Geriatrics Patient Centered Geriatrics Patient Centered Medical HomeMedical Home

Audrey Chun, MDAudrey Chun, MD

Mount Sinai School of Mount Sinai School of MedicineMedicine

Nature of ProblemNature of Problem

Traditional primary care model:Traditional primary care model:• Fragmented care without reimbursement for Fragmented care without reimbursement for

non-procedure care. non-procedure care. • Staff and physician burnout.Staff and physician burnout.• Patient dissatisfaction with healthcare system. Patient dissatisfaction with healthcare system.

Department and Medical Center mission:Department and Medical Center mission:• Explore models to improve the care of older Explore models to improve the care of older

adults and those with serious illness.adults and those with serious illness.• Improve patient satisfaction. Improve patient satisfaction.

Results of Environmental ScanResults of Environmental Scan

Potential models of care:Potential models of care:• Chronic care modelChronic care model• Guided care modelGuided care model• Disease based team management (CHF, Disease based team management (CHF,

IMPACT- depression)IMPACT- depression)• Hospital at homeHospital at home• Geriatrics models: GRACE, home-based Geriatrics models: GRACE, home-based

primary care, PACEprimary care, PACE• Patient centered-medical homePatient centered-medical home

Results of Environmental ScanResults of Environmental Scan

Potential models of care:Potential models of care:• Chronic care modelChronic care model• Guided care modelGuided care model• Disease based team management (CHF, IMPACT-Disease based team management (CHF, IMPACT-

depression)depression)• Hospital at homeHospital at home• Geriatrics models: GRACE, home-based primary care, Geriatrics models: GRACE, home-based primary care,

PACEPACE

• Patient centered-medical home (PCMH)Patient centered-medical home (PCMH) Potential reimbursementPotential reimbursement Fit into our current model of care/resourcesFit into our current model of care/resources Adaptable for geriatrics careAdaptable for geriatrics care

2nd Environmental Scan2nd Environmental Scan

PCMHPCMH• Primary Care Collaborative (PCC)Primary Care Collaborative (PCC)• National Committee for Quality National Committee for Quality

Assurance (NCQA)Assurance (NCQA) GeriatricsGeriatrics

• AGS subcommitteeAGS subcommittee• ACOVEACOVE

Approach to the ProblemApproach to the Problem

Update/transform the existing Update/transform the existing primary care delivery model in our primary care delivery model in our outpatient geriatrics practice to align outpatient geriatrics practice to align with the patient centered medical with the patient centered medical home (PCMH) model with an home (PCMH) model with an emphasis on care for older adults. emphasis on care for older adults.

Target PopulationTarget Population

Academic geriatrics practiceAcademic geriatrics practice• 2,500 community-dwelling older adults2,500 community-dwelling older adults• Average age 85 yearsAverage age 85 years• 1/3 Medicaid eligible1/3 Medicaid eligible• 1/3 identify themselves as Hispanic 1/3 identify themselves as Hispanic • 25% as African-American 25% as African-American • Border of Upper East Side and East HarlemBorder of Upper East Side and East Harlem• No full time providers (fellows, academic No full time providers (fellows, academic

geriatricians) but dedicated full time staff (SW, geriatricians) but dedicated full time staff (SW, NP, RN, MA, registrars)NP, RN, MA, registrars)

Process and Outcome Process and Outcome MeasuresMeasures

Patient satisfactionPatient satisfaction• Outsourced (Press-Ganey) surveyOutsourced (Press-Ganey) survey• Patient “rounding” Patient “rounding”

Staff satisfaction, affective performance:Staff satisfaction, affective performance:• surveys, 360 evals, physician report cardssurveys, 360 evals, physician report cards

QI from ACOVE (screen + appropriate action)QI from ACOVE (screen + appropriate action)• FallsFalls• urinary incontinenceurinary incontinence• memory loss screening and treatmentmemory loss screening and treatment

# Hospital admissions # Hospital admissions Costs (by CMS data)Costs (by CMS data)

Project TimelineProject Timeline

Resource/needs assessment: Resource/needs assessment: August, SeptemberAugust, September

Faculty/staff development: Faculty/staff development: Quarterly, starting in SeptemberQuarterly, starting in September

Staged implementation of QI, patient Staged implementation of QI, patient satisfaction, care coordination satisfaction, care coordination initiatives 2009-2010initiatives 2009-2010

Application for CMS demonstration Application for CMS demonstration project if NY region qualifies.project if NY region qualifies.

Implementing the ProgramImplementing the Program

LeverageLeverage• Funding from Medicare Demonstration projectFunding from Medicare Demonstration project• Initiative to improve patient satisfaction/care qualityInitiative to improve patient satisfaction/care quality

Opportunities Opportunities • Hospital QIHospital QI

StakeholdersStakeholders• PatientsPatients• ProvidersProviders• StaffStaff• Departmental and Hospital AdministrationDepartmental and Hospital Administration• Medical school and studentMedical school and student

Perceived Facilitators/BarriersPerceived Facilitators/Barriers FacilitatorsFacilitators

• Department Chair as advocateDepartment Chair as advocate• MD and nursing championsMD and nursing champions• Patient demand and appreciation of current Patient demand and appreciation of current

carecare BarriersBarriers

• Culture changeCulture change• Healthcare unionHealthcare union• Limited financial resources to add additional Limited financial resources to add additional

FTEs or support additional supportFTEs or support additional support• Increasing demand for services greater than Increasing demand for services greater than

supplysupply

Patient SatisfactionPatient Satisfaction

Patient SatisfactionPatient Satisfaction

Staff SatisfactionStaff Satisfaction

QIQI

FallsFalls• 30% screening documentation30% screening documentation• Initiated reminder for screening Initiated reminder for screening

documentation and decision pathway for documentation and decision pathway for assessment/treatment planassessment/treatment plan

Hospital and Hospital and Emergency Emergency

Room by Coffey Room by Coffey Geriatrics Geriatrics PatientsPatients

ED Use

Inpatient Admissions

None 58%

1 adm. 24%

2+ adm. 18%

2+ visits 9%

None 72%

1 visit 19%

Sustaining the ProgramSustaining the Program

Improvements in any of the outcomes Improvements in any of the outcomes areas would be considered “successful” areas would be considered “successful” to maintain current resources and FTEs. to maintain current resources and FTEs.

Additional funding would provide Additional funding would provide incentive for expansion to meet needs. incentive for expansion to meet needs.

Exportable deliverables regarding Exportable deliverables regarding practice design for older adults. practice design for older adults.

What I am LearningWhat I am Learning

Even with a supporting environment, Even with a supporting environment, culture change is challenging.culture change is challenging.

Theory to practice is not always so Theory to practice is not always so obvious.obvious.

QuestionsQuestions

Which would have more meaningful Which would have more meaningful impact in the care older adults?impact in the care older adults?• To model a patient centered medical To model a patient centered medical

home that incorporates geriatrics within home that incorporates geriatrics within the current guidelines.the current guidelines.

OROR• To model a geriatrics patient centered To model a geriatrics patient centered

medical home separate from the medical home separate from the existing structure that would better existing structure that would better meet the needs of older adults.meet the needs of older adults.