Dementia Capable Care Transitions: Better Care and Better Outcomes January 16, 2018

1. Dementia Capable Care Transitions: Better Care and Better OutcomesJanuary 16, 2018 Stakeholder Planning Summit

2. Welcome MISSION NEVADA SENIOR SERVICES Jeffrey B. Klein, FACHE, President & CEO STRATEGY NO WRONG DOOR ACCESS Community Clinical CPI PROGRAMS Nevada Senior Services, Inc.

3. Conference Agenda Facilitator Mike Splaine, Splaine Associates

4. Conference Agenda Facilitator Mike Splaine, Splaine Associates

5. THE NEEDImproving Health Outcomes for Persons with Alzheimer’s Disease and Related Conditions and Their Care Partners Jane Gruner, Special Projects, Nevada Senior Services

6. Start with big picture… …what we do today creates the system of tomorrow.

7. Nevada Population 65+

8. Fastest Population Growth States with fastest population growth in U.S. (2017) • Idaho – 2.2% • Nevada – 2.0% • Utah – 1.9% • Washington – 1.7% • Florida – 1.6% • Arizona – 1.6%

9. Increase in Adults 65+ Largest increase in adults 65+ (ACL 2005 to 2015) • Nevada – 55.3% • Colorado – 53.8% • Georgia – 50.2% • So. Carolina – 48.9% • Arizona – 48%

10. Dementia

11. Nevada Population by the Numbers • # of people: 2.9 million • # age 65+: approx. 435,000 • # age 65+ with dementia: 43,000

12. Nevada Caregivers by the Numbers • # of Caregivers: 145,000 • # of hours of unpaid care: 165 million hours of care annually • Value of unpaid care: $2 billion

13. Increases in Diagnoses and Deaths Increase in # of individuals diagnosed with dementia • 130% SINCE 2000 Deaths from Alzheimer’s dementia • Nationwide increase of 89% from 2000-2014 • Nevada has increased 211%

14. Nevada Medicaid Cost Nevada Medicaid Cost of caring for people with dementia (2017) • $158 million

15. Clark County by the Numbers

16. Clark County by the Numbers # of people: 2.2 million # age 65+: 339,390 # age 65+ with dementia: 33,500 # of Caregivers: 113,000

17. Service Gaps

18. Unmet Needs in Nevada • Funding • Support for family caregivers • Health care system • Education

19. Time for Change!

20. Building Dementia Capability in Southern Nevada • Task Force on Alzheimer’s Disease • Initiatives focused on building dementia-friendly communities. • Development of programs designed to support family care givers. • Collection of statewide data related to dementia, caregivers and cost. • Seeking grant funding to develop innovative solutions to the needs of NV citizens.

21. Nevada Senior Services • Collaborating with partners to provide innovative service solutions. • Adopting dementia capable evidence-based programs. • Creation of the Care Partner Institute • Designation as the Aging and Disability Resource Center for Southern Nevada.

22. Nevada Senior Services • Geriatric Assessment Center • Wellness initiatives • Home Modification Program

23. The Big Idea

24. Care Transitions • Deliver the evidence-based Bridge Transition of Care Model • Provided by a licensed social worker • Collaboration with hospital to ensure seamless continuum of health and community care across settings. • Evidence informed dementia education and innovative practices offered to the individual and care partner.

25. Post-care Transition Plan • Person-centered focused on the values and desires of the individual. • Includes internal and external referrals for on-going supports

26. Short-term Respite Coaching • Short-term respite following acute hospitalization • Provided by dementia trained respite professionals • Assist in managing challenges relate to care transitions

27. Education and Training • Dementia capable education tosupport hospital staff caringfor individual withAlzheimer’s Disease andRelated Dementias. • Deliver information and best practice education to individuals and their care partners as they transition from hospital to home.

28. Expected Outcomes

29. Expected Outcomes • Reduced readmission rates • Reduced emergency department visits • Increased health indicators • Decreased caregiver burden • Increased caregiver coping • Decreased depression • Enhanced patient and caregiver activation

30. Expected Outcomes

31. Together we make a better Nevada

32. The Bridge Model,A Rush University Medical Center Product UNDERSTANDING THE DEMENTIA CARE TRANSITIONS PROJECT Marissa Shoop, MPA, Care Partner Institute Manager, Nevada Senior Services

33. Grants Awarded Nevada Aging and Disability Services Division • Primary Goal: Improve health outcomes & quality of life for people with dementia. • Secondary Goal: Reduce 30 day hospital readmission rates • Objective: Implement an evidence based model that can be sustained and replicated throughout Nevada.

34. Grants Awarded Administration on Community Living • Primary Goal: Improving health outcomes & quality of life with individuals living with dementia • Objective 1: Deliver evidenced-based care transitions model and post care transitions services within a community based dementia capable framework • Objective 2: Offer short-term intensive respite (respite coaching) to care partners for up to 30 days following hospital discharge • Objective 3: Provide dementia capable education and training to hospital staff to better service patients with ADRD and their care partners.

35. Selection of a Model • Identified and reviewed possible evidence-based interventions • Researched care transitions interventions specific to individuals living with ADRD • Community-based model • Ability to integrate within a dementia capable system

36. The Bridge Model • Person-centered, social work-led model • Emphasizes collaboration • Ability to incorporateenhancements of evidence baseddementia education tools • Integration of dementia specificenhancements approved

37. Three Model Phases • Decreased readmissions • Increased physician follow-up • Decreased ED visits • Improved patient engagement • Increased understanding of medications and plan of care • Decreased patient and caregiver stress • Decreased mortality

38. At-a-glance • Delivery: in-person and/or telephonic • First contact: 1 to 2 days post-discharge • Duration: 30 days

39. At-a-glance • Intensity: 20-25 telephonic and/or in-person contacts • Patient, caregiver, family members • Medical providers • Community providers • Resources • Caseloads: 40-45 per month per social worker • Peak activity: 3 to 5 days post-discharge

40. Service Population Criteria Defined by grant requirements and stakeholder input • Currently Serving individuals with ADRD (diagnosed or self-identified) of all ages • Currently hospitalized for any medical condition • Lives at home • Care Partner and Person with ADRD reside together • CP provides +4 hours per week with ADL and IADL • Discharge from hospital to home • Medicare fee-for-service OR

41. Model Enhancement: Understanding the Dyad Patient with ADRD • Health / Physical Well-Being • Health Care Utilization • Patient Health Questionnaire • MOCA (Cognitive Screen) • KATZ (ADL & IADL Caregiver • Health / Physical Well-Being • Health Care Utilization • Patient Health Questionnaire • MOCA • Zarit Screen Measure of Caregiver Burden • Desire to Institutionalize • MOCA (Cognitive Screen)

42. Model Enhancement: Post Care Transitions Service Delivery • 30-day post assessment • Personalized Care Plans • Internal and external information and referrals • Assistance to manager behavioral and psychological symptoms of dementia (BPSD) • Goal: Supporting patient and caregiver to continue to engage in other services for continued support

43. Model Enhancement: Post Care Transitions Service Delivery Internal • Caregiver evidenced-based programs: • RCI REACH • Skills2Care • BRI Care Consultation • Caring For You, Caring For Me • Other supportive programs: • Respite • Support Groups • Home modifications • Wellness programs

44. Model Enhancement: Post Care Transitions Service Delivery External • Referrals to community public and private resources • Long term supportive resources • Basic need programs • Caregiver education and support services

45. Respite Coaching • Post hospitalization increases stress and caregiver burden • Provides a short-term intensive respite services post hospitalization • Dementia trained respite professional • Part of Care Transitions Team • Identify and support the changing needs of individuals with ADRD • Assist in reducing caregiver burden • Understand behavioral and psychological symptoms of dementia (BPSD)

46. Dementia Education and Training For healthcare partners and caregiver Providing support to hospital staff and caregivers by offering education to address challenges and reduce barriers to care. Sample topics: • Communication strategies and techniques • Non-pharmacological modalities to decrease and manage behavioral and psychological symptoms of dementia (BPSD) • Increasing care partner engagement • Care partner support • General dementia education

47. Why Hospitalized as Our Target Population Jeffrey Klein, President & CEO, Nevada Senior Services

48. The Problem Persons with dementia and their care partners experience challenges receiving dementia capable health care and related community-based care transitions services, during and after a hospital stay.

49. The Problem • 25% Hospitalized elderly may have a dementia (with or without diagnosis) • Hospitalization rate persons with dementia 2X cognitively healthy • ED visits & hospitalizations often triggered by • Challenging Behaviors • Chronic or Acute Illnesses • Falls • Admission rate for Urinary Tract infections (UTI) & Pneumonia 80% higher in dementia population

50. Potential For Surprises # of Care Recipients: 167 # of Care Partners: 29