Transcript TITLE HERE - American Academy of Home Care Medicine

Improving Care for Older
Adults with Complex Needs
“There’s No Place Like Home”
Steven R. Counsell, MD
Mary Elizabeth Mitchell Professor
Director, IU Geriatrics
Scientist, IU Center for Aging Research
E-mail: [email protected]
IU Geriatrics
Disclosures
• Salary: Indiana University and IU Health Physicians
• President & Board of Directors, American Geriatrics Society
• Honoraria: Temple University, Health Dimensions Group,
North Shore-Long Island Jewish Health System
• Grants and contracts:
 GRACE Team Care Implementation and Training:
MetroHealth Cleveland, BCBS-Michigan, University of Michigan
Health System, Atlanta VAMC, and Cleveland VAMC
 IU CoE in Geriatric Medicine: The John A. Hartford Foundation
 IU Geriatrics Workforce Enhancement Program: HRSA
 Medical Director, Division of Aging, State of Indiana
Objectives
1. Identify unique aspects of geriatrics practice,
characteristics of who benefits most from geriatric
care, and clinical roles of IU geriatricians.
2. Describe effective models of care for older adults
with complex needs that include home visits as a
key component.
3. Discuss future directions and policy drivers for
the care of older adults with complex needs.
Geriatrics Healthcare Professionals
How are they different? When are they needed?
• Strive to optimize quality
of life and independence
• Use an interdisciplinary
team approach
• Integrate medical and
social care
• Provide services in
multiple settings
• Normal aging vs. disease
• Geriatric syndromes
• Multiple chronic illnesses
with functional limitations
• Care transitions
• Primary care and
consultation
Principles of Clinical Geriatrics
• Atypical and nonspecific presentation of illness
• Under-reporting of symptoms
• Communication issues
• Polypharmacy and adverse drug reactions
• Functional status
• Involvement of family and caregivers
• Level of care and housing alternatives
• Advance care planning and palliative care
Older People with Chronic Diseases
and Functional Limitations
• Need more medical services and social supports
• Geriatric syndromes (e.g., dementia, depression, falls)
• Socioeconomic stressors, low health literacy, limited
access and fragmented healthcare
• Have high healthcare costs
 Of community-dwelling adults 65 and over, the
20 percent with multiple chronic conditions and
who receive help in instrumental or basic ADLs
represent 40 percent of all healthcare spending.
Older Person with Chronic Diseases
and Functional Limitations
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Multiple chronic illnesses:
HTN, CHF, and DM
Geriatric syndromes:
dementia, falls, and ADLs
Family and caregiver support needs
Medicaid HCBS waiver case manager
Primary and specialty care physicians
Healthcare providers with limited geriatrics expertise
Poor continuity and coordination of care
Clinical Role of the IU Geriatrician
(The Nephrologist Analogy)
• Publish guidelines and teach about wellness and
prevention of functional and cognitive decline
• Consult and co-manage older adults having
geriatric syndromes in hospital and office settings
• Deliver primary care for elders dependent in ADLs
• Provide leadership for health system interventions
to optimize care transitions and care coordination
Proven Models of Care with
Home Visits as Key Component
Acute/Subacute Care
• Hospital at Home
Care Transitions
• Transitional Care Model
Primary Care
• GRACE Team Care
Geriatric Resources for Assessment and Care of Elders
• Home-Based Primary Care
Hospital at Home
Acute/Subacute Care
Patients
Model of Care
• Qualifying Condition
• Nurse assesses eligibility
• Physician evaluation in ED
• Patient transported home
(Diagnosed with certainty in ED
& low risk of decompensation)
 Pneumonia, UTI
 COPD, CHF, Dehydration
 DVT, Cellulitis
• Home Suitable
 Cleanliness
 Climate control
 Phone service
 Accompanied by nurse
 Take needed equipment,
medications, oxygen, etc.
• RN meets patient at home
and implements care plan
• MD visits daily
Hospital at Home
Acute/Subacute Care
Outcomes
Dissemination
• Fewer complications:
• VA Medical Centers
 Incident delirium
 Chemical restraints
• Greater patient and
caregiver satisfaction
• Shorter LOS
• Lower hospital costs
• Reduction in mortality
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Boise, ID
Honolulu, HI
New Orleans, LA
Philadelphia, PA
Portland, OR
• Medicare Advantage Plan
 Presbyterian Health Systems
Albuquerque, NM
• CMS Innovation Center
 Icahn School of Medicine
at Mount Sinai, New York
Transitional Care Model
Care Transitions
Patients
Model of Care
• ≥1 Risk for Poor Outcomes • APN hospital visits
 Standardized protocol
 Age 80 years or older
 Patient/caregiver
 Inadequate support system
assessment
 Multiple Chronic Illnesses
 Individualized care plan
 Collaboration with physician
 Depression
 Functional impairment
• APN home visits
 1st:48 hours, 2nd:7-10 days
 Hospital admits ≥2, 6 months
 Additional as needed
 Hospital admit past 30 days
 Fair or poor self-rated health • APN telephone contacts
 At least weekly
 History of nonadherence to
 Available 7 days
therapeutic regimen
per week
Transitional Care Model
Care Transitions
Outcomes
Dissemination
• Improved physical function
and quality of life
• Greater patient and
caregiver satisfaction
• Reduced hospital
readmission rates
• 344 unique replications or
adaptations (national scan)
• Fewer hospital days
• Lower costs
 Health systems
 ACOs
 PCMHs
 Home health care
GRACE Team Care
Primary Care
Patients
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Model of Care
Age 65 years or older
• Collaboration with PCP
Low-income
• NP/SW initial home visit
Established PCP
 Geriatric assessment
 Individualized care plan
High risk of hospitalization
(Probability of Repeated Admissions)
 Age
 Gender
 Perceived health
 Availability of caregiver
 Heart disease
 Diabetes
 Physician visits
 Hospitalizations
 GRACE protocols
• Weekly team conference
(geriatrician, pharmacist, and
mental health specialist)
• NP/SW home visits and
telephone contacts
• Care transitions
GRACE Team Care
Primary Care
Outcomes
Dissemination
• Improved quality of life
• Better quality of care
• High PCP satisfaction
• Reduced ED visits
In High Risk Patients
• Reduced hospitalizations
• Fewer readmissions
• Lower costs
• Eskenazi Health, Indianapolis, IN
• UCSF Medical Center
• Medicare Advantage Plans
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HealthCare Partners Medical Group, CA
Indiana University Health, IN
Health Plan of San Mateo, CA
Central Health Plan, CA
Blue Cross Blue Shield of Michigan
• Accountable Care Organizations
 University of Michigan Health System
 MetroHealth System, Cleveland, OH
• VA Medical Centers
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Indianapolis, IN
San Francisco, CA
Atlanta, GA
Cleveland, OH
Home-Based Primary Care
Primary Care
Patients
Model of Care
• Impaired mobility
• Comprehensive in-home
primary care services
• Interprofessional team
home visits
 Physical disability
 Functional limitation
• Inability to cope with clinic
environment
 Cognitive impairment
 Mental health conditions
 Geriatric assessment
 Individualized care plan
• Weekly team conferences
• Requires frequent medical • Frequent home visits and
visits to maintain stability
telephone contacts
• End of life and hospice
• Urgent care
Home-Based Primary Care
Primary Care
Outcomes
Dissemination
• Greater patient and
• All 139 VA Medical Centers
caregiver satisfaction
• 272 HBPC practices/non-VA
• Reduced hospitalizations
(national survey)
• Reduced readmissions
• CMS Independence at
Home Demonstration
• Reduced nursing facility
days
• Lower costs
Benefits of Home Visits
• Access to care improved and less burdensome for
those with mobility, ADL and mental health issues
• More accurate and complete information obtained
about the individual... “the rest of the story”
• Medications can be more thoroughly reviewed
• Living environment, social supports and safety are
more accurately assessed
• Stronger and more trusting relationships are developed
• Care plan better personalized to an individuals
preferences, capabilities and needs
Are Medical Home Visits Enough?
Lesson Learned from a GRACE Replication
• HealthCare Partners Medical Group, Los Angeles, CA
 Patients in high risk chronic care program
 HBPC model with MD, NP and social worker
 No geriatrics healthcare professional involvement
• GRACE Enhancements and Results
 NP/SW geriatric assessment
 Individualized care plan using GRACE protocols
 Weekly team conferences with geriatrician, mental health
specialist and pharmacist
 Reduced hospital, SNF, and ED utilization
Identifying Older Adults for
Proven Models of Care
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Multiple chronic conditions and functional limitations
Cognitive impairment
Depression
Low health literacy
Inadequate social support
Cultural and/or financial barriers
• High utilization of acute care services
• Lack of established primary care
Common Components of
Proven Models of Care
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Home visitation by physician and/or APN
Interprofessional team care
Geriatric assessment and individualized care plan
Special attention to geriatric syndromes
Integration of medical and social care
Implementation of care plan and follow-up
• Collaboration with patient’s physician(s)
Decrease work or burden on patient
Increase patient capacity for self-care
IU Geriatrics – Clinical Services
Eskenazi Health
• Center for Senior Health
 Health Aging Brain Center
 Geriatrics Consultation
 Geriatrics Primary Care
 Specialty Consultation
• ABC Medical Home
• Senior Connection
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ACE Consult Service
Extended Care Network
GRACE Team Care
House Calls for Seniors
IU Geriatrics – Clinical Services
IU Health
Indianapolis VAMC
• Senior Health Center
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 Geriatrics Consultation
• ACE Consult Service
 Methodist Hospital
 West Hospital
• SNF Network
• GRACE Team Care
Geriatrics Consult Clinic
GeriPACT
ACE Consult Service
GRACE Team Care
Home-Based Primary
Care (HBPC)
Future Directions
• Integration between home and hospital settings
• Integration between medical and social care
 Community-based organizations
 Medicaid Community-Based LTSS
• Integrated care involving Medicare and Medicaid
benefits for dual eligible enrollees
 Program for All Inclusive Care for the Elderly (PACE)
 State Option to Provide Health Homes for Enrollees
with Chronic Conditions
Integration Between
Home and Hospital Settings
Hospital Medical Care by HBPC Providers
• HBPC Program, MedStar Washington Hospital Center
 Physicians follow patients in the hospital and in the home
 Fewer hospitalizations, SNF days, and ED visits
 Lower total Medicare costs
ACE Plus GRACE
• Eskenazi Health, IU Health, Indianapolis VAMC
 ACE Consults by geriatrician/NP team with hospitalists
 Transitional care by GRACE team
 Reduced hospital readmissions
Integration Between
Medical and Social Care
HBPC and AAA Collaboration
• ElderPAC – Elder Partnership for All-Inclusive Care
 Penn’s In-Home Primary Care/Philadelphia Corp for Aging
 Serve Medicaid HCBS waiver clients
 Provide integrated care to emulate PACE
 Reduced hospital and NH utilization and total costs
GRACE and AAA Collaboration
• Eskenazi Health GRACE Team Care
 Partnership with CICOA Aging & In-Home Solutions
 CICOA social worker serves as both GRACE social
worker and HCBS waiver case manager
 Reduced hospital readmissions
Health Policy Drivers
• Value-Based Health Care Delivery and
Payment Methods
Bundled or episode-based payment
Accountable Care Organizations
Medicare Advantage and Special Needs Plans
State Dual Eligible Demonstrations
Independence at Home Demonstration
• Workforce Enhancement Initiatives
• Person-centered care
Take Home Message
Improving Care for Older Adults with Complex Needs...
Truly, “There’s No Place Like Home”
Outcomes are best using a combination of home
visitation and geriatric care principles.
Both geriatrics as primary provider and geriatrics
co-management models are effective.
Our time has come!... Home Care Medicine and
Geriatrics should lead the way in advancing the care
of older Americans with complex needs.