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The Role of the RN Care Manager in the Geriatric Assessment Clinic Our Unique Medical Home Model for the Cognitively Impaired. Lori Willis, BS, RN, CPHQ Hazel Torres, MN, RN. Florence Nightingale Quote.
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The Role of the RN Care Manager in the Geriatric Assessment ClinicOur Unique Medical Home Model for the Cognitively Impaired • Lori Willis, BS, RN, CPHQ • Hazel Torres, MN, RN
Florence Nightingale Quote “ So never lose an opportunity of urging a practical beginning, however small, for it is wonderful how often in such matters the mustard-seed germinates and roots itself. ”
Our “Practical Beginning” • One MD, one afternoon • Geriatric focus • To assist primary care providers • To improve utilization • To help the patients stay home
Dementia and Cognitive Impairment • Over 5.4 M Americans diagnosed • 5th leading cause of death over 65 years • 80% of care delivered by (unpaid) family members – about $210 billion • Cost of Care about $183 billion annually
Our Journey • Our team • RN Care Managers • Geriatric MD • Social Worker • Pharmacist • Support staff • Services provided • Initial Consults and Assessment • Care Management by the RNs • Telehealth with extended hours • Neurology and Psychiatry services
When Change is Inevitable • When the home is no longer safe • Home Health • Referral and Placement into Long-Term Care facility • End of Life Care • Palliative Care • POLST
The RN Role Coordinate Communicate Advocate Plan of care throughout the continuum For advice, support and consistency of care For the patient and the caregivers
Letter from Family Member “ Throughout this whole adventure of Alzheimer’s, you have been my help, my support, my source of information and the people who knew and understood what he and I were going through and cared about.” — Ann, wife of former patient
Where We Are Today 1500 patients being followed in our program Two interdisciplinary teams in place Focus on care coordination Resource to other providers and departments
Where We Are Today • Referral volume steadily increasing:
Where We Are Today – Program Strengths Comprehensive multidisciplinary consult Team conference with development of detailed treatment plan Geriatric staff availability
For the Patient For the Department For the Organization Geriatric Assessment Clinic – A Win For All • Treatment plan tailored to individual needs and situation • Improved compliance means better quality of life • Greater satisfaction knowing every aspect of care is addressed • High scores in patient satisfaction surveys • Increased staff satisfaction with team environment • Lower turnover rates and sick days • Improved utilization of emergency resources • Successful medical home; decreased hospital admissions • Greater patient & family satisfaction
The Role of the RN Care Manager in the Geriatric Assessment ClinicOur Unique Medical Home Model for the Cognitively Impaired • Lori Willis, BS, RN, CPHQ (Lori.X.Willis@kp.org) • Hazel Torres, MN, RN (Hazel.Torres@kp.org)
