L.A. COUNTY COORDINATED CARE INITIATIVE (CCI) Stakeholder Workgroup

MEETING MINUTES Thursday, July 20th, 2017; 1-3 p.m.

The Braille Institute 741 N Vermont Avenue

Los Angeles, CA 90029 Call-In: 1 800-948-1333 Code: 927-006-849

WebEx https://care1st.webex.com/care1st/j.php?MTID=m5d8c00dac2f987ca9f05eacbd8cc0b82

TIME TOPIC PRESENTER 1:00PM- Welcome And Introductions Eddy Moreno 1:10PM

Eddy Moreno: Good afternoon everybody and welcome to today’s All Plan CCI Stakeholder Meeting. My name is Eddy Moreno; I am currently the AVP of Community Outreach & Enrollment for Care1st Health Plan. Really happy to be here today. It’s been definitely a few years of us meeting and it seems like a lot of familiar faces so very nice to see you guys again. We are going to go ahead and get started. What I will do as part of the agenda is the introductions but usually we don’t get an opportunity to touch base with the folks on the phone to the WebEx, so I wanted to kind of start with and my colleague here is in charge with the WebEx, so we’re going to go ahead and read off the names so that the folks that are on the WebEx, if they typed in their name as they’re logged in and called in, we’re going to start with the introductions and on the WebEx first and then will go around here and do the introductions in the room as well.

Rina Cruz: Acknowledged and announced attendees who are logged in via WebEx.

Eddy: Okay thank you, and one last thing for those on the WebEx, we will be putting you on mute, but you do have the chat function, so if there is any questions that you want to share with us here, Rina will be capturing those questions and we’ll be able to have them and play them on here and we will hopefully be able to answer them here today. Let’s start with introductions here in the room please. Attendees in the rooms announced their presence.

AVP, Community Outreach & Enrollment, Care1st Health Plan Dr. Greg Buchert President and CEO, Care1st Health Plan

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Eddy: The pause is because I really want to give an opportunity to a couple of new leaders who have joined our company, so I wanted to start off and give the introductions to our new Chief Medical Officer for Care1st Dr. Tanya Danski

Dr. Danski: Thank you Eddy and my contribution here in addition to being so excited to being a part of this group here are to introduce Greg Buchert who is our new CEO for care1st.

Dr. Buchert: Thank you Tanya and I’d like to thank the Braille Institute for providing us a great place for us all to meet and I’m here today as, number 1 a physician, and number 2 a proud father of a child with some significant disabilities and so we can put the empty, and number 3 as the very proud president and Chief Executive Officer for Care1st, the host of this even today. I can’t stress enough how important these type of meetings are and I had the good fortune to be a part of CalOptima when we launched one of the state programs serving dual eligible members and we also forced the philosophy of, while we may not be able to touch all of the members on a daily basis, we can touch, and most importantly listen to an respond to the individuals the care takers and the advocates and the organizations working with the dual eligible population and that the only way to get better is to constantly listen and constantly respond and constantly make sure there are forms to get that input. And so, I’d like to thank all of you for being here today for taking time out of your day to be here today and I’m very happy to be here. We have a lot of people here too. I did see a couple of folks David King from the legal Services decided to come in a little bit late and we are going to have a representative that is going to be speaking. And I'm Doctor Stephanie All Med senior community director services at La care. Hello I'm Araceli Garcia from CareFirst, Linda Luna also from CareFirst. Thank you everybody so we are going to go ahead and get started with our next agenda topic and next on our agenda will be Hillary Haycock president for Harbage consultant. She is here to give us DHCS updates.

1:10PM- DHCS Updates Hilary Haycock President 1:20PM Thank you Eddy. All right so just a very few quick updates today let's go over the enrollment update.

The June dashboard is on my CalDuals. We've got about a hundred sixteen thousand folks enrolled in Cal MediConnect Statewide and around 38,000 enrolled here in Los Angeles County and we are working on finalizing the July dashboard. No June dashboard and the data in the department systems that are going a little out of line. It looks like the numbers are holding steady for June so that's great. a couple of other updates folks may have saw this week the doors plan letters and opening letters on the HRA changes to create a new standardized questions for LTSS referrals has been posted. Those are finally final so we are really looking forward to working with the plans to get those implemented and make some certain criteria’s for the LTSS referral sheets with them. We’re continuing our best practices…with the Cal MediConnect plans is next in line and we are…has come up on improper billing practices assuming that the plans have been working on and we know that the Ombudsman have been

Harbage Consulting

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working on a very long-standing issue with the plan to launch. and starting to launch and we are starting to see some good signs out there around that and I just want to let you know that next we will have some of our friends at Justice and aging on that call with the plans as well as for our partners at CMS. the next best ... will be around these new HRA questions for LTSS referrals and how they make the plans understand the work group process behind them, really talking through the intent of all of those questions and implications and then we're looking forward to hopefully partnering with the UC researchers who have been really working on evaluations of the Cal MediConnect program to do some best practices meetings in the fall around reports all around the behavioral health integration. That one’s very distinct and I would encourage you to take a look as well as LTSS issues. I believe this morning we had a Statewide CCS stakeholder call. I know that just a few of you we're on that so don't want to completely go over all of those results. One of the researchers could not totally answer questions very well, especially on an airplane for half of the call. But they presented some preliminary data on the longitudinal study that UC is doing on how CalMediConnect and opt-out beneficiaries following the same cohort of folks over time and while it's very preliminary data they still want to do more analysis and there are a couple of points that we really think are encouraging and satisfaction Cal MediConnect emphasis is going up over time. There's some decreased emergency room use and there are also things that you know the department wants to take a deeper look at including unmet for DME and of course the second half of the presentation is forming around unmet need for LTSS which as folks know has been a focus on the departmental... Really connect folks with those long term services and supports they need, particularly this population, given their greater level of need. So those are my overall updates. If you missed the presentation this morning, the recording will be on CalDuals.org. We aren't Distributing the PowerPoint just because it still is preliminary data but more final in-depth analysis will be released this fall the scan LTSS conference. Are there any questions? No questions.

Dr. Danski: I'm helping with Eddy's introductions today so I would like to introduce Debra cherry who a lot of you probably already know. I got to meet her through reading her bio to prepare for this, very impressive I would like to say as a fellow Phi Beta Kappa who ended up being a scientist, I'm proud to introduce her as a USC graduate she also went to UCLA for her post doc, so not too many people who have gone to both USC and UCLA here in Los Angeles so I don't know quite how she fights with herself during Sports Seasons, but more importantly her work around health disparities and really trying to make some important differences in this population is very impressive so I'm very happy to be here to welcome her today to give us some more information.

1:30PM- Overview: CMS Dementia Informational Bulletin for CA. MMP’s Debra Cherry 1:45PM Well you know this feels like my home group. I spent so much time with the folks in this room that you

guys gave started becoming my friends as well as my colleagues and so I'm really pleased to be here and be able to make this brief presentation the aforementioned Bulletin that was recently released by Department of Health Care Services go deeply into it, let me say a few words about the prevalence

Executive Vice-President Alzheimer’s Greater Los Angeles

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cost equality care people with dementia receive. And just briefly you can see that there are about 5.5 million people with Alzheimer's disease or related disorder in the United States. More than 10% of them live in the state of California and probably about 5% of them live in Southern California which is pretty remarkable actually, so we have over 600,000 in the state of California in LA County have 177,000 people with Alzheimer's disease related dementia. That’s the population of about Fort Lauderdale Florida. I used to say that these are equal opportunity diseases and I no longer can say that because the data has come up and it shows that Latinos and African-Americans have a higher incidence and prevalence of the disease and there are a lot of reasons for it. Today is not my day to do that talk. So we know that about 10% of people age 65 and older have the disease and about 35% of those 85 and older. But amongst the duals it’s about 23% of the duals 65+ population. And you ask why would the duels b you know, so disproportionately affected by these diseases. There are a number of reasons for it. Part of the reason is that they have lack of access to quality healthcare; there are socioeconomic reasons off the bat as well as cultural reasons, immigration reasons linguistic reasons. Also they have high levels of chronic health conditions and as you can see from this light, people with dementia also have rates of chronic patience. I don't need to have to go through them one by one you can see but notably about 60% of people with dementia have hypertension today we were on a webinar some of us, listening to a webinar put on by the state on what causes a lack of access to long-term services and supports and it was interesting that they noted that people with dementia, are less likely to get In Home Supportive Services and you think, oh my god the guy said, if you're from a wealthy neighborhood maybe you don't, maybe you get more In-Home Supportive Services because you have a better advocate. And I would say, if you have dementia, maybe you get less in Home Supportive Services because you don't have a good advocate. I know that when social workers have In Home Supportive Services come to the home, homes of the families that I work with, those families clean up the house, get all dressed up when they're asked if anything's wrong, they say oh no nothing's wrong I'm fine, nothing wrong here. And so I think that there is a problem, a barrier in getting home & Community Based Services, long-term services and supports, in particular In Home Supportive Services, to this population and as the guy today says what the gentleman who is your spoke about today, as a result they have more instrumental activities of daily living, they don't manage their medications well, that means they don't manage their medication for all these conditions wrong. And they are more likely to be housebound and that was the researcher hired by the state and by SCAN Foundation talking about it today and I don't think the pieces got pulled together. I hope that they will I'm going to talk to the researcher tomorrow and I've already gotten emails from San Diego's In Home Supportive Services department, I mean, just a little bit of interpretation. So this going to cost very expensive. you're not even concerned with their quality of care, take a look, you see that they cost MediCare 3 times more than other Medicare beneficiaries, but when you publish this, they costing Medicaid 19 times more than other MediCare level, Medicare aged beneficiaries on Medicaid. Now that has gone up to 23%. Cost are driven Medicare by hospitalization and re-hospitalizations and more

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hospitalizations. And for Medicaid it's often by nursing home placement and a few of these folks are the folks costing a fortune and not getting good quality care. I know a lot of you have already heard me say this. If you ran your ICD - 10 codes you'd find perhaps a forth of your people amongst your membership who has the disease, because half of the people with Alzheimer's related to dementia never get a diagnosis. And half of those the diagnosis doesn’t get it documented in their charts, and the families don't feel in control that the family member is going through this... There is a lot of stigma in here come on it. So what are the implications for the health plans? Through our informational Bulletin, one thing is that, if you serve people aged 65, you're probably serving people with dementia many people won't have, don't have a diagnosis so you're not so, and the first step is, taking a look at ICD-10 cost and see how many people do have a diagnosis and multiply to figure out how many are likely to be there. Because people are not being diagnosed they are not getting the proper care and they may be getting actually anti-psychotic medication that can be very dramatic for them. If I were to do it step-by-step I would... ICD-10 codes and say these are people with one of these dementias I'm happy to send ICD-10 codes to anyone here, and then I would say, okay that population, have we identified family caregiver?…Because people we haven't we have an extra problem with the contractual requirements of that that we face here in California,...contracts between Medicare and Medicaid and between CMS and the Department of Health Care Services and each of your plans say that there will be specifically designated coordination Care staff in dementia Care Management. And every one of your plans has specifically designated care managers who are dementia Care Specialists. Quote-unquote that is the language that comes from the contract. These are people who have the kind of expertise you see here on the slide, they understand dementia symptoms and progression. they know how to manage challenging behaviors and talk to families about how to speak and understand their loved one they provide support to caregivers and they can coordinate Family Resources the fact of the matter is, that while everyone in the health plans in this room has a dementia care specialist, not one of the health plans in this room systematically assigns people with dementia, even if they have high levels of risk and high levels of utilization, those people are not systematically going to dementia Care Specialists, and that's something that we can all approve on. The contract requires that everyone's Workforce is trained in dementia and I give kudos to all of you. People in this room have really tried hard to get everyone trained. There is also an effort to be online trained because project goes for a while longer, but not forever and you probably will be serving people with dementia weather in Cal MediConnect or in your other lines of business for a long time. And so we have some online modules you can adapt to your needs or develop your own and the three-way informational bulletin says that you need to provide regular dementia training opportunities, especially given the tremendous turnover in the plans. It also says that screening is required as one of the health risk assessment components. I'd also point out that there an annual Wellness physical for older adults and cognitive screening is a part of that as well. Again as I said before don't assume that the people who have ICD - 10 codes in your system are the only ones with dementia, there are others going to be there. And so what are some of

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the opportunities that I haven't mentioned already? For...care? Fun way to think about this is, maybe if we have been using the strong language, as my colleague Deborah Schlessinger said this to me, 'Maybe we should be talking about complex Care Management for people with dementia, instead of dementia Care Specialists getting a sign these patients. so I think what we need is, we need to build a system, a complex care management system that leads to better detection of the disease that leads to Better Care Management of their/your beneficiaries with dementia. That builds better relationships between your help providers, your family caregiver. Think about that if you give someone that prescription... And feel the need to take this one 3 times a day and this one 5 times a day.. Is that going to be your beneficiary with dementia it probably will be your family caregiver. They are the real backbone long-term services and supports. It's not In Home Supportive Services, it's those family members and whatever we can do to support them, you're going to have better health outcomes and you're less hospitalizations when you're single placements. Good Complex Dementia Care Management will also mean better Partnerships with dementia specific community based organizations in our counties, Los Angeles County came from Riverside San Bernardino that will be working with Alzheimer’s Greater Los Angeles and there are other organizations in other part of the state that do the same kind of work. And yet we see there are barriers to making a referral. I believe that in 3 years of advocating for referrals and giving plenty of people Alzheimer’s director forms; these are forms that ask the family if they can be called by us. In this last year, I think what? 87 referrals 79 throughout the CMC health plans Los Angeles. 79 referrals. Offering free supports disease education. Think about of a way to include us in your complex care management system. Because we are there to provide help to these families. There are many opportunities to integrate dementia care in two systems of care. We have the training modules I mentioned, to help people develop the processes for dementia care specialist on complex care management for people with dementia. We need to have technological integration, of a validated cognitive screen and maybe a caregiver name assessment and I'd say again, kudos to a number of the plans in the room. There are three plants in this room, working on taking their e Medical Management Systems and try to include a couple validated cognitive screening the, the name of the caregiver and a screening test to see what the needs of the caregiver is. That's way ahead of the country and its really terrific and it embeds what we're trying to do in the system so that, if you leave you job and go health plan, the system is going to stay there, even though your personal Commitment and knowledge moves on somewhere, so that's really something we can all work on. Quality improvement, there is a health plan in this room that bought it, it's Care Management to see if it's doing what it's actually recommended. That’s part of their performance evaluations. and of course we recommend that you think of picking making more referrals to us we are happy to work with you, help you integrate your requirements and recommendations of the informational Bulletin I guess that's all I really say today because I think that our panel of people with the disease and caregivers will say so much more, so let me introduce my partner-in-crime Jennifer Schlessinger and she's going to take over from here. Thank you.

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Panel Presentation: Caregivers and Member perspective on Dementia Jennifer Schlesinger, • Carmen Vazquez MPH, CHES • Kim Ridley Director, Professional • Alicia Gonzalez Training and Healthcare • Malcom Cross Services, Alzheimer’s • Gurteen Taylor-Schiavo Greater Los Angeles

Jennifer: I'm going to welcome our panelists to come up and join me here. Kim, Gurteen, Malcolm, Alicia, I think I'm going to sit in the middle I think. So as Debra said I'm Jennifer Schlessinger and I have been working on the Dementia CalMediConnect project and have the pleasure of sitting here analysts today. So I just want to acknowledge that fact that all of our panelists here today are in the throes of this disease Journey so to speak. All at different stages this process and just coming to speak to you today takes an enormous amount of logistical planning especially when you care for someone who has this disease who needs 24/7 supervision, not to mention sharing their personal information, it certainly has a personal connection as well. so what I'm going to start is I like to introduce our list, sitting here to my right is Alicia she is in her sixties and cares for her two cousins with dementia cousin Martha is in the late stage of the disease. She is non-ambulatory nonverbal incontinent and needs helping fed. Martha has diabetes high cholesterol and some kidney failure. Donecio, Martha's husband, who is here today, thank you for being here. Is experiencing memory problems himself, they live alone I fixed income and are barely able to pay for rent food medical supplies and medications. They have one twin bed in the house and Alicia was sleeping on the floor because they need to sell their furniture to pay for food. And Donecio leave the house sometimes leaving Martha alone to collect cans to supplement their income. Alicia spent hours helping her cousins get approved for Medi-Cal, and will Martha was approved for Medi-cal only a year ago, Donecio is still waiting for a county social worker to contact him. IHSS just started a few months ago and they receive four hours of IHSS a day. Alicia takes her cousins to appointments, fills out paperwork regular to check on things and she as our own health issues and family to care for. Most recently Alicia has been dealing with Martha's insurance not covering the cost of appointment, the supplies needed to check her blood sugar, the incontinent supplies and medication it's been two months since Martha's blood sugar has been checked at home and their medications have still not been filled. Carmen cares for her mom with Alzheimer's, and bow Carmen saw signs that concerned her who was told that this is a “viejito disease” and that her mom was too young to have it. Carmen's mom has several challenging Behavior such as accusing Carmen of stealing saying that her husband is cheating, throwing tantrums so to speak and not sleeping at night.

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Obviously these can be very stressful to deal with and Carmen experiences her own caregiver stress and burnout. Carmen has been attending support groups for about three years and attends Alzheimer’s greater la caregiver in East LA. Okay and now to my direct left is the primary caregiver for her 87 year old mom. Kim's mom lives alone and is in the early stage of disease and among many responsibilities, Kim pays the bills, gets mom to medical appointments that's often challenging because her mom has hard to get out of the house as these appointments can take 3 hours or more. Kim was connected to our organization through Alzheimer's connect. Referral was made by her health plan, resulting in and her family receiving disease education and being connected to social workers. Gurteen, is 74 years Young, and started having signs of cognitive impairment when she was diagnosed with dementia when she was living in North Carolina and then 2013 move to California to live with her son come who is also with us today. Malcolm cut back working full time to be for his mom, leading to some significant financial strain. And the disease it's also led to some relationship strain as well for Malcolm. So can we all please welcome our panelists for coming to be with us today? I'm going to structure questions around the three goals of our dementia Cal MediConnect we are going to talk about disease prevention and management. Issues related to care giving and relationships with community-based organizations. so our health plans were asked in preparation for this meeting to run their iCD-10 codes so that you can identify how many members you have with this disease and the event that you are unable to run your data, I did take the liberty of doing some number crunching on your behalf, so according to the prevalence as Miss Deborah provided and the number of CMC members in La over 65, I'm estimating that they are likely over 6100 CMC members in La who have Alzheimer's disease or dementia so as you are listening to our panelists please think about how they represent thousands of your members. So I'm going to start with Gurteen. And ask you around the diagnostic experience can you share with us, what some of your early signs of dementia were? And what finally got you to the doctor?

Gurteen: At that time I was living in North Carolina, Malcolm was living in Los Angeles, my daughter was living in Maryland because she has a grandchildren, I'm almost you know a grandma so I really found a lot of comfort my grandchildren and on this day I decided to drive to North Carolina to go see them. And I usually wake up actually at night how long trip, it was dark and quiet, and hit the busier areas when he was just starting to get busy and I could just sit through traffic. But this particular night, I got pitifully lost untangle myself, could not understand what was happening, after driving about maybe four to five hours I decided to pull off 7-Eleven and just get a Coke two kind of pick-me-up sugar, which is bad for us, so that I could get to where I needed to be and just to reorganize. I blamed it on being tired, so after doing this I started out again and trip would usually took Maybe, about 7 to 8 hours, I did not arrive until almost, a long time. My daughter was panicked, and she looked at me reason she couldn't tell written across my forehead was her mom has got something going on so the process between my children started of having me being diagnosed. When I was it was such a gentle diagnosis that after, I was just about to leave the doctor's office and I could not quite understand what

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was going on. And so I looked at him, and I said, “What is this all about? What is it that you diagnosed me with?” And he looked at me and said, “Alzheimer’s.” And I left just crushed. My father had the disease, my grandfather had the disease, I have it, and that was the start. Malcolm came and got me, he quickly came and got me, wrapped his arms around me, which gave me a lot of support and security, and took me to Greater LA.

Jennifer: So Malcolm piggybacking off of that, do you think your Mom's doctor would have easily seen the signs?

Malcolm: In the office? During a regular visit? In a regular checkup what time my mom. at that time, my mom had implemented numerous tool for her to manage everyday life, lots of calendars multiple GPS's that drove me crazy. When I came to visit because I always knew it's going but she needed five to get to the same store. I don’t think he actually had a view of her regular day life, my sister bringing her to the doctor, she explain to all the symptoms the things are happening to her, and then he had a scope of what was going on with her.

Jennifer: So it sounds like your sister played a very important role in filling in some pieces for that diagnostic experience.

Malcolm: My sister is a doctor and has multiple friends that are a doctor, so my mom arrived at her initially after being lost. She called some friends, goggled and she researched, she is a total scientist and um that's how it went.

Jennifer: Carmen, can we turn to you and I wanted to ask your mom it was diagnosed when she was 65 what was your experience getting a diagnosis for her and why was getting a diagnosis so important for you to get for her?

Carmen: I wish my experience would have been as wonderful as yours, unfortunately my mother had several Strokes prior to Her diagnosis and I see my mom kind of getting lost and telling me stories I knew had told her what to do she's smart woman. She has always helped father with his construction company and no the language despite the fact that she doesn't speak it so much but she will understand everything that was going on and I saw my mom going downhill and the experience was that I told her please don't cut my son's hair, and she did, despite the fact that my 70 year old nanny told her not to do it before and I kind of just looked at my mom and I was like, “What is going on with you mom? You always respect my space and what’s going on?” And I kept on going to the doctor's and telling them that my mom is losing something, that she not following through with instructions. They kept on telling me well, it's the late effects of the strokes. And I would look at them and go okay, show

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me the damage on the MRI you're telling me there is no residual nothing on her MRI strokes, why is my mother losing her mind? And they said, well we are going to submit it can ask for a referral, that referral came a year and 4 months later. When my mother had already had Medicare and a different doctor. So bottom line is, for me, it was a very bad experience, it took a long time and I wish it would have been better because it would have represented that I was able to file for Social Security and she would have been able to get Social Security and now that she is getting it at a later stage, we would have had the financial to be able to give extra help, and not deal with all of the burden that is coming our way.

Jennifer: Thank you Kim I know your moms primary care provider referred her to a memory clinic for a full diagnostic evaluation. What was that experience like, kind of having that integrated approach?

Kim: I come from a family of seven, and I started noticing our mother forgetting things. All of her children she remembered, she remembered her mother and she remembered everything but she would forget the date, she would forget if it was Monday or Tuesday and what's the date and she kept repeating it. So we went into the doctor have her checked out, and we didn't think Alzheimer's, we just thought she's 86 years old and she's getting older and getting older and getting a little memory loss as we all probably will. So at the time, the doctor went on, she is very healthy, except for that arthritis and fibromyalgia, which is very painful, so it is very painful but other than that she is healthy no kidney problems no hypertension, nothing else going on, so the doctor said I'm going to refer her to a memory clinic. She asked her a couple of questions and because you don't have a history of my mom she answered them correctly, so at the memory Clinic (…inaudible) I'm going to hand you a piece of paper, I want you to fold it and place it in your lap. Well, they said I'm going to hand you a piece of paper, take your right hand and put it in your lap. She picked up the paper with her right hand and the second thing, she couldn't remember what to do, so they said they think it's early stage Alzheimer's and that had their brain scan to rule out if she had a stroke or not, so she did not have a stroke. It actually was dementia, and on the third visit, it all took place within a month thank goodness it didn't take a year-and-a-half, but it took just a month and they did identify it as early stage Alzheimer's.

Jennifer: So these are probably good examples of service delivery when it's streamlined and integrated, how much more effective it could be with the diagnosis experience. I want to ask a few questions around the care management experience and care coordination and as Deborah mentioned, the 3-way contract that stipulates that the health plans have specially designated care coordination staff and dementia care management. And so has our panelists share with you their experience in relation to care coordination and Care Management, I like all of our stakeholders and help on colleagues to consider dementia care specialist who is actually assigned to two members with cognitive impairment could possibly be more effective in managing care and streamlining Services

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delivery so I'm going to turn to you Alicia and ask you, I understand that Martha has diabetes, and has not been able to get equipment, supplies, and medication, can you share what has been going on?

Alicia (translator): That's what I don't understand it's going on it's because when we went to about we're not able to get all the necessary items that we need, we did get the strips or we can't get the machine to monitor her sugar. And that's what makes me very anxious because I'm the one that's fighting for her fighting here and fighting there and if she could speak, she would probably be different but I'm the one doing it everything so finally yesterday I was able to get the machine to check her sugar. I also ask the doctor if he could fill out some paperwork so that I can get nutritional food for her, and he said he couldn't because he didn't have the information necessary. Also when we go to the pharmacy to pick up the prescription, they tell us that the doctor denied the paperwork, and so we go back to the doctor and he tells us that they did, so it's just going back and forth and we never get a straight answer.

Jennifer: There was also, I know a recent experience where the doctor did some blood tests and you needed to get the results from the blood test, what happened with that experience?

Alicia (Translator): One time they wanted to do lab work on her that the doctor denied the order so when I went to get the lab work done they said that I didn't have the orders so I had to wait for the next doctor's appointment, I finally got the water and took her to get lab work done and then they called us to say the results & were ready and I didn't want to go out that particular day because it was very hot, it was three at the afternoon, so I went myself to get the results and when I get to the doctor's office, they say that they needed Martha to be there to give me the results, so they would not give me any information. Told that I need to make another appointment and bring Martha with me, otherwise I would not have access to those results.

Jennifer: How easy is it for you to take Martha to her appointments?

Alicia (Translator): Very hard because we have to take the bus or we have to walk.

Jennifer: Malcolm, going to turn to you now and ask you, can you describe a typical doctor's appointment with Mom?

Malcolm: There is nothing typical about going to the doctor, or my mom. Every one of the instances are individually challenging in a sense, there is always and anxiety that builds from the night before. I think my very first experience being diagnosed with dementia put her in a state of shock and so every time, it's beautiful the things that she can recall, but she goes back to that all the time, initially so we

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have a pretty solid doctor, but no doctors are really busy, and overwhelmed, so he has 20 minutes to talk, and if you go over the 20 minutes, there is a buzzer in the room and that buzz's, so he is in a rush, she's feeling anxious. so it's about being in the room, balancing my mom, keeping her calm, and also being really clear and concise with our doctor, making sure the information that she wants to know is explain to her, I guess you can say repetitively so we can recall it, first, they did not get along because our doctor was super busy, and did not have the capacity to slow down. Then we started booking double visits, just telling him that we needed 40 minutes and it got better after that eventually and as the relationship built between him and her I believe that it did he was of Greater service as much as he could be.

Jennifer: Does he have anyone on his team so that if you have any follow-up questions or need to go over information?

Malcolm: He does have an assistant and it started off really good with but as time has come to pass she has become a little laxed in returning phone calls and we going for test and we are wondering two weeks later what the results were. Well, if there was nothing in the results that would still is good to know. Because like I said my mom hangs onto these beautiful nuggets of information, and meanwhile we go to the doctors and she is stressing about the results and even if it is nothing she's still stressing. Going back in is a significant of time and effort just to get dressed and to go follow-up would be really appreciated, which is really not easy.

Jennifer: Malcolm, when we spoke, you said something that really struck me, you said you cringe when your mom sneezes, why is that?

Malcolm: I think I said I cringe when I or my girlfriend sneezes, and it's because I can deal with cold or a flu and so can my girl, but my mom has this thing where I am her caretaker, I am her son, she is my mom that dynamic in itself makes her not want to ask me anything it exponentially multiplies any problem because she doesn't tell me about it she basically falls over or doesn't get out of bed for 2 days, so when she coughs or sneezes it makes me wonder how long has she had this going on without telling me and the second fear of if I know have to call our awesome doctor, getting there, sitting with him and have him go through another list of elements that might be wrong, my mom is looking at him like he is crazy, he's looking at her for the right answer, and it's this really complicated jigsaw puzzle. Don't let it be on Friday, because then paranoid that she is going to be all weekend long illness. And so to fight those things off really be observant. And that is why it's a big deal to me

Jennifer: So Gurteen, as someone living with Alzheimer's what is your greatest challenge with the Healthcare System?

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Gurteen: You know, it's I am from a generation when you have no Health Care system you have a doctor little hard to overcome, sometimes finding the right person to do the right thing difficult, um, for the right service rather. I had a doctor and I just called, and he knew it was wrong. so now I have to go through the whole system, to me it was difficult and I'm glad I don't have to deal with it, I just complain to my son and he has to deal with it.

Jennifer: Carmen I have to ask you, as I mentioned in my intro, your mom has had some very challenging behaviors that have been stressful to deal with, what education has your health care team given you to deal with these behaviors?

Carmen: Some brochures. When I would ask for stuff, they would well I gave you some information right? And you reach out to these people, wonder why you can't just walk into the doctors and they down and talk to me and send me to a class where I can get the information and not have to drive around the whole world to knock on doors to try to find educational information for me to be able to do with it. Really done very much in regards to training. And I know that they don't most of them don't, been with a couple of the…my mom has been with several of them and they don't even to leave a Jeanette, reliance the resources of outside agencies like Greater Los Angeles profit organizations I really hard sometimes to find or get more information on where to go.

Jennifer: So I want to turn a little and talk about some caregiver issues 103 taking care of somebody with Alzheimer’s has severe depression and rates are very high as far as experiencing anxiety as well. Malcolm you spoke a little bit about that. As you know caregivers are often not identified nor assessed for their own needs. And without our family or friends or caregivers, consider how your members could sustain community. So common I'm going to go back to you, you were recently hospitalized. Do you mind sharing what happened to cause the hospitalization?

Carmen: Dealing with the stress of watching my mom and my own children that have autism. and getting their care and what happened is I got overwhelmed and I ended up in the ER stroke symptoms and suck my body was trying to, half of my body was, I thought I was, and they thought that I was having a stroke it turned out it was just stress. It's kind of hard sometimes, just dealing with it

Jennifer: So when you were discharged, what was put in place to help you so that you would not end up back in the ER for stress?

Carmen: Told me to reach out to my primary doctor which typically takes me about 3 weeks to get to see my doctor go home and rest. How can I go home and rest? With my kids? And my mom? I'm a mom and I still have to go to work, I still have to go drop off mom because we can't afford to provide a

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caregiver. For her. Classes at least $30-40 an hour.

Jennifer: Malcolm, can you give us an example or two, of how care giving for your mom has impacted your life?

Malcolm: Caring for my mom has impacted my life in a multitude of ways I mean like we can all go down the road of all the sad stuff that I've been less focused on my career, and just hustling jobs to survive, relationships have gone marriage has come and gone, finances, blah blah blah. I think that diving into that that space of loss is service for me being present as a caregiver for my mom so I do my best to not to wallow in that space, and the benefits are really sitting a place for gratitude for being able to provide a living space in the sunshine for my mom these years of her life and knowing that that's of value. Because everything else comes and goes I have new relationships, better friends now that are showing up to the village is actually developing, thank God and dialed into certain places and I cannot say enough for Alzheimer's Greater Los Angeles, for all of their support we have gone for you guys I'm only sitting on this panel because of you. I am not kidding. we have been to Washington DC, we have been invited to so many other places and ripping off this Band-Aid for a wound that does not heal is not good at all okay so if I feel the call to come and be of service, here I am. It has been challenging and we can definitely use support, as caregivers.

Jennifer: Malcolm, has a doctor or a care manager ever asked you how you are doing or how they can support you as a caregiver?

Malcolm: I was actually thinking of this earlier. my Mom's doctor dr. t one day I was in the office and he asked me how I was doing and I was so shocked that he I don't know I didn't think he was talking to me so I said what, and he said how are you doing. I told him I was stressed financially overwhelmed, and I'm feeling underappreciated and overworked underpaid really tired. and he looked at me and the look on his face, he did not expect for me answer him I think everybody says I'm fine, exactly what you said earlier, everybody says I'm fine, so I gave him the truth, that's what I do. He looked and said, Gurteen? Because he already knew that he was in it, with my mom. I think that was the one time anybody's ever checked in, I mean besides people at Alzheimer's Greater Los Angeles

Jennifer: Alicia a question for you if you could no longer care for cousins, what do you think would happen?

Alicia: I have no idea what's going to happen to her and she kind of glance to him, because the husband she can't take care of them, she has no idea what is going to happen to them. Neither of them have kids or other family. And they do not know how to search for help

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Jennifer: Alicia, has a doctor care manager or social worker ever ask you how you are doing and how they can support you through this process?

Alicia: I have my own social worker at my own doctor but they have no idea what I'm going through, kids don't know this for me to take care of these people and nobody has ever asked me except one from La Alzheimer's. Juan has been the only person that has asked how am I doing. He has also helped with their rent and him and his friends are the ones that had given me a little rent.

Jennifer: And you have said that you have been offered respite? As well? Alicia: Juan has gotten her a person to give her a break 6 hours so she can relax a little bit

Jennifer: So I want to transition a little bit to talk about community based organizations providing an array of services often at no cost. Our organization service LA riverside and San Bernardino counties. And we have social workers who have that dementia expertise. Alicia just referred to Juan Seveedra. He's one of our social workers who receives are owls Direct Connect or handoff referrals who is able to proactively reach out to families. I see my colleague Donna is hear from USC family caregiver resource Center and so there are organizations that are in our community to help serve the needs of families Kim I want to turn to you because many families are not connected to services & supports until later in the disease process and your family was connected quite early through Alzhs door connect. Can you share with how connecting to the organization has impacted you and your family?

Kim: Yes we were connected within the first week or second week of our diagnosis. Juan called me as our case manager and we were overwhelmed. I allowed time for my siblings to digest Her diagnosis because everyone accepted it at different stages the health field so I did not want to bombarded them with websites and paperwork, so I gave them a month or two because it was right at the time of her 86th birthday, so we took April and May off and everyone just loved on her, and after that, Juan was in touch with me via email have him come speak to the family. I'm the youngest of 7. Well there was 10 of us, but I am the youngest of 7 knew something was kind of going on with her a few years earlier and put me in charge. And so I had Juan and some of his colleagues come and visit the family and let them speak directly to my siblings because now I'm dealing with not so much her disease, they understand that but it's the inviting of the siblings of what they say should and should not be done. so Alzheimer's greater La came out to speak with the family, they provided us with resources whenever there is a walk, whenever there is a big early member last form at the Getty Center, so my family attended and we were able to see that we are not in this alone. And that everybody different levels economic educational level and I think that gave them an understanding that we have to be her eyes and her ears and we have to love what's left of her begged her to be even though here is a mother we have to love her wherever she is at every stage. The memory clinic at our health plan is very helpful but the kind of

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handed us off to Greater Los Angeles Alzheimer's, and I felt a little bit more comfortable to talk to Juan, but if I have a medical concern or need to call them, they are right there as well so actually I feel blessed to have two resources and not everyone best place to have two resources help them navigate this, in addition to seven sisters and brothers to fight with.

Jennifer: Carmen you’ve been attending a support group for a few years, can you tell change from going to a support group?

Carmen: I think the first thing is knowledge, because it's a very challenging thing and listening to other people and knowing that your parents are not at that stage, but understanding some of the warning signs prior to that behavior, or listening to some suggestions, it helps a lot. Even though I don't have the support from all my brothers and sisters, because they don't want to go or some of them are still in denial and others are accepting and they think they're going to change more, it's helped a lot. It's given me some relief and someone to speak to that understands exactly where I'm at, because they’ve been there and sometimes they're in the stage that I've already been and passed it is a relief that I can be of service to someone else and give that support that I once needed when I walked in the door. When I walked in the door, I was overwhelmed and I could not handle it, I was about to lose it. It was 4:30 in the afternoon they were about to close the door, and I walked in and I was like, I need help. And my mom is there and my younger sister was there with me and I was like I need help, I cannot handle this, you know, I don't know what to do. I know what her diagnosis is and I’ve been yelling, screaming, telling her doctors what her diagnosis is. I need to help and you know it just gives you that benefit that real good feeling do you know what it's not as bad as you think, it's the end of the world like when you hear someone else tell you going through it or that there what you're going through, it gives you a blessing and it makes you feel like oh my God I am not the only one in this boat, there's plenty of us in here

Jennifer: Thank you. Gurteen, what has been the most helpful resource to you in dealing with this disease?

Gurteen: I really believe it's Alzheimer's of Greater Los Angeles. I have a doctor so I didn't have to look for resource there but it gave us he gave me a sense of togetherness when we met as a group. Alzheimer’s patients and talked and shared about our accomplishments and our tires in our tribulations sorrows, but also we shared a lot of happiness together just knowing that that I was talking to someone who is experiencing the same that they were talking about and understood. So it was just collaboration was the love that we gave to each other get from each other

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Jennifer: Malcolm what has been most helpful resource to you in dealing with this disease?

Malcolm: I hate to jump on the Alzheimer's Greater Los Angeles train but I have to they won my girlfriend at the time who was in healthcare you sourced you all out and it was nice to be able to be in a room with people who authentically, I felt, cared what was going on. but also reversed that was about to happen, gave me some insights and just Honestly, by the point that I got there get to listen I had taken so much on I really didn't have a whole lot of people to talk to or to share thoughts feelings or concerns, and so at the time it was just nice to be heard, and then resources were offered and programs were offered and support, I can't tell you how much it meant to be heard period for our individual stories which it is individualized, to make it personal it was that's happened

Jennifer: And let me just ask Alicia, what has been provided to you and your family that has been helpful? Alicia (Translator): The only help that we have had as one and his co-workers that organized and helps and until now that is the only help that we have received, the Greater Los Angeles Alzheimer's.

Jennifer: So I have a lot of other questions I like to ask, however I do want to open up to all of you to ask some questions before we ask the hell plans to answer some specific questions that were distributed before this meeting. So are there any questions from people in this room that would like to hear from members and what their experiences have been, to hopefully improve systems of care and make them more dementia capable? I guess I just hit the nail on the head with my questions. Anyone?

Attendee from audience: I have a comment. You all are to be commended for the greatest and what you are going through with the disease and also for those of you that are caregivers, you are doing phenomenal, you are giving a phenomenal gift family member and you are to be commended for that.

Jennifer: So if there are no questions right now, what I am going to do is, I want to open it up to our health plan Partners, who were given some questions before the meeting share out some of the work that they have been doing and certainly if we have time and if our panelists have any questions for them, I think that would be appropriate as well, so the three questions that were posed prior to this meeting the first was given the unique cognitive behavior and functional needs of people with dementia and the high rates of coexisting conditions, what is your plan doing differently to managed care for people with this disease clearly it's not a business as usual disease, and how are your dementia specialist being used to the needs of members? So how are members assigned to dementia specialist so that they are getting the case management that is unique for this disease? We are going to keep the answers obviously brief, but hopefully robust and sustainable

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Health Plan Introductions: Good afternoon everyone Cynthia Almaden with LA Care Health Plan senior director to the CalDual (…inaudible) services. What we are working on now actually, I've heard that you say that CMC what we are working on is hard wiring the process via our business lines. I think Alzheimer and dementia diagnosis does not selectively pick CMC members or patience or beneficiaries. So some of the steps we are working on is with the training, the training obviously starts with the on boarding staff, new staff, as well as annual training refresher training anniversary of the, you know the training itself, and the training typically involved information of the disease, the differentiation between the symptoms presenting themselves and to figure out what's going on with this person what type of help to offer and how to approach it. So part of it was started with the Duals first came about so we have the 2015 we've trained around the counted that we have and I'm going to give you the total not just the Nuance of case managers but we have trained about 50 in total, anybody that is touching the membership indirectly, so to speak as we do mostly at this point telephonic so we have trained everybody that is speaking to members regardless of rolls so we have about 50 as well as the providers that we have, around 300 and on top of that we also have nine trained as subject-matter experts that have they’re Alzheimer’s Greater LA Tier 1 and Tier 2 trainings in 2016. We repeated that training obviously nursery, we trained about 25 from across teams within the health plan. So to speak to the hard wiring it has been a process and I want to say kudos to Debra cherry prefer because they have been the biggest advocates for this. I used to think that I'm one, but this has surpassed me with that so I have had the pleasure working with them few months it was more of a driver to hardwire it Beyond just training so now (…inaudible) procedure, it just got through the committee, it's also revising the workflows, because we have to reach broader numbers. You mentioned identifying them. I'm here to tell you that I got the news today after a lot of matching we would be identifying the folks that we got, thank you for being such a good advocate, so the flagging of those that need us, the complex Care Management not just specialist, you mention specialist, because I firmly believe in having Medi-Cal social workers the clinical nurses, the case managers, playing a big part in your life because we always have to remember person we know and care for and the caregivers even though the person may be struggling with Illness, but the caregivers hang on lots more looking at the person they'll know and love and watch them with pain struggling with a condition. So the workflows also at this time. We are approaching it as I said multiple venues to hide wire it into our organization. Sorry I took longer.

Hi Chris with HealthNet: I want to Echo many of the things that dr. Ahmed had spoken to. Many of our beneficiaries in CalMediConnect have a high degree of complex needs and so they require multi-dimensional care approach especially after when the beneficiary has limits to their ability to participate in their own care and that's definitely an issue with individuals with Alzheimer’s or dementia, so in addition to our normal care management approaches where we do have complex patients we do some specific things that we implemented around the Alzheimer's and Dementia population, for example we are one of those plans that has Incorporated our ADA department

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assessment in to our medical management imitation and so that becomes available to everyone in our organization needs or needs to see that kind of data and has available to them helps them create the best specialized Care. We also have a tool that we give out called our caregiver assessment two caregivers stress and strain tool that we can use when we are asking caregivers and make the results of that also available in our systems for the medical management documentation. Another point though is that it is really important for us as health plans, especially in California and particularly in Los Angeles to be very good about working with our medical groups, are contracted medical groups around working with these patients. Our model is one in which we have these large multi-specialty medical groups who take on large responsibility for managing our. (…inaudible). And so we have to work in partnership with them acknowledging that in many respects, we have an oversight role with them around their coordination with these patients and it adds an extra layer of complexity we have to work really hard to make sure we are partnering with them and giving them resources. Having said that, one of the things that we do with our dementia Care Specialists, we do have dementia care specialist and they are available to participate in there care teams to of the Care team, the primary care physician, but we also leverage them within our organizations to train our care managers so that there’s more of an expertise that is available through the entire care Management and they are available to help us in an our educational medical groups. One of the things that I would say is that although we have done a really concentrated job within our plan and we are trying to connect people to Community Resources and Community Resources are available to help them, there have probably been times where we have approach that through the provision of Education or materials and one of the things that we will be doing after this re examining our processes and seeing what ways we can increase those warm handoffs outreach and encourage our providers to do the same.

Hi I'm Steve with Molina: You know our case managers are routinely, I Echo that the training is such an important part to be able to do this work effectively. We have our dementia care specialist; they are training the rest of the team on how to identify and to work with caregivers. On top of that what we know is that anyone to comfortably diagnose and track exactly how one is doing, we also have(…inaudible) In our system we are finally live, we had a little bit of a hiccup it's been a long journey trying to put that in our system. It is live for our case managers so we are systematically tracking exactly the progression of what's Happening. The other thing is, it goes beyond just the (…inaudible) Inventory or the test so the test should not be taken in a vacuum, what happens to the test after a case manager identifies it after we actually have the results and so we are right now in the mist of working out who should know about this with the members and the family's permission of course. Should there be an automatic process where the PCP contacted and we have that comes of the ADA, who else should be contacted immediately once we know the outcome of that? We are working with the experts on this obviously with Alzheimer's greater la on that as well we are also working on the caregiver assessment. We have one in the final stages of testing. And the final stages of testing for

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way too long but we expect that to be in our system as well. And not just for now we are expecting our transition to a documentation system. And lastly we have a pilot project placing a lot of our follow-up.. What happens a lot of the times as a case manager will telephonically contact a member of a family member and they will say yes, I’m beginning recognize some memory impairment or there is some cognitive impairments but not quite at the level they are wanting Assistance or they're not at the time where they want to do anything or action on them done. What we do is, this new report is able to capture that information, and that we are going to come back to that member and to that caregiver, little while later on perhaps six months, eight months later you know some time ago you answered positive where you answered yes on this do you still need any or are you still okay. We are just in the beginning of the pilot so thank you

Hi I'm Karla and I am with CareMore: CareMore has integrated. We really have many opportunities in this mode of working, we have more centralized case management program, our nurses are care coordinators, interacting with the members, reassessing telephonically about the needs of the member. we can also recognize the opportunity of having clinics which we always try hard to get our members to go and attend to our clinic. In our clinics we have advanced partitions the series of tools to assess for multiple brain and within our clinics we have the specialized disease management program which is called Brain Health and over there that's where the assessment occur so from the case management perspective identify any red flags memory issues if there is some changes in the.. Behavior and we can always refer the member because one of the pieces is just getting to the diagnosis as you mentioned and so having a face-to-face encounter with our members is also opportunity to actually get to the diagnosis and to have that in the medical records, the Next Step which is documentation and from there really have a legacy and a medical record and clinician that touches our members can follow through with that and in terms of the use of our dementia care specialist we have an interdisciplinary care team we have been working with social Work case management and also our Behavioral Health Team to the internal capacity. and mostly Within my department which is case management, what we do is that these people attend the ICT and they are the subject matter experts who help their coding skills capacity as well so I think that partnering with the Alzheimer's Greater Los Angeles and having the ability for these trainings is really good because you really get to a higher level of understanding one that this is something exposed to, some of us get to experience disease and challenge for caring for others but even as Healthcare professionals we are detached from this, we just haven't really had the exposure so the training he's very dynamic because it speaks very strongly to our stuff.

Chris wheeler with LA Care: and I'm representing Dr. Amezcua today and he sends his regards. One of the things that we were going to speak to was really in relationship to the discrepancy between how many referrals have been made to Greater la the number of population I'm Sherry he really did touch on a lot of that. Number one sometimes the diagnosis doesn't get made and so to put in ICD-10 codes

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for dementia or for Alzheimer's is not going to pop up. I think that the other thing that we hit on as well is you know, the families for whatever reason sometimes it's cultural or whether it's a cultural that the family takes care of a family and we don't bring Outsiders in so or that families feel like failures if they can't do it on their own as caregivers. I would ask whether it's Alzheimer’s or dementia, how many in this room are currently a caregiver? Please just raise your hand. Care giving for any care giving diagnosis this goes beyond dementia. mine's happens to be 17 years with Parkinson's, by the way that diagnosis, 50% of Parkinson's patients have Lewy Body dementia so don't just be thinking about, go beyond that because it impacts Beyond at. And one of the things that when I came to La care when I was sitting in the ICD team meeting, almost brought me to tears because in 17 years and I'm a nurse case manager, has any provider asked me how Chris is doing. In 17 years at a city healthcare provider. So that culture has to change. And when I sat in the ICT and I heard dr. Amezcua say, "How about the caregiver?" I almost started crying. It's so important. And so as we go forward, what I heard today my nurse case manager brain started thinking Okay let’s get the care plan together. So as we are thinking together going forward, certainly how can we get that diagnosis for that patient. What other interventions from the health plan can we do to help those families get that diagnosis early, to help you get through the system. Because that does impact you financially. The other thing is identifying them, so what are the other processes besides Alzheimer’s and dementia that we need to be looking at that we know triggers that. Also the complex case management as far as the screen. And I loved that you mentioned getting the screening in to your case complex cm assessments, because that is going to be huge, and certainly screening for the caregivers, were just a few things, as I was sitting here listening to you all, you all were giving us the solutions, right off the bat. And so I think going forward we certainly have some great resources, and partnering again with Alzheimer’s Greater Los Angeles because you do give some great training and the partnership is there. And I think it’s really continuing to keep that education, getting us work flows, and those standardized ICP’s in place in order to help our case managers moving forward.

Cynthia Almaden: Actually, Chris, this is already, that’s what I meant by hardwired, they would be identified as the diagnosis and that’s one of the ADA is actually being put in to the process on the workflows as they’re conducting the comprehensive care management assessment, they ask questions, that triggers the use of the ADA, based on the score, they would run the Benjamin rules… and there is a lot of work going on programming the system to collect the rules of care….

Jennifer: Let’s here from Care1st.

Deshawn: Okay so Care1st Health Plan, we use, I am part of the complex case management team, I manage the team. We also adopted the Care Management Practice of Dementia Care Specialist on the training of the Alzheimer’s Association of Greater Los Angeles. We have 4 training complex case

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managers that are doing just complex. How we utilize our Dementia Care Specialist they are utilized as triage and case evaluation nurses so they are also trained our entire case management team on the patient tools that have been provided by greater Los Angeles Alzheimer's and with that, they are also Consultants to the other team members, nurses, social workers, whomever else, by the way our social services team, they also have training in dementia care specialist on their team so with that triage roll and a dementia care specialist they are also the initiators of the plans for the members and the caregivers so that is part of our assessment of the member needs and to address dismembered and we also do the caregiver assessment so that we can identify what needs the care giver has. We also try to align those resources part of what the triage case evaluation nurse does as well, is initiate those resources and initiate that care plan within the first 30 days of being in contact with that member, so I did bring one of our dementia Care Specialists here then she'll get more into talking about of those rules are that she plays. Two of the major takeaways we got from the Alzheimer's association was advocacy for a diagnosis. That is one of our primary goals. Because we helped a lot of members who have co morbidities and they have challenges but they do not have diagnosis, so that is one of the main avenues that we tried to pursue, is the appropriateness of primary care provider and the appropriateness of the specialty provider that can make the diagnosis and we advocated for it and we push for it to ensure that our members are served and that they have a care plan in place to be able to support their needs. And the second thing is just aligning resources in a timely manner. Assessing the caregivers needs so that we can advocate for if it's needed or for caregiver support. I will let the dementia care specialist tell you about what she does and how our social services team will also talk about the caregiver resources that they include with our members.

Speaker: I think she covered a lot so I am just going to add that in that initial evaluation, we receive the red flags, and then we contact the primary care provider and ask him to also do a cognitive assessment on the patient. Soon as we do the evaluation for complex case management we actually ask if there is anything else that you are finding is a barrier to your care, you have memory, because you're not only going over the physiological systems but you are also going over a full psychosocial and cognitive evaluation as well as Medical and oftentimes these patients are not diagnosed. And so we ask those additional questions and then in the initial care plan, we are passing it off to the dementia care specialist to manage that patient. Also asked for the referrals to be put in place for Alzheimer's of Greater Los Angeles. may or may not be a yes at that point but part of our process is to continue to reintroduce that conversation and keep moving forward with them and not only just going over medical conditions but also the Alzheimer's so that we can continue that conversation again. Getting them in the direction and towards that process. And asking to reach out to their family members as well to see if can maybe do more open conferences to see if we can get the entire family too be engaged in that referral process as well.

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Hi good afternoon my name is Hannah, I am the social service manager here at CareFirst, we have Master Level social workers and Care coordinators and we have partnered with our case management team and we work hand-in-hand with our members. Quite often and they refer all the members really who they encounter to have a diagnosis of Dementia or perhaps or a caregiver that they have spoken to and our social workers are actually in the field so they do conduct home visits. So they will do in-home assessment to make sure that there are safety concerns speak with the member, speak with the family and if the caregiver and to really do an assessment of what their needs are, especially with caregiver burnout and this was me .. earlier this is so common with every diagnosis but certainly of course with Alzheimer's or dementia. That is one of our first and foremost concerns because this is often times the main and single support for this member and we want to make sure that they are feeling supported. So often times we assess the members caregiver to find out how are they supporting themselves, how are they dressing their own self care? We have had members whose and caregivers are often times with other health plans, and myself actually when I did this work, would actually request at the caregiver pull out their membership ID find out which health plan they were with and encourage and show them this is the behavior Health Plan. If you need to talk to someone please do please don't let it fester and linger because at the end of the day you are stuck with all of these feelings, feeling overwhelmed, needing to go to the hospital because it's just too much. And often times we actually find out that that the member’s caregiver, family is ours as well. Alzheimer's greater La I have to say is really the first and foremost resource that we connect our members to. The old-timers connect resource has been a wonderful resource that streamlines the process and oftentimes there social workers will reach out to the referring to check in with them, weather, quite recently from all greater La team had contact peter saying that reach her, and our coordinator had many telephonic conversations our member and we inquired why and asked what was going on, what was the barrier and asked what we could do to support the member about speaking with someone who is a stranger really to the person. As Shelly mentioned, often times a person will initially say no or our caregiver will say no, I'm practically fine, I can take care of things that we do. And you know we will work through our resources that we link them too, additional IHSS hours, whether it be transportation resources, food resources, and we will continue to emphasize the importance of getting linked to the community that can support and understanding educate the caregivers and the members especially our team really encourages the telephonic groups that Alzheimer's greater La offers. Knowing that oftentimes the caregivers don't have an opportunity to leave the house for an hour or two to deal with traffic to come support groups. And that is really quite tremendous and supportive for our members.

Jennifer: We certainly appreciate hearing from our health plan partners. I know I was taking copious notes so I can follow up with Sarah love you but I do kind of and in the interest of time I have to be write to the extremely brief hopefully in hearing from our panelists today, you see the importance of embedding in your systems dementia capable practices and so I'm going to ask everyone here from a

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health plan if you can't take out a pen and paper to do very quickly a check off list.

Questions: 1. Do you have a validated cognitive screen in your system? yes or no 2. Do you have a validated caregiver assessment tool in your system? 3. Workflow process? Embedded in your system so that when you use these validated tools, they go

somewhere? 4. Do you have a system for making referrals for LTSS? Timers associations? Four other community-

based organizations? 5. Do you offer respite? 6. Do you provide education around this disease?

Jennifer: And hopefully we can start looking at yes or no, are these things happening? And we are going to be convening a work group on august 24th and everyone from our health plans has affirmatively said that they will that work group and we are hoping that we can again learn from our colleagues on what's working well and how you have done it and hopefully we can go through that checklist and say yes we have these things embedded systems and we are listening to our members experiences and we are taking it to heart so that Malcolm will say that these panels are certainly worth my time to come. I'm going to hand it over to Eddy, thank you all very much.

Eddy Moreno: And thank you Jennifer from Harbage I think you guys for coming and standing in front of us and showing your personal experience, we very much appreciate it. But I did forget to get the approval on April 17 minutes, so there are a couple of folks out here that are going to help me get through that real quickly it's. The minutes are in front of you and they were also sent to you guys electronically, so if I can get a move to approve the minutes, that would help. One person approved

Terrance Henson: Another person approved

2:45PM– 3:00PM

Questions | Announcements | Closing Remarks

Announcements: Rudy Contreras the executive director of Southern California services for Independent Living make an announcement

Rudy Contreras: So SCRS-IL in collaboration with the other 10 Independent Living Centers California has put together a

Eddy Moreno AVP, Community Outreach & Enrollment

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systems change advocacy network. we represent the largest diverse community of people with disabilities in the entire state, so representatives from centers system change advocates and they will all be meeting at the California endowment here in LA 22nd and we would like one representative from all of the healthcare plans to be in attendance with us as well. I have a flyer for those health plans that need one. we will also be having our state senators is Representatives at the federal level to be in attendance with this Roundtable discussion the purpose of the independent living centers is to advocate for systemic change and the biggest conversation is Healthcare. So getting everyone in one room go to see how we can align ourselves to advocate and push certain policies California but beyond it. Next week I will be in Washington DC along with other representatives from various independent Living centers throughout the United States and we will be meeting with all the senators up at the Capitol and we will get to discuss a lot of these system change efforts. So if interested please reach out so we can get a head count and get all of that done

Eddy: Okay thank you Rudy. And again I want to let you know that our last quarterly meeting will be led by CareMore health Plan and it will be scheduled for October 2017. I don't think we've got it down the date yet. Date and location is to be determined. We really appreciate you guys being here and thank you, the stakeholders. We've done this a second time, last time Health Net led and putting on some of the community-based organizations speak on behalf this time we brought another panel, we brought some of the members to change it a little bit on how you're doing things, but it's really from the feedback that we are getting from all of you so continue to share your feedback so we can continue to share your feedback with us so we can continue to have better presentation moving forward so thank you all for coming and have a great day.

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