Staying Home Matters:Proactive Care Management Protocols for Medicaid Waiver Members
Sharon Foerster, L.C.S.W.Director, Elder Independence of Maine
~ a division of SeniorsPlus, Area Agency on AgingMay 21, 2010
Thanks: Atlantic Philanthropies and John A. Hartford FoundationPractice Change Fellows
Elder Independence of Maine (EIM)
Care Management Model
Coordinate in-home servicesLicensed nurses and social workers
3100 consumers throughout Maine
Telephone-based and home visits
Receive assessment, authorized plan of carefrom separate assessing agency
EIM Consumers and Programs
Contract with Office of Elder Services Oversee 3 Medicaid and state-funded
programs Out of the ~ 3100 on 3 programs, ~860 onMedicaid Waiver:
1915 (c) “elderly and adults with disabilities”Nursing facility level of care ~ Maine criteria
most restrictive, high need~ 450: 60 + ~ 153 of those with dementia
EIM Current EnvironmentChallenging!Very tight state budgetsRegulation ChangesProposed legislative actionsAll internal processes under reviewCare managers learning new practices, culture,
new JDReadiness of staff to change practice drops
But before all of this……just over one short year ago
Strategic AlignmentEIM strategically seeking to update the care
management modelUse evidence-based practices, add valueAllow for incorporation of chronic disease
managementAligns with state’s initiative to rebalance
community-based and facility carePractice Change project dovetailed with the
organizational strategy Fundamental components to this project, but will move
us forward in this waiver program in state of Maine
Nature of ProblemCare management practice not based on proactive, evidence-
based approaches with specified protocols Focus on service monitoring, in-home services Little attention to overall health conditions No risk level assignment or screening for risk factors No specific steps taken due to the medical diagnosis Caregivers not systematically approached; even though a key
support, providing much careMissed opportunity to use proactive intervention based on
diagnosis and evidence-based findingsConsumers & caregivers coping with dementia are among
those at highest risk : 5X greater risk of nursing home entry, increased use of medical services
Environmental ScanDementia and long term care are major drivers of Medicaid long-
term care costsResearch demonstrates role of informal caregiver is key:
influences well-being of consumer and nursing home entry decision
Adverse outcomes for caregivers well documented: stress, depression
Involvement of consumer & caregiver is key
Identification of other models for dementia beneficiaries: Medicaid managed long term care (MA and WN) Partners in Dementia Care Model (VA and Alzheimer’s
Association) Cleveland Alzheimer’s Managed Care Model: positive for
clients and caregiversValidated Risk Appraisal Measurement (RAM) tool helps target
interventions
ApproachEIM current practice: not systematic nor evidence
drivenSo – potential for real impact and change, but how?Build on previous success of EBP: this model used:
Screening, education, linkage, action plan Concepts familiar to care managers
New protocols fit in this known framework Example: Use Risk Screening tool (RAM), target the
CM intervention Creates a focused question - guides a targeted
intervention Six Domains: depression, burden, self-care and health
behaviors, social support, safety, and patient problem behaviors
Systematically include the caregiver
Project ApproachDevelop and standardize care management protocols,
stemming from diagnosis, based on evidence to systematically carry out with all Medicaid waivers consumers and their caregivers
Assign and Screen for Risk Assume high risk of the member with dementia Use a validated risk measurement tool (RAM) with
caregiver and member to target the care management intervention and reduce risk
Partner with the Maine Alzheimer’s Association to strengthen linkage of caregiver to this resource
Provide educational materials Chose one chronic illness to start– dementia….
Target PopulationEIM data shows ~33 % - 37 % of our Med Waiver population has a
diagnosis of dementia134 female, 19 male96% white, 2% Asian, 2% Black85% live with a caregiver54% caregivers adult children, 36% spouseAverage length of stay on program is 18 monthsMany in rural areasAssume high utilizers of services (hosp, ER,
readmissions)Assume most at-risk for institutionalization (5 x)
Process and Outcome MeasuresMeasure risk level for caregiver and member
Risk Appraisal Measure (RAM) given at baseline and then three month intervals
Review length of stayGive a satisfaction survey to caregivers at
baseline to measure care manager serviceMeasure care manager process through chart
review of Action Plans where intervention is captured
Anticipated OutcomesFor each month of delayed NF placement, $3000
is saved per person; x153, $476,000 per monthReduction in risk levels
Ease caregiver strainSafer environment for consumer
Goals and targeted interventions met on Action Plan
Increased average length of stay on programPolicy considerations: (by-product) modernize policy
to guide evidence-based practice (new practice inform policy)
Project TimelinePhase 1: through June 2010:
Engaged stakeholders; champions, pioneersPartnered with Maine Alzheimer’s AssociationDeveloped Protocols, mini testChose Measurement Tool, Trained staff on dementia, protocolsCredential staff as Chronic Care Professionals
Phase 2: May 2010 – March 2011:Begin measures
Baseline survey and risk measures of caregivers Pilot protocols, carry out with 50 - 75 consumers and
caregiversReview data at least monthly
Phase 3: November 2010 – June 2011:Begin interpreting data to determine sustainability, need for
change
Lessons Learned – to dateUnderestimated the process of developing a “new”
model of standards and starting from scratchLeading a practice change during a time of
unpredictability is extremely challenging; but also an opportunity
Unlearning the old more difficult than learning the new
Check out “WIIFM?” Financial savings to community-based care is
significant; but to the person with dementia and the family, staying at home cannot be measured in dollars
Staying Home Matters“One of the most precious things that happened as a result of Dad living with us is we make sure he
spends lots of time with my two youngest nieces.”