Models of Community Based Long Models of Community Based Long Term CareTerm Care

University of PennsylvaniaUniversity of PennsylvaniaJean Yudin, Jeanette Gallagher, Bruce Kinosian Jean Yudin, Jeanette Gallagher, Bruce Kinosian

AgendaAgenda• Expanded evidence of Interdisciplinary Team

directed, community based long term care, withdirected, community based long term care, with focus on Home-based Primary Care

• Implementation of Independence at Home (section p p (3024 Affordable Care Act)

• Hospital at Home and other Non-institutional Care pInitiatives at VA

• Challenges and Opportunities in Pennsylvania

The Population is Aging and Increasingly FrailThe Population is Aging and Increasingly Frail% f Old Ad lt% f Old Ad lt% of Older Adults % of Older Adults

Who Need Daily Who Need Daily Personal CarePersonal Care

•• There are ~ 2There are ~ 2--3 3 million older adultsmillion older adultsPersonal CarePersonal Care million older adults million older adults with high grade with high grade functional impairmentfunctional impairmentfunctional impairmentfunctional impairment

•• Will double in aboutWill double in about•• Will double in about Will double in about 15 years15 years

Problem of Duals• Sickest, frailest, least educated and most

expensive Medicare and Medicaid beneficiariesbeneficiaries

• The 8M duals represent 46% Medicaid and 25% of Medicare expenditures25% of Medicare expenditures

• More than ¼ have 3 or more ADL dependencies, while 11% have 5 or more h i ditichronic conditions

• Complex social and medical needs• Current siloed programs create inefficiencies• Current siloed programs create inefficiencies,

overlaps, and gaping holes through which beneficiaries end up institutionalized

h f b dThe Spectrum of Home-based Care

I f l F l Skill d H H it l tInformal Services

Formal Personal

Care Services

Skilled Home Care

Home-Based

Primary Care

Hospital at Home

Low acuity High acuityLow acuityChronic careLittle or no MD involvement

High acuityAcute careHigh level NP/MD involvement

dOur Focus Today

I f l F l Skill d H H it l tInformal Services

Formal Personal

Care Services

Skilled Home Care

Home-Based

Primary Care

Hospital at Home

Low acuity High acuityLow acuityChronic careLittle or no MD involvement

High acuityAcute careHigh level MD/NP involvement

BJW BJW •• 78 yo AA woman,78 yo AA woman,•• Lives independently in Lives independently in

neighborhood for past 50 yearsneighborhood for past 50 years•• 22 story row homestory row home

•• 491.21 COPD491.21 COPD•• 518.83 Resp Fail 02518.83 Resp Fail 02•• 327.3 Sleep Apnea327.3 Sleep Apnea

440 2 PVD440 2 PVD•• 22--story row homestory row home•• BiPolar daughter who lives in BiPolar daughter who lives in

home with her along with her 2 home with her along with her 2 children (one with autism)children (one with autism)Recurrent utility crisis due to poorRecurrent utility crisis due to poor

•• 440.2 PVD440.2 PVD•• 585.3 CKD585.3 CKD•• 404.11 HTN c CKD and HF404.11 HTN c CKD and HF•• 416.8 Pulmonary Htn416.8 Pulmonary Htn•• Recurrent utility crisis due to poor Recurrent utility crisis due to poor

money managementmoney management•• Oxygen dependentOxygen dependent•• Held and personally catered Held and personally catered

annual block partyannual block party

416.8 Pulmonary Htn416.8 Pulmonary Htn•• 428.3 Diastolic CHF428.3 Diastolic CHF•• 427.89 SVT427.89 SVT•• 358.8 Neuropathy358.8 Neuropathy

274 0 gout274 0 goutannual block partyannual block party•• Multiple cats with fleasMultiple cats with fleas•• Medicare risk score 4.6Medicare risk score 4.6•• Personal goal to survive to 80Personal goal to survive to 80thth

•• 274.0 gout274.0 gout•• 285.29 anemia 285.29 anemia •• 721.9 Cervical spondylosis721.9 Cervical spondylosis•• 366.9 cataract366.9 cataractgg

birthday birthday •• 530.81 GERD530.81 GERD•• 389.9 Hearing loss389.9 Hearing loss

BJW H i li i P /P BJW H i li i P /P BJW Hospitalizations Pre/Post BJW Hospitalizations Pre/Post Housecall ManagementHousecall Managementgg

Start Housecall

COPD COPD/ICU

COPD/ICU

COPDCOPD/ICU

COPD/ICUCOPD/ICU

ED 80th birthday

2004 2005 2006 2007 2008 2004 2005 2006 2007 2008 20092009

ElderPACElderPAC•• integrated interdisciplinary team care for 16integrated interdisciplinary team care for 16•• integrated, interdisciplinary team care for 16 integrated, interdisciplinary team care for 16

years years •• combines home and community based services combines home and community based services

th h Phil d l hi C ti A i ithth h Phil d l hi C ti A i iththrough Philadelphia Corporation on Aging with through Philadelphia Corporation on Aging with medical care (Inmedical care (In--Home Primary Care Program) Home Primary Care Program) in an IAHin an IAH--type programtype programyp p gyp p g

•• ElderPAC team:ElderPAC team:NP/MD SW f UPHSNP/MD SW f UPHS–– NP/MD, SW from UPHSNP/MD, SW from UPHS

–– case manager from PCAcase manager from PCA–– community nurse from Caring Waycommunity nurse from Caring Wayy g yy g y

•• serves both Waiver (dual) and Options (nonserves both Waiver (dual) and Options (non--dual) nursingdual) nursing facility clinically eligible consumersfacility clinically eligible consumersdual) nursingdual) nursing--facility clinically eligible consumers facility clinically eligible consumers

Long Term Care: Long Term Care: D i N i HD i N i HDeconstructing a Nursing HomeDeconstructing a Nursing Home

Complex Health ManagementComplex Health Management

Independence at Independence at HomeHome

HCBC waiversHCBC waiversHCBC waiversHCBC waivers

Supportive Living Services Housing Supportive Living Services Housing

PrePre--Elder PACElder PAC3 Nurse Practitioners 39 Case 3 Nurse Practitioners 39 Case

ManagersManagers180 patients 180 patients at PCAat PCA

Case ManagerCase Manager60 PCA 5060 PCA 5060 PCA consumers 50 60 PCA consumers 50 providersproviders

ElderElder--PACPAC

Philadelphia CorporationSenior Centers

Elder

Corporationfor Aging

Caregivers

Home HealthAgencies

In-Home PrimaryCare Program

UPHS InUPHS In--Home Primary Care Home Primary Care P P Program Program

•• Active census of 200 homebound elderly patients in InActive census of 200 homebound elderly patients in In--Home Program; 38 homebound elderly patients in Home Program; 38 homebound elderly patients in Medicare AdvantageMedicare Advantage

•• Primary Care provided by NP/SW/MD teams Primary Care provided by NP/SW/MD teams •• Many patients receiving PCA services when they enter Many patients receiving PCA services when they enter

the Inthe In--Home ProgramHome Programthe Inthe In--Home Program Home Program •• Nearly 2/3 receive PCA services while in program. Nearly 2/3 receive PCA services while in program. •• Majority of patients receiving skilled home health Majority of patients receiving skilled home health

services, including chronic care coordination.services, including chronic care coordination.

Home Visit ActivityHome Visit Activity•• Social WorkerSocial Worker

---- Makes initial contactMakes initial contact---- Social/service mapSocial/service map---- Usually biUsually bi--weekly contact weekly contact

•• NPNP--Physician teamsPhysician teams-- see patients every 6see patients every 6--8 weeks (6 NP/2 MD visits/yr) 8 weeks (6 NP/2 MD visits/yr) -- Physical exams, diagnostic studiesPhysical exams, diagnostic studies-- Home environmental modificationsHome environmental modificationsHome environmental modificationsHome environmental modifications-- Evaluate and strengthen social supportsEvaluate and strengthen social supports-- Ensure contact with appropriate community agencies Ensure contact with appropriate community agencies

---- CONSUMER CHOICE (sort of)CONSUMER CHOICE (sort of)Weekly team meeting /monthly with communityWeekly team meeting /monthly with community-- Weekly team meeting /monthly with community Weekly team meeting /monthly with community agenciesagencies

2009 average 7.5 visits/pt (6 NP:1 MD)2009 average 7.5 visits/pt (6 NP:1 MD)

Supportive Living Service IntegrationSupportive Living Service Integration•• EnvironmentEnvironment

–– Information for modification and repair Information for modification and repair programsprograms

–– Durable medical equipmentDurable medical equipment–– StairglidesStairglides

•• TransportationTransportation–– Shared Ride SLSShared Ride SLS–– Shared Ride SLS Shared Ride SLS –– NonNon--Emergency AmbulanceEmergency Ambulance

MA / WheelsMA / Wheels–– MA / WheelsMA / Wheels

ElderPAC Team MembersElderPAC Team Members

•• Case Managers (2) from the Case Managers (2) from the Options/Waiver Programs of theOptions/Waiver Programs of theOptions/Waiver Programs of the Options/Waiver Programs of the Philadelphia Corporation for AgingPhiladelphia Corporation for Aging

•• Social worker from GeriatricsSocial worker from Geriatrics•• Social worker from Geriatrics Social worker from Geriatrics •• Geriatric Nurse Practitioners (GNP)Geriatric Nurse Practitioners (GNP)•• Physicians from Geriatric MedicinePhysicians from Geriatric Medicine•• Home care nurse from HHAHome care nurse from HHA

(Penn Care at Home)(Penn Care at Home)

•• SocializationSocialization–– Information, lists and application process for:Information, lists and application process for:Information, lists and application process for:Information, lists and application process for:

•• Senior CentersSenior Centers•• Adult Day CareAdult Day Care•• Senior CompanionSenior Companion•• Senior CompanionSenior Companion•• Friendly VisitingFriendly Visiting

•• Counseling / Mental HealthCounseling / Mental HealthC it M t l H lth C t / B S i U itC it M t l H lth C t / B S i U it–– Community Mental Health Center / Base Service UnitsCommunity Mental Health Center / Base Service Units

•• Home Health Aides / Personal Care AidesHome Health Aides / Personal Care Aides•• SafetySafety•• SafetySafety

–– Emergency Response SystemsEmergency Response Systems–– Locks / Windows ProgramLocks / Windows Program

Fi i l M tFi i l M t–– Financial ManagementFinancial Management–– Older Adult Protective ServicesOlder Adult Protective Services

Medical / Health:Medical / Health://Switching between AAA and CMS before IAHSwitching between AAA and CMS before IAH

•• Home Health AgenciesHome Health Agencies•• Registered NurseRegistered Nurse•• Registered NurseRegistered Nurse•• Physical TherapistPhysical Therapist•• Occupational TherapistOccupational Therapist•• Speech TherapistSpeech Therapistp pp p•• Home Health AideHome Health Aide•• Incontinence SpecialistsIncontinence Specialists•• Incontinence SpecialistsIncontinence Specialists

Cement

• Weekly team meeting for In-Home Primary Care Team (NP/SW/MD)Primary Care Team (NP/SW/MD), community and hospice nurses

• Monthly team meeting with PCA• Monthly team meeting with PCA• Care Plans (PCA, Home Health Agency) • Daily electronic communication:

Text, email, phone, EMR, , p ,

Does it work?

Objectives:

Determine if an inter-agency IDT providing comprehensive, all-inclusiveproviding comprehensive, all inclusive care could:

• Increase the share of total survival spent in the community for frail elders; and

• Reduce Medicaid nursing home costs by providing home and community based care toproviding home and community based care to frail elders.

Evaluation

• Original EPAC cohort study 1997-2002• Reassembled E-PAC cohort for 2004 base year• Accrued new consumers during subsequent 4 years

I l d d ll li i d f i l lli ll–Included all living at end of interval, rolling enrollment• Controls: consumers matched for program (waiver/options), age,

gender, zip code, LTC intake risk score (1-85, mean =69.2), year of enrollment e o e t

• Medicare costs estimated from HCC score for EPAC patients• Medicaid costs for NH and HCBS taken from State SAMS system• Death from state vital records• Utilization (hospitalization) from program data• HCBS costs (from AAA and from State Medicaid )

F ti l f AAA• Functional scores from AAA(all participants screened with common intake

assessment)• Measures: community survival (Kaplan-Meier) NH use mortality• Measures: community survival (Kaplan Meier), NH use, mortality,

costs

3 Comparison Groups

• PACE (national) --Benchmark• HCBS without ElderPac IDT• HCBS without ElderPac IDT

(216 Waiver, 84 Options;6910 waiver th )months )

• HCBS with ElderPAC IDT(72 waiver, 20 Options; 4360 member-months))

E-PAC 2(2004-2009)

Waiver/Options Controls(2004 2009)

(N=92/4360 member months)

Controls(N=216/ 6910 member-months )

Hospital 3.8 /100 mm 7.2/100 mmLong-term Nursing Home

5.9% 24.9%Nursing HomeCommunity Survival/ Survival 5-year

38% /43% 20%/28%

HCBS C Pl $ $HCBS Care Plan mean cost/month

Est. mean HCCAnnual/ 5 yr Total

$1942 +/- 1117

3.55

$1084+/- 477

n/aAnnual/ 5-yr Total $41,962/$15.3MMedicare Savings

Annual/ 5-yr Totaly@ .48@ .37

$20,054/$7.22M$15,458/ $5.5M

ElderPAC Increases both Survival and Community Survival d l C Scompared to usual HCBS

Community months of survival/total months survival EPAC 44 3/46 8 th W i 24 2/31 9 thEPAC 44.3/46.8 months Waiver 24.2/31.9 months

C i S i l i h IC i S i l i h I H LTC S iH LTC S iCommunity Survival with InCommunity Survival with In--Home LTC ServicesHome LTC ServicesEPAC, PAEPAC, PA-- PACE, PAPACE, PA--Waiver Waiver

0 91

0.60.70.80.9

HCBS‐Nat

HCBS‐PHI

0 20.30.40.5 LIFE‐PA

LIFE‐1

LIFE‐2

00.10.2

Y1 Y2 Y3 Y4 Y5

E‐PAC

Community Choices, Palmetto Senior Care, nursing home Overall survival y , , g(Kaplan–Meier) trajectories, by program cohort

Log-rank (Mantel–Cox) test = 40.27 (df = 2); p < .001

Survival for Low and High risk admissions to Waiver, PACE, and NH: Simpson’s paradox revealedWa ve , CE, a d N : S pso s pa adox evea ed

Median survival among moderate-risk admissions to PSC was 4.7 years compared with 3 4 years in CC (log rank = 3 08; p = 079) Among the high riskcompared with 3.4 years in CC (log rank = 3.08; p =.079). Among the high risk, PSC and CC median survival was 3.0 and 2.0 years, respectively (log rank = 6.53; p = .01).

Risk Strata by Program

30.7%44 2% 47 0%80%

90%

100% 5+

4‐5

0‐3

28.1%28 3% 24 6%

44.2% 47.0%

50%

60%

70%

41.2%27.4% 28.4%

28.3% 24.6%

10%

20%

30%

40%

0%

0%

Waiver PACE NH

χ2(4) = 57.45; p=0.000

EPAC reduces Average Monthly Costs Compared to Waiver ControlsCompared to Waiver Controls

Medicaid : EPAC 24% less

Medicaid+Medicare : 32% lessless less

$5,000

$6,000 $5710/MM

$3,000

$4,000

$5,000

Medicare

$3919/MM

$1,000

$2,000 NH

HCBC

$0

EPAC $47,028   Waiver $68,520EPAC : $20,640;  Waiver $27,084

5-Year Total Cost of State Nursing Home and HCBS payments for E-PAC and Waiver/Options Consumers

Medicaid Only $2.3M saving for 4360

$$18

ns $15 6M$17.1M$ g

member months (23%)$6740/ Year of Life Saved N=92 $12

$14$16

Million $15.6M

Saved N=92(4360 MM EPAC, 2994 MM HCBS)

$6$8$10 $9.8M

$6.7M$7.5M

Medicare & Medicaid$7M - $8.7M saving for 4360 member months $0

$2$4

for 4360 member months$170 K - 1.7M saving for N=92

$0

(4360 MM EPAC, 2994 MM HCBS) Medicare NH HCBC

Summary• All-inclusive care delivered through a• All inclusive care delivered through a

housecall practice can reduce Medicaid costs by 23% compared to usual HCBScosts by 23% compared to usual HCBS.

• Despite a 46% increase in survival there was a net cost savings (up to $1.7M) to Medicare and Medicaid in an Integrated gCare Organization/Independence at Home structure.structure.

What’s missing

• Financing structure to cover the cement that keeps the bricks togetherthat keeps the bricks together.

• Currently dependent upon individual commitment and effort to keep patientscommitment and effort to keep patients connected with all team membersN d f d l f fi i• Need for new models of financing integrated care beyond single all-inclusive

i tiorganizations–e.g., Independence at Home

Independence at HomeIndependence at Home

•• Authorized in the Patient Protection and Affordable Authorized in the Patient Protection and Affordable Care Act as a demonstration to run 2012Care Act as a demonstration to run 2012 20152015Care Act  as a demonstration to run 2012Care Act  as a demonstration to run 2012‐‐20152015

•• Focuses on top  5% of Medicare beneficiaries by Focuses on top  5% of Medicare beneficiaries by costcost——clinically complex multiple hospitalizationsclinically complex multiple hospitalizationscostcost——clinically complex, multiple hospitalizations, clinically complex, multiple hospitalizations, multiple functional impairments.multiple functional impairments.

•• Provides for gainProvides for gain‐‐sharing between CMS andsharing between CMS and•• Provides for gainProvides for gain sharing between CMS and sharing between CMS and housecall providers. housecall providers. 

•• Interdisciplinary, longitudinal care in homeInterdisciplinary, longitudinal care in homep y, gp y, g•• Geriatric skills, EHR, quality, satisfactionGeriatric skills, EHR, quality, satisfaction•• Outcomes: Fewer inpatient days, lower cost, savings Outcomes: Fewer inpatient days, lower cost, savings

shared by home care team (all partners)shared by home care team (all partners)

Independence at Home (IAH)

• Three options for practices to join: – Independent Practices (15) size 100-700 minimum average sizeIndependent Practices (15) size 100 700, minimum average size

200 first year– Consortia (3) – National pool (0)

• Patient criteria: 1.4 M nationally meet; mean HCC=3.4– Prior hospitalization– Post-acute rehab (MDS or OASIS)

2 Ch i diti– 2+ Chronic conditions– 2+ ADL dependencies– FFS Medicare (excludes Medicare Advantage; includes ESRD, duals)

• Outcomes:• Outcomes:– Quality measures– Advance directives, Comprehensive Geriatric

Assessment annually, 48-hr follow-up after hosp/ED discharge and after admission

– Hospital/ED/ Potentially avoidable hosp (CHF/COPD/DM)– Gain sharing– Practice spending target set by pre-enrollment HCC– predicted, with annual cost factor; 1% outlier cost protection.

Individual Practices (Announced April 2012):• Boston Medical Center (Boston, Massachusetts)• Christiana Care Health Services (Wilmington, Delaware)• Cleveland Clinic Home Care Services: Medical Care at Home

Program (Independence, Ohio)g ( p , )• Comprehensive Geriatric Medicine P.C. (Brooklyn, New York)• Doctors Making Housecalls, LLC (Durham, North Carolina)• Housecall Providers Inc (Portland Oregon)• Housecall Providers, Inc. (Portland, Oregon)• MD2U (Louisville, Kentucky)• National House Call Practitioners Group (Austin, Texas)

h h l d i h l h• North Shore – Long Island Jewish Health Care Inc.: Physician House Calls Program (Westbury, New York)

• RMED, LLC (Jacksonville, Florida)• Visiting Nurse Housecall, LLC (Atlanta, Georgia)

Hospitalat Home

37

• Visiting Physicians Association, P.C. –Flint/Saginaw/Marysville (Flint, Michigan)

• Visiting Physicians Association, P.C. – Lansing/Ann Arbor(Okemos, Michigan)

• Visiting Physicians Association, P.C. – Milwaukee (West Allis, Wisconsin)

• Visiting Physicians Association of Texas, PLLC – Dallas(Irving, Texas)

• Consortia (Announced August 2012):• Innovative Primary Senior Care LLC (Skokie, Illinois)

T C t H lth LLC (St t Fl id )• Treasure Coast Healthcare, LLC (Stuart, Florida)• Virginia Commonwealth University Health System/University

of Pennsylvania, Washington Hospital Center (Richmond, Virginia)

38

Inspiris’ IAH-type program and Outcomes

• Housecall team (MD, NP, RN, SW) contracted to manage a defined panel of high risk patients (2+ chronic conditions 1+ admission) across 8 marketsconditions, 1+ admission) across 8 markets

• 63% reduction in hospital admissions among 800 matched duals (1608/1000 to 593/1000 pts/yr)

• 33% reduction in 30-day readmissions (21% to 13%)42% d ti t t l t 2009 2010 (15%• 42% reduction total cost over 2009-2010 (15% absolute net reduction for 300 pts compared to all high risk duals in 15,000 member plan), p )

• 74% reduction in SNF days, 40% reduction in ED use among 1000 pts in 50,000 member plan.

Inspiris IAH model within Medicare Advantage 12,445 beneficiary months of observation12,445 beneficiary months of observation

Avg. Risk Score on IAH =3.95 (HCC + frailty @ 0.28)$60,000

$50,740

$40,000

$50,000

$33 960

$50,740

$40,300

$20,000

$30,000 Observed Cost

Expected Costs

$33,960$29,580

$0

$10,000

$Pre‐Post IAH IAH IAH w/100K 

reinsurance

First two blue bars are actual pre and post, with some regression to the mean Red = Modeled costs using HCC score method Last two bars assume IAH program is relieved

of outlier costs above $100,000

Why We Need Hospital at HomeWhy We Need It How it Helps Spreading Success The Future

Why We Need Hospital at Home• Walter, 82, lives with his cat• Multiple chronic conditions, meds, p , ,

and admissions• Walter’s Gripes

– “I can’t get nebs on time so I endI can t get nebs on time so I end up on the tube”

– “Food stinks”– “Wake up in middle of night andWake up in middle of night and

can’t get to bathroom”– “No one talks to me”

“I get confused get tied down”– I get confused –get tied down– “I always come home with a

completely new set of medicines”

41

–• “I won’t go to the hospital”

How Hospital at Home Can HelpWhy We Need It How it Helps Spreading Success Case Studies

How Hospital at Home Can Help

Hospitalat Home

Why We Need It How it Helps Spreading Success The Future

• 61% chose HAH care• HaH is feasible and efficacious

• Less CG stress• Better function

• High-quality care• Fewer complications

Higher satisfaction

• High provider satisfaction

• Higher satisfaction • Lower costs of careAnn Intern Med 143:798 808 2005 J Am Geriatr Soc 54:1355 1363 2006 J Am

43

Ann Intern Med. 143:798-808, 2005. J Am Geriatr Soc. 54:1355-1363, 2006. J Am Geriatr Soc. 2008;56(1):117-23. Am J Manag Care. 15:49-56, 2009. J Am Geriatr Soc. 2009;57(2):273-8. Medical Care, 47(9):979-85, 2009.

Why We Need It How it Helps Spreading Success Case Studies

What Did Walter Think?“I definitely would have yended up on a breathing machine if I had been in the hospital.”p

“It was great to get the attention I had from theattention I had from the nurses and to have the doctor see me at home.”

“I didn’t have to worry about my cat.”

Hospitalat Home

VA T-21 Non-institutional Care I i i iInitiatives

Nationally Philadelphia VAMCNationally• Hospital at Home (5 sites)

• VA-PACE partnership (7 sites)

Philadelphia VAMC• PACE (2010)• Medical Foster Home (2011)VA PACE partnership (7 sites)

• Geriatric Primary Care• GRACE

Medical Foster Home (2011)• Hospital at Home (2011)• Veteran Directed Care (2012)

• Veteran Directed Care• Transitions care • Transitions (2012?) --internal

(Naylor,Coleman)

Hospitalat Home

45

Philadelphia Hospital at HomePhiladelphia Hospital at Home

PVAMC model First 6 monthsPVAMC model• Provider Agreement—

Penn Home and Hospice

First 6 months• 25 patients

– 16 CHFpservices– Physician, Coordinator,SW

from VA-- .3 total FTE

– 7 ED admits– aLOS 3.4 d/ 4.6 DRG pred– 4% 30d readmitfrom VA .3 total FTE

– PH&H provides infusion,nursing,CNA, Thereapies

– 4% 30d readmit– 28% repeat customers (2

called directly )Average cost/admit $2400;Thereapies

– VA provides DME,oxygen– All with 4 hour delivery cap

– Average cost/admit $2400; PVAMC expected $6500

Hospitalat Home

46

Environmental Challenges : PCA’s ability to provide a broad range of services to older patients

has now become much more limited. • Act 22

– No longer a lump sum received each month for care managers. The position is now a service coordinator and they must submit billing hour units and then getand they must submit billing hour units and then get reimbursed.

– Case management is a bid service, consumer choiceg ,– Direct Cuts: No more nursing, extermination,

ambulance rides

– Big changes to the Personal Care/PAS programs and how they are managed/reimbursed. New financial manager about to be installedmanager about to be installed.

47

OpportunitiesOpportunities

• Jimmo v Sebelius settlement with CMS• Jimmo v. Sebelius– settlement with CMS to re-write Medicare manual to remove “improvement” requirement for skilledimprovement requirement for skilled home health/therapiesD t t f A i t li t EPAC i• Department of Aging to replicate EPAC in Pittsburgh

• Medicaid managed care/ICOs auto-enrollment

Hospitalat Home

48

House Call Medicine Clinical Model: Focuses on Cement, Not Just BricksFocuses on Cement, Not Just Bricks

• Continuous, comprehensive, longitudinal medical care in a ti t’ idpatient’s residence,

• Interdisciplinary team care - coordinate ALL medical AND social servicesservices

• Geriatrics and palliative care skill sets• Strong medical component, MD, NP - extraordinary means to

prevent crises• Careful selection of specialists

P t bl di ti• Portable diagnostics• Support and empowerment of caregivers / family• 24/7 ready access to care• 24/7 ready access to care• Not in the body part business!

Common Care Processes* Common Care Processes

• Comprehensive geriatric assessmentp g• Evidence-based care planning, monitoring• Self- and caregiver activation, education, supportSelf and caregiver activation, education, support• Interdisciplinary team management and

coordination of medical and social inputsp– …all tailored to patients’ goals and preferences.

* Boult C, Wieland D: Comprehensive primary care for older patients with multiple chronic conditions: “Nobody rushes you through.” JAMA. 2010;304(17):1936-43. doi:10.1001/jama.2010.1623

Why it Works: Targeted Population, Right Tool, Right OutcomeRight Tool, Right Outcome

OutcomesOutcomes•Safer, higher quality, more q y,satisfactory care•Lower costs

Summary - HBPC, IAH, and lHospital at Home

• Bring care to ill elders, when and where they need it

• Disruptive mobile innovation that prevents high-cost events --• Disruptive, mobile innovation that prevents high-cost events --more convenience, higher satisfaction

Tackles FFS incenti es that d i e high costs and poo ca e and• Tackles FFS incentives that drive high costs and poor care and will save serious Medicare $$

Al l i f d d M di id• Also a solution for managed care and Medicaid

Substantial reduction in institutional care can be achieved by integrating services and adding flexibility rather than restricting services

Success in reducing institutional care requires trust built best by the patient provider relationshiptrust, built best by the patient provider relationship established within the home

Greatest success in reducing institutional care requires an interdisciplinary team, and the economic incentives to sustain them.