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ASSURING QUALITY IN GERIATRICS PRACTICE-A CHANGING ENVIRONMENT
Georgia GAPNA and Arkansas GECMarch 1, 2013Jennie Chin Hansen, RN, MS, FAAN-CEO
www.americangeriatrics.org#geriatrics #3ormore
Agenda
Current Environment Present Situation of Workforce Public Perception of Need The Health Policy and Payment Environment
Alignment What Innovations are Happening to Improve Care
and their Diffusion The Need, Our Opportunity and New Context
Evolving Directions in Framing Health and Care of Older Adults
There is speed in the momentum of reimbursement and delivery system changes in health care
Focus on improving quality and those areas most expensive has become a new culture
There are more concrete population health initiatives that go beyond the hospital and facility settings
Health care payors and providers are learning to expand their consideration of “patient” to “older adult”
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• Survey designed to understand the health care experience of older patients
• Do you have a regular doctor? Are you satisfied with their clinic and hospital-based care?
• Are your doctors asking you about ADLS, IADLs, medications, falls, mental health problems?
• Are they recommending non-medical resources?
• Do you think better training in geriatrics might help?
“How Does It Feel?”
John A Hartford Foundation 04.12
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•Partnered with Lake Research Partners •National survey of 1,028 adults 65 and
older
•Fielded February 29 through March 3, 2012
•Margin of Error: + 3.1 percentage points
Methodology
John A Hartford Foundation 04.12
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Majority Satisfied with Primary Care
0%
3%
27%
69%
Not at all satisfied
Not very satisfied
Somewhat satisfied
Completely satisfied
How satisfied are you with the care you get from your primary care provider?
(N = 976 who have regular primary care MD)
John A Hartford Foundation 04.12
Yes, 93%
No, 6%
DK, Ref 1%
Do you currently have a primary care doctor you see regularly?
Majority Satisfied with Primary Care
0%
3%
27%
69%
Not at all satisfied
Not very satisfied
Somewhat satisfied
Completely satisfied
How satisfied are you with the care you get from your primary care provider?
(N = 976 who have regular primary care MD)
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Attitudes Toward Geriatric Training
Yes, 93%
No, 6%DK, Ref
1%
All medical students and nursing students must take classes and be trained in caring
for children. Do you think medical and nursing students should also be required to take classes in caring for older people?
John A Hartford Foundation 04.12
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Awareness of Shortage
40% of adults 65+ with a college degree or higher have heard of the shortage.
John A Hartford Foundation 04.12
Finance1. Dependable and fair Social Security2. Bring back traditional pensions.3. Higher interest rates
Aging in Place4. Good public transportation5. Walkable neighborhoods6. Universal design
Healthcare7. Home-based healthcare
8. More geriatricians
Technology9. Self-driving cars
10. Intuitive Technology products
10 THINGS AGING AMERICANS WANTU.S. NEWS & WORLD REPORT
Source: Moeller, Philip, http://money.usnews.com/money/blogs/the-best-life/2012/08/06/10-things-aging-americans-want U.S. News & World Report August 6, 2012.
From Our Core Knowledge of Geriatrics Syndromes To..
Population Based Segmentation Well Older Adults, Chronic Conditions, Advanced Illness
and Complexity, Frailty Use of Prevention Based Evidence and greater self care Self Management and Care Coordination Risk Management and Care Transitions Palliative Care Management of Complexity Care and Management of Frailty
The Triple Aimfor the Older Adult
Better Care
Better Health Lower Costs
Maintain best function and engagement in home and community: prevention, self care, coordination
Hospital-Quality and Safety• ACE-Acute Care for Elders• Transitions Programs-
Naylor, Coleman, Boost, Project Red
• NICHE• Value Based Purchasing• Partnership for Patients
Save $$$ for consumer/family, payors, society-Medicare, Medicaid
Examples of Innovative Practices
CMS-Center for Innovations and Other ACA Enabled Efforts Partnership for Patients
Long Term Quality Alliance Coalition example of best practice
Independence at Home ACA Section 3024
Hospital at Home (Johns Hopkins!)
Innovation Center PortfolioLong-Term Care Involvement in Many Areas
Primary Care Transformation● Comprehensive Primary Care Initiative (CPC)● Multi-Payer Advanced Primary Care Practice (MAPCP) Demonstration
● Federally Qualified Health Center (FQHC) Advanced Primary Care Practice Demonstration● Independence at Home Demonstration ● Graduate Nursing Education Demonstration
ACOs● Medicare Shared Savings Program● Pioneer ACO Model● Advance Payment ACO Model
● PGP Transition Demonstration
Bundled Payment for Care Improvement ● Model1: Retrospective Acute Care ● Model 2: Retrospective Acute Care Episode & Post
Acute ● Model 3: Retrospective Post Acute Care ● Model 4: Prospective Acute Care
Capacity to Spread Innovation
● Partnership for Patients ● Community-Based Care
Transitions ● Million Hearts ● Innovation Advisors Program ● Health Care Innovation Challenge
Initiatives Focused on the Medicaid Population
● Medicaid Emergency Psychiatric Demonstration ● Medicaid Incentives for Prevention of Chronic
Diseases● Strong Start Initiative
Dual Eligible Beneficiaries● State Demonstration to Integrate Care for Dual Eligible Individuals
● Financial Models to Support State Efforts to Integrate Care
● Demonstration to Reduce Avoidable Hospitalizations of Nursing Facility Residents
Source: CMMS 2012
Partnership for PatientsTen Priority Areas of Focus
1. Adverse Drug Events2. Catheter-Associated Urinary Tract Infections3. Central Line Associated Blood Stream Infections4. Injuries from Falls and Immobility5. Obstetrical Adverse Events *6. Pressure Ulcers7. Surgical Site Infections8. Venous Thromboembolism9. Ventilator-Associated Pneumonia10. Reducing Readmissions
Source: CMMS 2012* Only area that would not relate to older adults
Community Based Care Transitions Program (CCTP)-Section 3026
Provide Payment for Care Transitions Services to Improve Health and Reduce Readmissions
An Engine & Asset to Connect Hospitals and Communities to Help Patients
47 Sites in Place with Many More on the Way Buttressed by Hospital Engagement Networks,
QIOs, AAAs, ADRCs and Many Other Resources to Reduce ReadmissionsCMS 2012
Frailty Care SettingsHospital-based Services
Clinic-based Services
Geriatrics principles embedded in all services and programsConnected by an integrated, informed, accurate, and available information systemSystem measurement and monitoring across the continuum of care
Status: RobustLinked Services
Status: Progressive FrailtyCoordinated Services
Status: End of LifeFully Integrated Services
Frailty Care Services (at home)
Home and Community-based Services
System Features Enabling Older Adults with Complex Conditions to Live at Home
Warren Wong, MD Kaiser Permanente 2012
Long Term Quality Alliance Initial Best Practices
Cathedral Square Corporation (Housing Corporation)• Evolved from landlord role to advocate monitoring health and
coordinating services help resident stability-• 1 year outcome-22% falls reduction, 19% reduced risk reduction
of those of moderate risk; physically inactive residents reduced by 10%
• July 2011-112 housing projects added• Estimated $40million w health care Savings to Medicare
Independence at Home (IAH) 2009 HB 2560 (Markey) + S 1131 (Wyden) 2010 ACA section 3024 Medically-led interdisciplinary team (MD or NP)
House calls, with technology Portable diagnostics, telemedicine
24-7-365 availability Electronic health record Expertise and experience with model
Keep + use existing Medicare benefits (A,B) Savings (gain-sharing)
First 5% Medicare; then 80% IAH 10,000 beneficiary cap in current demo
Why Independence At Home (IAH)
Immobile, complex population is better served at home Patient and family centered Better insight into illness and needs, better care plan More timely response when getting sick Real opportunity for near term cost savings
Targets highest cost subset with a viable solution that people prefer
Header
Hospital at Home®: Disseminating an Innovative Health Service Delivery Model into Practice Bruce Leff, MD
Professor of MedicineJohns Hopkins University Schools of Medicine & Public Health
Hospitalat Home®23
How Hospital at Home Can HelpWhy We Need It How it Helps Spreading
SuccessCase Studies
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Why We Need It How it Helps Spreading Success
The Future
• 61% chose HAH care• HaH is feasible and efficacious• High-quality care• Fewer complications• Higher satisfaction • Lower costs of careAnn 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.
Less CG stress Better function High provider
satisfaction
Hospitalat Home®
Takeaway themes
Incentives for all are moving in the direction of the “whole person” over time-geriatrics knowledge and quality of care (e.g.transitions of care)
Treating segments of population with the most appropriate health and health care in settings that are most conducive to effectiveness
Consider the whole environment of the person as an asset to health and chronicity maintenance
Engagement and enabling capacity of the person/patient toward health and well being
Enlargement of the caring provider roles-i.e. not just the professionally licensed
Current Heightened Opportunities
Health Systems, Hospitals, Post acute and Community Settings Health Systems-segmentation: focus on most complex ,
at risk Hospitals: reduction of infections and readmissions,
focus on falls, pressure ulcers, medication reconciliation
Post Acute-transfers between hospitals and nursing homes
Community-hospitals working with community orgs
Implications of Our Changing World
Others are Paying Attention-there are specific needs for “older adults”: boomers and those who “show up for care” Traditional: hospitals, post acute and long term care New: e.g ACOs, patient centered medical homes,
convenient care clinics, telehealth, Federally Qualified Health Centers, Naturally Occurring Retirement Communities (NORCs)
Other “Providers” Housing YMCAs Entrepreneurs
Game Changers From Outside Our Usual Players
Mathematicians-using voice technology to help diagnose Parkinson’s disease (10 mins)-implications for neurologists (CNN ”Next” Innovators)
Chronic Disease-Tackled by National Networks (YMCA, OASIS) at 25% of usual cost (adult diabetes)
Aging 2.0-social entrepreneurs
Geriatric Leaders, Catalysts and Facilitators Framing a value that function reigns supreme Person’s (family) goals, confidence and capacity matter
(knowledge, capability and resources) A plan of health, health status and well being is necessary Multiple conditions need competent team management Evidence we have needs to be used Advancing understanding and appreciation of quality of life
while living with disability* Advancing the known “science and best practice” to that of
new inputs that “improve best practice and advance science”
Perceptions of Successful Aging Among Diverse Elders with Late-Life Disability, Romo et al,Gerontologist: Dec 2012
Roles We Can Contribute in Geriatrics Clinical Expert/Care Provider in institutions and home Consultant in Acute, Outpatient, Post Acute, LTC Clinician and Academic Researcher-classic and applying new adaptive models Systems Designer in Various Settings including the
Community
Consultant-a bridge to Those Who “Discover” geriatrics (GEC)
Diffusion Expert of Evidenced Models
Conclusion and Discussion
The need and opportunity for our framing of care, along with our knowledge and skills, is high and will continue to grow Hold to our values of assuring dignity, respect,
voice of our older person and family Assuring the best competency and quality possible from
ourselves and those we enable as teachers, researchers and facilitators
Engage in awareness: Geri-Pal Blog New York Times: New Old Age Blog
Visit us at:
Facebook.com/AmericanGeriatricsSociety
Twitter.com/AmerGeriatrics
www.americangeriatrics.org
Thank you
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