lori willis, bs, rn, cphq hazel torres, mn, rn
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The Role of the RN Care Manager in the Geriatric Assessment ClinicOur Unique Medical Home Model for the Cognitively ImpairedLori Willis, BS, RN, CPHQHazel Torres, MN, RN
2
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. ”
3
Our “Practical Beginning”
One MD, one afternoon
Geriatric focus
To assist primary care providers
To improve utilization
To help the patients stay home
4
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
5
The Model
6
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
7
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
8
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
9
Letter from Family Member
— Ann, wife of former patient
“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.”
10
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
11
Where We Are Today Referral volume steadily increasing:
40
50
60
70
80
90
100
Jan
Feb
Mar
Apr
May
June
July
Aug
Sept
Oct
Nov
Dec
2009
2010
2011
12
Where We Are Today – Program Strengths
Comprehensive multidisciplinary consult
Team conference with development ofdetailed treatment plan
Geriatric staff availability
Geriatric Assessment ClinicQuality and Outcome Monitors
14
75%
84%
76%
50%
60%
70%
80%
90%
2010
2011
2012 NationalMedicare 90%(5 StarsBenchmark)
GAC Influenza Immunization Rates
15
97%
78%
50%
60%
70%
80%
90%
100%
Administered
2012 NationalMedicare 90%(5 StarsBenchmark)
GAC Pneumococcal Immunization Rates
16
148
266
828
0
200
400
600
800
1000
2010
2011
Benchmark
GAC Annual Hospitalization Rates (per 1000 pts)
17
9.04
9.18
9.43
9
8.5
9
9.5
YE 2009
YE 2010
YE 2011
RegionalTarget
GAC Overall Satisfaction with Visit
18
92.2%
93.1%92.8%
88.9%
85.0%
90.0%
95.0%
YE 2009
YE 2010
YE 2011
RegionalTarget
GAC Satisfaction with Nursing Staff
19
Geriatric Assessment Clinic – A Win For All
For the Patient For the Department For the Organization
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
20
The Geriatric Assessment Team …
The Role of the RN Care Manager in the Geriatric Assessment ClinicOur Unique Medical Home Model for the Cognitively ImpairedLori Willis, BS, RN, CPHQ (Lori.X.Willis@kp.org)Hazel Torres, MN, RN (Hazel.Torres@kp.org)
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