Brenda Schmitthenner, MPA

Transcription

1 Brenda Schmitthenner, MPA 1

2 San Diego s ADRC implemented Care Transitions Intervention (CTI) in August 2010 Evidence based Coleman Model to coach, not do, using Four Pillars Establish and maintain a PHR Establish and maintain a Medication List Prompt follow up with specialists Recognition of Red Flags Building Better Health by building better systems- 10 year strategy in San Diego Improve care coordination and communication across healthcare and social service providers by virtual teaming Engaged community providers in TEAM SAN DIEGO training 2

3 Goals: To activate chronically ill patients to manage their chronic conditions through the PHR on the Network of Care Engage formal and informal caregivers in supporting chronically ill patients by communicating and coordinating care teaming virtually through the PHR on the Network of Care Activate patients to use the Network of Care site to locate services and resources, plan for their long term care needs and learn how to improve their health and wellbeing 3

4 URL Link: 4

5 Network of Care Website 5

6 1. Service Directory 2. Library 3. Assistive Devices 4. Links 5. Legislate 6. My Folder 6

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9 *Personal Health Record *Grant Visitor Access 9

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11 Patient Preferences Treatment Plans Health Maintenance Health Facilities Medical History Legal Documents Services and resources Self Assessments Family History Healthcare Providers Conditions Medical Devices Service Documents Notes Wrap 11

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18 Delays and challenges Contracting Equipment Target population Timing Opportunities to link technology into broader system changes: Beacon-Health Information Exchange West Wireless Health Institute Community-based Care Transitions Program 18

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20 Geriatric Resources for Assessment and Care of Elders Steven R. Counsell, MD Mary Elizabeth Mitchell Professor and Director, IU Geriatrics Scientist, IU Center for Aging Research

21 Unique Features of In-home assessment and care management by team of experts Specific care protocols to manage common geriatric conditions Integrated EMR documentation Web-based care management tracking Integrated pharmacy, mental health, hospital, home health, and communitybased services All Together Better Care 2

22 GRACE Team Care Model

23 GRACE Team Care 1. In-home transition visit and geriatric assessment by a NP and SW team 2. Individualized care plan using GRACE protocols 3. Weekly interdisciplinary team conference Geriatrician Pharmacist Psychologist All Together Better Care 4

24 GRACE Team Care 4. NP and SW meet with PCP 5. Implement care plan consistent with older Veteran s goals 6. Ongoing care management and caregiver support 7. Ensure continuity and coordination of care, and smooth care transitions All Together Better Care 5

25 Transitional Care Home ED or Hospital Hospital or ED Home Hospital Nursing Facility Home No Assistance Medicaid HCBS Waiver Specialty Care Primary Care Primary Care Specialty Care All Together Better Care 6

26 Transitional Care Communicate baseline status and care plan Collaborate in planning transition Deliver transitional care including home visit Proactive support of Veteran and family/caregiver Reconcile medications/provide new medication list Ensure post-discharge arrangements implemented Inform PCP and schedule follow-up visit Review in GRACE team conference All Together Better Care 7

27 GRACE Results

28 Better Quality and Outcomes High ratings by physicians for being helpful Better performance on ACOVE Quality Indicators General health care (e.g., immunizations, continuity) Geriatric conditions (e.g., falls, depression) Enhanced quality of life by SF-36 Scales General Health, Vitality, Social Function & Mental Health Mental Component Summary Counsell SR, et al. JAMA 2007;298(22): All Together Better Care 9

29 Lower Resource Use and Costs High risk patients in the GRACE program had: Fewer ED visits Decreased hospital admissions by Year 2 Lower hospital readmission rates Lower overall program costs Reduced hospital costs offset the program costs Counsell SR, et al. J Am Geriatr Soc 2009;57: All Together Better Care 10

30 High Risk Patients: Decreased Admissions GRACE 1000 Intervention * * 400 *P< Year 1 Year 2 Year 3 All Together Better Care 11

31 High Risk Patients: Fewer Readmission *P<.05 60% 50% 40% 30% 20% 10% 0% * 7 days 30 days 90 days * All Together Better Care

32 High Risk Patients Lower Costs GRACE Intervention $15,000 $10,000 $5,000 $10,700 $10,500 $7,500 $9,000 $5,100 * $6,600 $0 *P<.05 Year 1 (n=226) Year 2 (n=210) Year 3 (n=196) Intervention Usual Care All Together Better Care

33 Keys to Success 1. Created by collaboration of geriatrics and primary care 2. NP/SW team assigned by physician and practice site 3. Focused on geriatric conditions to complement care 4. Provided recommendations for care and resources for implementation and follow-up 5. Incorporated proven care transition strategies 6. Provided home-based and proactive care management 7. Integrated with community resources and social services 8. Developed relationships through longitudinal care All Together Better Care 14

34 GRACE Dissemination

35 GRACE Team Care Implementations Wishard Complete Care Indianapolis ADVANTAGE Health Solutions MA Plan HealthCare Partners Southern California The SCAN Foundation VA Healthcare System Indianapolis VHA Office of Geriatrics and Extended Care ADRC Evidence-Based Care Transition Programs ACA: U.S. Administration on Aging & CMS Tech4Impact: Center for Technology and Aging All Together Better Care 16

36 2010 ADRC Care Transition Grant ACA funding to expand ADRCs; GRACE one of four selected models All Together Better Care

37 Indiana ADRC Care Transitions Program A collaboration between Indiana FSSA Division of Aging CICOA Aging & In-Home Solutions, The largest ADRC and Area Agency on Aging in Indiana Wishard Health Services and IU Medical Group A safety net healthcare system (~7,000 seniors) Indianapolis VA Medical Center IU Geriatrics A John A. Hartford Foundation Center of Excellence in Geriatric Medicine All Together Better Care

38 Indiana ADRC Integration Model ADRC care manager assumes GRACE social worker role with GRACE team Identify HCBS waiver clients on admission Collaborate in discharge planning Provide GRACE transitional and ongoing care Assume HCBS waiver case management Patient centered care transition, better care coordination, and reduced readmissions and nursing home placements. All Together Better Care

39 GRACE Technology: Web-Based Care Management Tracking System All Together Better Care 20

40 GRACE Technology: Web-Based Care Management Tracking System All Together Better Care 21

41 Indiana ADRC Care Transitions Program GRACE Primary Care GRACE Primary Care WHS Hospital Transition Team CICOA Aging & In-Home Solutions VA Hospital Transition Team IU Geriatrics

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43 Technologies for Improving Post-Acute Care Transitions ( Tech4Impact ) Lynn Redington, DrPH, MBA Senior Program Director Center for Technology and Aging lredington@techandaging.org n4a Annual Conference, National Association of Area Agencies on Aging Washington DC, 17 July 2011

44 Today s Topics Background on Center for Technology and Aging (CTA) and Tech4Impact Grant Program Role of health technologies in reducing hospitalizations and promoting better care, better health, lower costs Presentations from 2 Tech4Impact Grantees 2

45 Today s Panel Lynn Redington, Center for Technology and Aging Program director The Tech4Impact sponsor Steven Counsell, Indiana Univ. School of Medicine A Tech4Impact grantee Brenda Schmitthenner, Aging Program Administrator, County of San Diego A Tech4Impact grantee 3

46 Established in 2009 with funding from The SCAN Foundation, located at the Public Health Institute Mission: Accelerate diffusion of technologies that help older adults lead healthier lives and maintain independence Independent, non-profit resource center on issues related to diffusion of technology for older adults Technology Diffusion Grants Programs, e.g.: Tech4Impact Diffusion Grants Program 4

47 Purpose of Tech4Impact Diffusion Grants Program Advance the use of technologies that improve care transitions and reduce avoidable hospitalizations Better care, better health, lower costs Home and community based support Better care coordination, patient engagement Information and communications technologies Avoidable Readmissions: 1 in 5 patients readmitted w/in 30 days of discharge 76% of readmissions are preventable $25 billion savings potential 5

48 Tech4Impact Grant Awards RFP released September 2010 January-December 2011 grant period $500,000 in grant funds Tech4Impact designed to complement the AoA/CMS ADRC Evidence-Based Care Transition ( Option D ) Grant to States 16 States eligible 12 applied 5 selected 6

49 Tech4Impact Grant Awards States Technology Approach Today: California Indiana Rhode Island Texas Washington 1. Personal Health Records & Info 2. Care Management Software For more information about the 5 grant awards, see: 7

50 CTA Diffusion Grants Programs Four in various stages of development 1. Medication Optimization Technologies 2. Remote Patient Monitoring Technologies 3. Technologies for Improving Post-Acute Care 4. Mobile Health Technologies 22 grantees: learning laboratories Lessons Learned, Best Practices, Tools Foundation for CTA mission and role Collaborate, Demonstrate, Educate, Advocate 8

51 To Learn More... Contact: 9