximately 2.6 million seniors
◦ Nearly 1 in 5 Medicare patients discharged from a hospital
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Readmission cost of over $26 billion every year
2013: 2,225 hospitals penalized for Medicare
reimbursement
◦ Acute Myocardial Infarction (AMI), Heart Failure (HF) and
Pneumonia (PN)
Source: http://innovation.cms.gov/initiatives/CCTP/index.html
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Lack of physician follow up
Medication mismanagement
Lack of understanding of signs/symptoms of
exacerbation of chronic conditions
Poor transfer from one setting to another
Lack of use of home health services
Poor patient self management
Insufficient care giver support
Lack of availability or awareness of community
resources
Source: Polisher Research Institute
Response
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Link Medical and Social Models
Mission
◦ “… offers choice and guidance to older adults and their
caregivers by supporting individual well being …”
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Connection
◦ Provide resources
◦ Network with existing programs
Eldercare
Helpline
Senior
Housing
Adult Day
Program
In-Home
Support
Program
Saint
Monica
Eldercare
Program
Senior
Clubs
Senior
Senior
Care
Partners
Senior
Centers
Community Nurse
Liaison
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Language
◦ Medical versus social
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Approach
◦ Patient care oriented
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Perspective
◦ Analytical approach to chronic disease management
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Nursing services where seniors gather
Goal
◦ Self Management of Chronic disease
 Evidence based practice: The Omaha System
◦ Health Promotion
◦ Facilitate collaboration with Medical systems
◦ General Education
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Ask the Nurse Day
◦ Individualized assessment and treatment
◦ Documentation of medical diagnoses and health issues
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Health Consulting
◦ Analyze current programs
◦ Develop new programs
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Health Education
◦ Articles on health & wellness for seniors
◦ Monthly presentations
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Patient Care Process
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Evaluate
Develop a care plan
Reassessment upon next visit
Care Plan revision as necessary
Document all patient contact
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Problem Categories: Environmental, Psychosocial,
Physiological, Health-related Behaviors
Consists of three, five-point scales measuring the
range of severity:
◦ Knowledge: Understanding and management of the specific
problem.
◦ Behavior: Persons ability and approach towards managing
their problem.
◦ Status: Measures signs/symptoms of the problem.
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Services rendered Nov. 2013 through April 2015
◦ 391 Unduplicated Seniors
◦ 1,151 Patient Visits
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73.4% of patients show improvement
15% average improvement from initial score
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Weight Challenge
◦ 165 lbs. loss
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Pharmacy Program
COTA student Program
Respiratory Program
Eldercare
Helpline
Senior
Housing
Adult Day
Program
In-Home
Support
Program
Saint
Monica
Eldercare
Program
Senior
Senior
Care
Partners
Senior
Clubs
Senior
Centers
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SNF Transitions Project
Insurance Product
◦ Humana/SeniorBridge
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Private Pay
SNF Transitions
Project
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Concept: Support hospital by focusing on
minimizing 30-day readmission penalty
Purpose: Prevent re-hospitalization post SNF
discharge
Goal
◦ Enhance SNF/Hospital relationships
◦ Enhance transition process from SNF to home
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Hospital facing 30 day readmission challenge
Average CHCS SNF length of stay 19 days
Hospital at risk day 19 to 30 post SNF discharge
Pattern at SNF: Decline in home care services upon
discharge
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Protecting Access to Medicare Act of 2014 (PAMA)
◦ Establishes a value based purchasing (VBP) program for
SNFs
◦ Establishes an incentive pool for high performing SNFs as it
pertains to preventing unnecessary hospital readmissions
Source: The National Readmission Prevention Collaborative
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Health and Human Services (HHS) will specify a SNF
all-cause, all-condition readmission measure prior to
October 1, 2015
A risk-adjusted potentially preventable hospital
readmission rate by October 1, 2016
American Health Care Association 4/5/2014
(http://www.ahcancal.org/advocacy/solutions/Documents/Value%20Based%20Purchasing%20-%20IB.PDF)
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Based on the SNF readmission measure
◦ performance standard for SNFs
◦ scoring methodology for each SNF
◦ creation of in order to create a ranking system which will
rank SNFs annually.
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SNFs’ Medicare payment rates will be based on (in
part) their performance scores beginning on
October 1, 2018.
American Health Care Association 4/5/2014
(http://www.ahcancal.org/advocacy/solutions/Documents/Value%20Based%20Purchasing%20%20IB.PDF)
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SNFs with the highest rankings receive the highest
incentive payments
SNFs with the lowest rankings receiving the lowest
(or zero) incentive payments
The lowest 40 percent of SNFs (by ranking) will be
reimbursed less than they otherwise would be
reimbursed without the SNF VBP program
American Health Care Association 4/5/2014
(http://www.ahcancal.org/advocacy/solutions/Documents/Value%20Based%20Purchasing%20-%20IB.PDF)
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Funding the incentive payment pool
◦ CMS will withhold 2% of SNF Medicare payments starting
October 1, 2018
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CMS will redistribute 50-70% of the withheld
payments back by way of incentive payments
CMS will retain the remaining 30-50% of funds as
programmatic savings to Medicare
American Health Care Association 4/5/2014
(http://www.ahcancal.org/advocacy/solutions/Documents/Value%20Based%20Purchasing%20-%20IB.PDF)
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The program also requires the Secretary to publicly
report the performance on the readmission measure
for each SNF on Nursing Home Compare beginning
on October 1, 2017.
American Health Care Association 4/5/2014
(http://www.ahcancal.org/advocacy/solutions/Documents/Value%20Based%20Purchasing%20-%20IB.PDF)
American Health Care Association 4/5/2014
(http://www.ahcancal.org/advocacy/solutions/Documents/Value%20Based%20Purchasing%20-%20IB.PDF)
Program Design
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Secure meeting through nursing home relationship
◦ Vested Partner: Hospital Care Management Director
◦ NHA participation in hospital meeting: common goal
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Materials developed that highlight hospital
relationship
Electronic record transmission
Highlight provision of hospital specific reports
Meet with hospital based home health care agency
◦ Address concerns regarding coordination of services
Care Management
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Patient History: Used for general baseline date
Living Arrangements: Environment, Safety,
Available Supports, Impact on overall health
Sensory Status: Impact on overall social,
psychological, and physical well-being
Pain: as related to community based activities and
daily function
Incontinence: as related to community based
activities, daily function, and psychological wellbeing
Cognitive function: Caregiver support, community
support, follow-through on self-care
Mental Health (anxiety/depression): Caregiver
support, community support, follow-through on
self-care
ADLs/IADLs: Community function, home function
and relation to each other
Medications: financial impact of medications and
general review of medications
Home Health
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Patient History: In-depth, analytical, used for
payment
Living Arrangements: Availability of assistance
for medical care
Sensory Status: ability to manage medical care
Pain: Treatment focused and medical
management of pain
Incontinence: Treatment focused and medical
management of pain
Cognitive Function: Ques for depression
screening. Self-medical management
Mental Health: Medical treatment of
ADLs/IADLs: therapeutic intervention model
Medications: Medical management
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45 days of care management services
GCM attends discharge planning meeting at the SNF
◦ In-home assessment scheduled
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In-Home Assessment completed within 24-48 hours
of SNF discharge
◦ Within 72 hours if weekend discharge
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Results of assessment transmitted to hospital within
5 business
◦ Summary of Findings
◦ Completed Care Plan
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45 day follow up services
◦ Telephonic
◦ Site visit if needed
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Post Discharge from SNF
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Day 7
Day 10
Day 14
Day 21
Day 30
Day 45
Additional unscheduled follow-ups as necessary
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Physical Environment
Activities of Daily Living Status
Medication Management
Nutritional Support
Cognitive Status
Social and Spiritual Support
Confirmation of Community Medical Appointments
Scheduled
Identify Additional Community Resources
Hospitalization Timeline
SENIOR CARE PARTNERS FOLLOW UP
SNF
ADMISSION
SNF
DISCHARGE
Day 1
Day 19
DATE
CAPTURE
DATE
CAPTURE
DISCHARGE
FROM SCP
Day 30
Day 49
Day 64
HOSPITAL
DISCHARGE
Day 20
Hospitalization Timeline
SENIOR CARE PARTNERS FOLLOW UP
SNF
HOSPITAL
ADMISSION RE-ADMISSION
SNF
RE-ADMISSION
SNF
DISCHARGE
Day 1
Day
10
DATE
CAPTURE
DATE
CAPTURE
DISCHARGE
FROM SCP
Day
30
Day
40
Day
55
HOSPITAL
DISCHARGE
Day 1
Day 4
Day
11
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Nursing Home Administrator support
◦ Coordinated SNF Team
◦ Supported changes in the system
◦ Participation in Hospital meeting: common goal
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Social Service Department
◦ Coordination of data flow
◦ Coordination of patient contact
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Partnerships were formed with four local hospital
systems
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Aria Health (3 campuses)
Mercy Health (Trinity) (2 campuses)
Chester County Hospital
Brandywine Hospital
Hospitals received reports on their specific data and
comparative data for all participating entities
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Daily review of SNF census
Notification of Discharge Planning Meetings from
SNF
Information gathered into a tracking log for
statistical and reporting purposes
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Patient introduced to service by SNF SW
Provided with handout describing joint project with
hospital
Informed they would be contacted by SCP care
manager
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Met Care Manager at discharge planning meeting
Home assessment scheduled
On-site home assessment
Receipt of care plan and recommendations
Follow up phone calls/visits
Follow up documentation as needed
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Project Data from 11/1/2012 – 11/1/2014
◦ SNF Admissions: 803
◦ 282 cases not served
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Transition to long term
Death
Transfer to hospital with no return
Cases readmitted to hospital prior to being assessed
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Remaining Cases: 521
◦ Received Services: 330 (63.3%)
◦ Declined Service: 191 (36.7%)
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First data review: 30 days post last hospital day
◦ Includes nursing home days
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95.2% of clients free from hospitalizations
4.8% were re-hospitalized within 30 days
Re-Admissions within 30 days of
Hospital Discharge
No ReAdmits, 330
Re-Admits, 16
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Second Data review: 30 days post SNF discharge
85.5% of clients remained free from hospitalization
14.5% of clients were re-hospitalized within 30 days
Re-Admissions within 30 days of
SNF Discharge
Free from readmission,
330
Re-admitted
within 30
days of SNF
discharge, 48
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Comparative Data
◦ National average rate of hospitalization within 30 day of
SNF discharge is 23%
◦ 8.5% fewer admissions
Re-Admission Rate Comparison
25.0%
20.0%
15.0%
10.0%
5.0%
0.0%
23.0%
14.5%
Senior Care Partners
Re-admission Rate
National Re-admission
Rate
(Berkowitz et al., 2013)
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Medication Reconciliation
Medical Appointment Compliance
Discharge Instructions
◦ Location
◦ Resolution
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Satisfaction Surveys
Cases readmitted to hospital prior to assessment
Insurance Product
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Goals:
◦ Remain at home and avoid unnecessary hospitalizations
◦ Obtain medications, understand what medications to take
and how to take them
◦ Understand self-care requirements and be able to
implement them
◦ Access helpful resources if needed
◦ Continue PCP follow up as required
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SeniorBridge:
◦ LifeCare/Care Coordination Assessments
 One-time in-home comprehensive focused assessment
◦ Care Plan/Narrative Coordination Report
◦ Two resources per recommendation
 Must include:
 Contact information
 Pricing
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Care Transitions Program
◦ Involvement for 30 days post-discharge from a hospital, subacute or skilled facility
◦ 3 visits by a care manager within a 30 day timeframe
◦ Coordination with PCP
◦ Connection to local resources/supports
◦ Medication Reconciliation
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Long-Term In-Home Program
◦ Weekly visits for an extended period of time
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Goals:
◦ Reduce unnecessary hospitalizations and emergency room
visits
◦ Improve access to services
◦ Improve quality of care and outcomes
◦ Improve cost savings for Humana
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October 20, 2014 – May 31, 2015
◦ Number of Cases Assigned: 176
 Number Declined: 56
 Other closed Cases: 55
◦ Remaining Cases: 65
 Number Re-hospitalized: 4 (6.15%)
Eldercare
Helpline
Senior
Housing
Adult Day
Program
In-Home
Support
Program
Saint
Monica
Eldercare
Program
Senior
Senior
Care
Partners
Senior
Clubs
Senior
Centers
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Funded by the Farrell Townsend Trust
Serves registered parishioners and their families
in Saint Monica Parish in South Philadelphia
Started in September 2003
Provides direct service, connects to other
services, fills in gaps
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Information and Referral: 125 calls per year
Service Delivery for open cases
◦ Care Partner
◦ Care Management
 Form completion
 Connecting to organizations
 Facilitating Family meetings
◦ Spiritual Care and Guidance
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Number of Employees
◦ 1 FTE, Director CGCM (Certified Geriatric Care
Manager)
◦ 3 part time Care Partners
◦ 4 occasional Care Partners
◦ 10 hour/week Pastoral Care Partner
◦ 10 hour/week Administrative Support
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Budget: $194,356 per year
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July 2010,2011,2012
89 participants studied
Gathered data for all participants
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Demographic
Services rendered
Health information
Diagnoses, hospitalizations
Disposition
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Mean Age 85.1 years; Range 57-97
26% Live Alone
51% Receiving a psychotropic medication
30% Display Cognitive Impairment
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•
Average length of time in SMEP – 3.5 years
Average total number of self-reported medical
diagnoses = 4 (range 0-12)
66% Female
Average annual documented income for 33
individuals is $12,882
10 or 11% were receiving services typical of a
nursing home population (LIFE program,
Waiver services, hospice, 24 hr. private duty
aides, family care givers)
Red Dots = participants in the SMEP N=89
Blue Squares = services and referrals
Direct Services Diagram –subset from above
Referrals to other Programs (subset of entire graph above)
System Impact
Does not include those individuals still actively receiving services
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54% or 20 individuals were discharged due to death
◦ 11 died in their homes
◦ 4 died during short term NH stays (average 18 days)
 2 during rehab stay
 1 during hospice stay
 1 who would have converted to Long Term care
◦ 5 died during brief hospitalizations (average 3 days)
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SMEP had 5% versus 11% national average for nursing
home placement of individuals age 85+
SMEP
◦ SMEP 4
◦ National average projection: 10
◦ Result: 6 fewer long term admissions
11%
12%
10%
8%
6%
5%
4%
2%
0%
SMEP
National
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Average length of stay in nursing home in
Pennsylvania for long term care: 183.94 days
Average cost per day in PA: $221
Savings for one individual: $ 40,651
Source: http://www.amwarnerinsurance.com/ltc-insurance/cost.php
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SMEP average hospitalizations is 45%
National average of 58% for individuals 85+
Difference in hospitalization rate: 11%
Average cost to Medicare per hospitalization:
$11,600
70%
58%
60%
50%
45%
40%
30%
20%
10%
0%
SMEP
National
Source http://www.hcup-us.ahrq.gov/reports/statbriefs/sb103.jsp
http://www.hcup-us.ahrq.gov/reports/statbriefs/sb146.pdf
Eldercare
Helpline
Senior
Housing
Adult Day
Program
In-Home
Support
Program
Saint
Monica
Eldercare
Program
Senior
Senior
Care
Partners
Senior
Clubs
Senior
Centers
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St. John Neumann Place
◦ 75 one-bedroom Independent Living apartments for
income-eligible residents at the former SJN High School
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Casa Carmen Aponte
◦ Section 8 housing with 35 apartments
◦ Located above Norris Square Senior Community Center
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St. Mary Residence
◦ Former convent with supportive housing for women over
60 years old
Name
Units
Primary
Funding
Total
Cost
Timeline
Nativity B.V.M. Place
(Port Richmond,
Philadelphia)
63
HUD 202
$12.5m
Start Construction: Jan 2015
(maybe sooner)
Ready for residents: February,
2016
St. Francis Villa
(Kensington,
Philadelphia)
40
LIHTC
$12m
Start Construction: March, 2015
Ready for residents: April, 2015
$12m
Awarded funding: Innovation
start construction: April, 2016
Ready for residents: May, 2017
St. John Neumann Place
II
(South Philadelphia,
Philadelphia)
52
LIHTC
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Care Management Approach
Senior Center without Walls
◦ Coordination with St. Charles Senior Center
Collaborative effort between SJNP & St. Charles Senior Center
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Programs at SJNP
Grocery Shopping Trip
Exercise Class
Crochet Class
Shopping Center Trip
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Programs at St. Charles
Health & Wellness
Programs
Social Activities
Breakfast &
Lunch
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Care management services from a holistic and
prevention based model that fosters empowerment
of individual (Team Approach)
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Needs Assessments
Advocacy
Information & Referral
Case Management
Counseling
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Community Nurse Liaison
◦ Average monthly patient visits: 10
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Active Care Management cases per month: 37
◦ Referrals: 315 (Benefit Programs, Health Care Services,
Legal Services, Financial Services, Crisis Support)
◦ Hospice: 2 within 12 months
◦ Life Program: 12 residents
◦ PCA LTC Program: 11 residents
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Jody is an elderly resident living alone at SJNP
Needs Assessment Areas of Concern
Physical Health
Mental Health
Financial Health
Spiritual Health
Social Health
Fall Risk & ADL Needs
Depression
Low Income
Decrease in Access
Isolation
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Assistance with Areas of Concern
Fall Risk
ADL Needs
Depression
Low Income
Spiritual Access
Isolation
PT, OT, Walker, Shower Chair,
detachable shower head
PCA LTC Aid
MH Therapy
CAP, LIHEAP, Medicare Savings
Rosary Group, Mass, Communion
SJNP & St. Charles Activities
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Results in Improved Quality of Life
PT, OT, DME
PCA Aid
MH Therapy
Financial
Spiritual
Activities
Decrease in falls, increase
strength
Help with ADLs, Decrease in falls
Decreased anxiety & depression
Increase in funds, Decreased
stress
Sense of Peace
Decreased social isolation, friends
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Ask the Nurse Day
Balance Screenings
Anxiety & Depression
Screenings
BP and Glucose
Screenings
Emergency
Preparedness Training
Health Insurance
Counseling
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Community Resource
Presentations
Memory Screening
SNAP, LIHEAP,
Medicare Savings
Resident Volunteer Hosts Social & Spiritual Health
Programs
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Bingo
Birthday Parties
Barbeques
Holiday Dinners/Lunches
Rosary Hour
Religious Services
Card Games
Eldercare
Helpline
Senior
Housing
Adult Day
Program
In-Home
Support
Program
Saint
Monica
Eldercare
Program
Senior
Senior
Care
Partners
Senior
Clubs
Senior
Centers
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Partnership with PCA
South Philadelphia area
Target population
◦ Early intervention and prevention services for 60+
individuals
◦ Temporarily homebound or require assistance or
supervision to leave home
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Case Management Services
◦ Short Term Services: Less than 6 months
 Home care, chore service, minor home repair
◦ Long term services:
 Home-delivered meals, transportation, and senior companions.
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Home-bound
◦ Cannot access congregate meal sites
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Types of meals
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Frozen
Hot
Kosher
Diabetic
In September 222 consumers received meals.
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Conversations, reading, and reminiscing
Light meal preparations
Errands and light shopping
Taking walks
Accompanying to medical appointments
Respite care for family caregivers
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Provided by Septa CCT
Paid for by IHSP
65 years of age or older
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Light housekeeping
Personal care
Minor home repairs
Purchase of adaptive equipment, medical supplies,
incontinent supplies and safety equipment such as
Freedom Alert Systems.
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Intake
Assessment
Service plan approval
Service begins
Reassessment
Referral to LTC if necessary
Eldercare
Helpline
Senior
Housing
Adult Day
Program
In-Home
Support
Program
Saint
Monica
Eldercare
Program
Senior
Senior
Care
Partners
Senior
Clubs
Senior
Centers
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Opened its doors on April 29, 2015
Projected average daily census: 27
Provides ½ and full day services
◦ ½ day program partnership is Generations of Indian Valley
Senior Community Center
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Services Bucks and Montgomery Counties
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Nursing services
Assistance with medication management
Activities focused on cognitive, social, sensory
and physical needs
Full noontime meal and afternoon snacks
Gentle physical exercise
Individualized care planning
Family Support Groups
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Souderton Adult Day Care Center will focus on caring
for individuals who face physical and intellectual
challenges, such as:
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Alzheimer’s Disease
Parkinson’s
Traumatic Brain Injury
Congestive Heart Failure
Stroke
Eldercare
Helpline
Senior
Housing
Adult Day
Program
In-Home
Support
Program
Saint
Monica
Eldercare
Program
Senior
Senior
Care
Partners
Senior
Clubs
Senior
Centers
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The Archdiocesan Senior Citizen Council (ASCC)
Approximately 75 senior clubs
Self-directed, independently incorporated
Approximate combined membership 7,000
Connecting
◦ Participate in Club fairs and meetings
◦ ASCC Newsletter: CHCS Health and Wellness
◦ Marketing availability of services and programs
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Funding
◦ Philadelphia Corporation for Aging
◦ Catholic Health Care Services
◦ United Way
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Philadelphia Locations
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North Central: Norris Square: Hispanic
Port Richmond: St. Anne: Polish
West Philadelphia: Star Harbor: African American
South Philadelphia: St. Charles: Chinese African American
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Participants are 60 + and residents of Philadelphia
Total impact: 5,338
◦ Daily attendance: 239
◦ Unduplicated seniors: 1,965 last fiscal year
◦ Information and Assistance: 3,373 seniors
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Program Focus
◦ Social Isolation
◦ Health and Wellness
◦ Food Insecurity
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Congregate meal (lunch)
Social programs
Recreational activities
Day Trips
Arts and Music
Consumer/Health Education
Programs
Spirituality Program
Physical exercises
(yoga, tai chi, dance,
aerobics)
Computer lab and
classes
Health Screenings
Nutrition Education
and Supplemental
food programs
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Food Insecurity Program
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Breakfast Program: 29,057 meals
Congregate Lunch: 56,393 meals
Commodities Boxes: 4,041 boxes
Produce Vouchers: 949 vouchers
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Nutritional Risk Assessment
◦ Pa. Dept. Aging nutritional assessment tool
◦ 255 new registrants tested nutritionally at risk
◦ 167 retested after 6 month
 47% improvement
 24% same
 29% declined
◦ Evaluating reasons for decline
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Enhanced Fitness:
◦ 307 classes
◦ 6,846 attendees
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Health Promotions:
◦ 1,876 classes/sessions
◦ 25,355 attendees
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Health Education:
◦ 569 sessions/screening
◦ 10,086 attendees
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Ask the Nurse Day
Memory Screening
Other Services
◦ Podiatry
◦ Glaucoma screening
◦ Falls risk screening
Eldercare
Helpline
Senior
Housing
Adult Day
Program
In-Home
Support
Program
Saint
Monica
Eldercare
Program
Senior
Senior
Care
Partners
Senior
Clubs
Senior
Centers
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No-fee Information and Referral Service
Managed through Senior Care Partners
Entry Point for Internal and External Services
Resource for community, professionals, and pastors
Eldercare
Helpline
Senior
Housing
Adult Day
Program
In-Home
Support
Program
Saint
Monica
Eldercare
Program
Senior
Clubs
Senior
Senior
Care
Partners
Senior
Centers
"Aging is not lost youth but a new stage of
opportunity and strength."
Betty Friedan (1921-2006)