The Changing Faces of Medicare & Medicaid

1. The Changing Faces of Medicare & Medicaid Friday, May 27, 2011 Sheraton Suites Cuyahoga Falls Ohio

2. Improving Care through Collaboration: Integration of the Aging Network and Acute and Post AcuteMedical Care ServicesKyle R. Allen, D.O.,Medical Director, Post Acute & Senior Services Chief, Division of Geriatric Medicine Summa Health Systemsallenk@summahealth.org

3. The SAGE Project • A 15 year collaboration partnership • Multiple initiatives, a “cast of thousands” well, maybe 100s, but you get the point • Common goal to improve the health, well being and functional status of Akron region frail older adult population • Identified major gaps in the continuum and care processes from each partner • Searched and defined mutual benefits • Shared mutual threats and concerns • Built trust • Grew and multiplied to other regional health systems • Communication, communication, communication • Vision, Vision, Vision, Vision

4. SAGE Goal Goal: To integrate a comprehensive geriatric hospital-based clinical program with the community aging network to improve the health, functional status, and to prevent institutionalization of older adults at risk for nursing home placement. • S.A.G.E. Project is an example of how to partner with a community agency: • Acute hospital and medical care services and • A community-based Area Agency on Aging

5. Area Agency on Aging Programs Mission: To provide older adults and their caregivers long-term care choices, consumer protection and education so they can achieve the highest possible quality of life. Aging Resource Center PASSPORT Home Care Medicaid Waiver Assisted Living Medicaid Waiver Community Services Division Care Coordination Alzheimer’s Respite Program Family Caregiver Support Elder Rights Division

6. Who were the partners?Summa Health System Geriatric Medicine Department 6 Hospital System 2,027 licensed beds 61,800 admissions Level 1 Trauma 113,059 ED visits Community Locations 4 outpatient health centers Wellness Institute – medically-based fitness Health Plan 110,000 Covered Lives 16,000 Medicare Risk HMO Major Teaching Residency and Fellowship Program Post Acute/Senior Service Line 10 Certified Geriatricians 12 Geriatric Certified APNs Continuum of Care Acute Care/Acute Rehab/ LTAC/ SNF Beds Home Care/ Hospice/ Home Infusion/ HME SummaSt.Thomas Hospital Summa Akron City Hospital SummaCare, Inc. Summa Western Reserve Hospital

7. A Comprehensive ApproachSenior and Post Acute Services Existing Services and Programs>>>INSTITUTE

8. Wagner’s Chronic Illness Model Change that Works Community Resources and Policies Health System Organization of Health Care Self- Management Support • Clinical • Information • Systems Decision Delivery Support System Design Productive Interactions Prepared, Proactive Practice Team Informed, Activated Patient Improved Functional and Clinical Outcomes

9. The S.A.G.E. Project(Summa Health System/Area Agency on Aging, 10B/Geriatric Evaluation Project: A Successful Health Collaborative(Est. 1995) Improving Care through Collaboration: Integration of the Aging Network and Acute and Post Acute Medical Care Services

10. Key Historical Collaborative Programs • Interdisciplinary Community Aging Network Committee (ICAN) - forms and communication processes. (1995) • Imbedding AAA care managers in clinical sites, i.e., Center for Senior Health and Acute Care for Elders (ACE) Unit. (1998) • Widespread AAoA RN Assessor Program. (2000)

11. Key Historical Collaborative Programs Area Agency and ODA Grant: Integrated care planning for Medicare Advantage health plan and AAA case managers. Used Appreciative Inquiry technique to build relationship. (2003) Care Management Interdisciplinary Team at the AAoA with geriatrician and pharmacist (CMIT). (2006) Use of Extended Care Information Network (ECIN) between hospital and AAoA case managers. (2008)

12. Key Historical Collaborative Programs Integration of AAoA RN assessor and case manager to large rural primary care office. (2008) AHRQ funded - After Discharge Management of Low Income Frail Elderly (AD-LIFE) RCT Trial. (2005-2009) NPCRC funded - Promoting Effective Advance Care in the Elderly (PEACE) RCT Pilot Trial. (2009)

13. The Strength and Frailty of Interdisciplinary Teams “ The healthcare system is poorly organized to provide care to a population increasingly afflicted by chronic conditions. One remedy, is to provide team-based care to coordinate all aspects of patient treatment, from medical exams to social services”. -The Institute of Medicine report, Crossing the Quality Chasm: A New Health System for the 21st Century, March 2001

14. The AD-LIFE TrialAfter Discharge Care Management of Low Income Frail Elderly Kyle R. Allen, DO* Kathy Wright, MSN* Susan Hazelett, MS* Lynn Clough, MA* Dave Jarjoura, PhD** Eugene Pfister, MD*** Summa Health System *Health Services Research and Education Institute **The Ohio State University ***Akron General Medical Center Agency for Healthcare Research and Quality Supported by Grant # R01 HS014539 Supported by Summa Foundation

15. AD-LIFE: A Model of Integrated Care The AD-LIFE Trial will test the effectiveness of interdisciplinary care management that integrates medical and social care to improve patient’s overall health and well-being.

16. AD-LIFE: A Model of Integrated Care The AD-LIFE model was designed to test the effectiveness of interdisciplinary care management that integrates medical and social care to improve patient’s overall health and well-being Initiated at time of acute hospitalization Transitional care components applied after discharge at time of enrollment Care management intervention for 12 months (six months focus on health coaching and patient activation for self care)

17. Key Points Post-discharge care management of low income frail elderly Nurse care manager activation of client Collaboration between a hospital-based interdisciplinary team, Area Agency on Aging, and PCP Integration of acute and long-term care

18. Who > 65 years Hospitalized with likelihood of returning home Medicare/Medicaid, PASSPORT, or eligible CHF, COPD, DM, Stroke, Osteoarthritis, Osteoporosis, HTN, CAD 1 Activity of Daily Living or 2 Instrumental Activities of Daily Living prior to admission

19. Where, What, How:Post-Discharge Model Within 48 hrs post-discharge, the AD-LIFE RN Case Manager (RN-CM) will contact patient by phone to ensure immediate transitional care needs are met Within 1 week of discharge, the Geriatric Clinical Nurse Specialist (CNS) and RN-CM will perform an in-home comprehensive geriatric assessment Findings from assessment presented to interdisciplinary team (e.g. AD-LIFE CM, geriatrician, pharmacist, AAoA social worker)

20. Where, What, How:6-12 months care management Care plan developed and sent to primary care physician (PCP) using Assessing Care of Vulnerable Elders (ACOVE)* guidelines and geriatric principles as framework RN-CM meets face-to-face PCP to review care plan AD-LIFE RN CM in collaboration with PCP and other agencies, implement care plan over the next 6 months. Both groups measured at 6 months and 1 year. * Assessing Care of Vulnerable Elderly. Ann Intern Med. 2001;135:647-652

21. Assessing Care of Vulnerable Elders(ACOVE) Quality Indicators Change Multidisciplinary Consensus panel of the leading experts in geriatrics Developed first ever set of quality indicators (QI) for older adults and specifically for geriatric conditions, e.g., dementia, falls, incontinence.

22. Benefits of Office Visit Patient benefits: A “health coach” to help them navigate the health system Client then learns to navigate and self-manage Someone to educate them about health care and chronic conditions Physician/Office benefits: Assistance with the most complex and labor intensive patients Decrease office resources and staff time. Support and educational resource for care of complex patients.

23. Quality Outcomes • Functional Performance • Institutionalization • Quality of Life • Quality of Medical Management • Quality of Self-Management

24. AD-LIFE Demographics Mean age 74.78 (SD 7.42) range 65-96 Percentage Female 83.77% Living Arrangements Alone 63.40% Relative 32.45% Non-relative 3.96% Assisted living 0.19% Race African American 27.92% Caucasian 71.32% Other 0.76%

25. AD-LIFE Demographics Marital Status: Married 11.32% Widowed 39.80% Divorced 38.11% Single 10.19% Enrolled in Passport 68.3% Mean LOS for enrollment hospitalization 4.5 days (SD 3.6) Enrolled in traditional Medicare/Medicaid 67.7% 9.1% are Medicaid only, 2.8% traditional Medicare only, 20.2% Medicare Advantage Plans with or without Medicaid

26. Keys for Success Working collaboratively with PCP Goal setting with the patient ~ Emphasis on Chronic Disease Self Management principles Keeping care local and within established network and aging network resources and coordinated linkages Integrated health care system Willingness to participate and provide feedback

27. PEACE TRIAL Promoting Effective Advanced Care for Elders Kyle R. Allen, DO* Steven Radwany, MD* Susan Hazelett, MS, RN* Denise Ertle, MSN, RN, CNS* * Susan Fosnight, RPh, CGP, BCPS* Pamela Moore, PharmD, BCPS* Patricia Purcell, MSN, RN, CNS * * * Barbara Palmisano, MA * * * * Ruth Ludwick, PhD, RN.C, CNS* * * * * * Summa Health System, Health Services Research and Education Institute * * Area Agency on Aging 10B, Inc.* * * The University of Akron * * * * Northeastern Ohio Universities Colleges of Medicine and Pharmacy * * * * * Summa Affiliate, Robinson Memorial Hospital The PEACE Trial is supported by The National Palliative Care Research Center & the Summa Foundation Area Agency on Aging, 10B, Inc. | Summa Health System | NEOUCOM Kent State University | The University of Akron

28. Purpose of the PEACE Pilot Study • This randomized pilot study will determine the feasibility of a fully powered study to test the effectiveness of an in-home interdisciplinary geriatric- palliative care management intervention to improve the quality of palliative care for consumers of Ohio’s community-based long-term care Medicaid waiver program, PASSPORT.

29. Health Care Utilization Experience for Patients with Chronic Conditions: Current Health Care System Community-dwelling chronically ill patient with poor symptom control and coordination of care whose advance care wishes are rarely documented Hospitalization prompting advance care decisions (often by the family) Exacerbation of chronic illness

30. Palliative Care and Advance Care Planning Independent Management Advance Care Planning Hospice Symptom Management Disease Management Death Diagnosis

31. Patient Centered Care Well Older Adults Cancer AIDS Gait Disorders Cancer (<65) Stroke Preventive care Genetic/ Developmental Disorders Advanced Organ Failure Palliative Care Geriatrics Stable chronic dx Chronic Critical Illness Geriatric syndromes Pediatric Oncology Frailty Peri-operative care Cystic Fibrosis Dementia Osteoporosis TBI Morrison , Sean NPCRC

32. Target Population PEACE Pilot Study New PASSPORT enrollees >60 years old with one of the following diseases and the corresponding level of severity will be eligible for inclusion: • CHF and being actively treated (AHA class C) • COPD and on home O2 or nebulizer treatments • Diabetes with renal disease, neuropathy, visual problems, or CAD • End-stage liver disease, cirrhosis • Cancer (active, not history of) except skin cancer • Renal disease on dialysis • ALS with history of aspiration • Pulmonary hypertension • Parkinson’s disease (stages 3 and 4)

33. Unique Features/ Successes • Strong working relationship and commitment by the AAoA • Addressing advance care planning and activation for self management at time of “change in support needs” e.g. independent to LTC needs • Culture sensitivity and knowledge between aging network and acute care sector- “becoming bilingual” • Outgrowths of other educational projects, additional funding for PC research, and bridging the community network and acute sector

34. A success story • 60 y/o female, caregiver for two chronically mentally ill sons • COPD, CHF, Depression and Pain • Difficulty breathing with walking, on chronic oxygen now. • State goal: “I want to go back to work” • PEACE team meeting • Most disturbing symptoms • Medication changes per pharmacist • Pain better controlled • Outcome with PEACE intervention • Outcome without PEACE intervention????

35. Additional PEACE Related Projects: • A survey of knowledge and attitudes about ACP and PC sent to all area PCPs. Funded by the Summa Foundation. • A statewide survey of all care managers at all AAoA that will examine knowledge and attitudes regarding ACP and PC. Funded by Northeastern Ohio Universities Colleges of Medicine and Pharmacy. • An video on-line educational program to teach AAoA care managers how to bring PC upstream in the disease process. Funded by the First Merit Foundation.

36. Transitions of CareAD-LIFE, PEACE, and Bridge to Home • Post-discharge care management of low income frail elderly • Nurse care manager activation of client • Collaboration between a hospital-based interdisciplinary team, Area Agency on Aging, and PCP • Integration of acute and long-term care • Transitional care to reduce readmissions • The Center for Senior Health and Senior Services • Consult and support across the continuum including outpatient, inpatient, house calls and skilled/long- term care • Addresses medical and psychosocial • The Primary Care Physician • Medical model • Limited time with patient AD-LIFE, PEACE, & SummaCare’s Bridge to Home • The Area Agency on Aging • Social service model but now becoming more integrated • Care management and services for long-term care • Limited interaction with PCP • Addresses functional abilities/geriatric syndromes but challenged with high risk enrollees with multiple chronic illnesses • AD-LIFE trial is supported by the Agency for Healthcare Research and Quality Grant # R01 HS014539. PEACE is funded by the National Palliative Care Research Center. Both are supported by the Summa Foundation. • Bridge to Home is funded by SummaCare.

37. Key Points • No single organization can tackle complex social, community, human service problems in a silo. • Working in effective collaboration can overcome many obstacles and barriers that lie beyond the scope of any single entity through sharing and combining talents and creative solutions. • When done effectively “the whole is more than sum of the parts”. • Outputs are greater • Synergy builds • Energy builds • Effective collaboration is a team sport between two or more organizations.