improving advanced illness care · •622 aaas nationwide, in every community •45-year history of...

Supporting the Aging Network’s Role in Improving Advanced

Illness Care

C-TAC NATIONAL SUMMIT ON ADVANCED ILLNESS CARE

Breakout Session IV

Thursday, October 10th1:30pm–2:45pm

Brian Lindberg, Public Policy Advisor, Coalition to Transform Advanced

Care

It is well-established that the quality of care for persons with an advanced illness

is tied to both the health care services and the community-based services and supports that they receive. If these and other factors are in sync, it is more likely

that the individual with an advanced illness will receive the care and treatment

that reflect his/her values and preferences.

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Why Partner with the Aging Network?

Often die in hospital, in pain and isolation

THE PROBLEM OF “THE BIG GAP”

Often unwanted, ineffective over-treatment

At great cost to families and the nation.

What People Want What They Get

Often recycled in and out of the hospital

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1. Coordinated care in the home

2. Have pain managed and “comfort” care

3. Be at home with family, friends

4. Avoid impoverishing families/being a burden



• Integrating health care and social services, such as meals and nutrition services, transportation, case management, and caregiver support, is particularly important for those facing advanced illness who typically live with multiple chronic conditions, pain and other symptoms, functional dependency, frailty, and significant family caregiver needs.

• The Aging Network, especially the country’s Area Agencies on Aging (AAAs), are THE experts on these kinds of social supports. The Network brings:

• Local knowledge and community trust

• Nationwide scale

• A long history of person-and-family centeredness

• Unrivaled experience delivering home and community-based services

• An ever-increasing business sophistication enabling healthcare partnerships

National Association of Area Agencies on Aging

Area Agencies on Aging

• 622 AAAs nationwide, in every community

• 45-year history of being the trusted resource on aging at the community level

• Older Americans Act is foundational for all AAAs, but because the law calls for local control and decision-making, AAAs adapt to the unique demands of their communities to provide innovative programs that support the health and independence of older adults

• AAAs leverage other funding and operate other programs, such as Medicaid HCBS

C-TAC & n4a Partnership Objectives

• Supporting the nation’s Area Agencies on Aging (AAAs) and others in the Aging Network to develop programmatic and legislative solutions to strengthen community-based organizations (CBOs) and their ability to deliver community-based care and support to those living with advanced illness and their families.

• Key Vehicles: • Older Americans Act (OAA) Reauthorization• Projects and tools to support aging network knowledge and services

• Working together with other key health care, social service, and policymaking stakeholder groups, including the Administration for Community Living (ACL) and the CMS Center for Medicare and Medicaid Innovation (CMMI), to develop avenues for reimbursement and integration of AAAs and other CBOs into new payment and delivery models (APMs).

• Key Vehicle: CMMI Payment Models

Roadmap for Success

• Establishing workgroups of n4a and C-TAC members to identify and prioritize key issues and strategies to move work forward.

• Pursuing a broad outreach and communications strategy to educate stakeholders on the value of Aging Network – Advanced Illness Collaboration

• Webinars (like this one!)

• Blogs (First in series : Pima Council on Aging’s advance care planning innovation)

• White papers (ex. A roadmap for AAAs and aging network providers on how to integrate advanced care principles and best practices.)

• Toolkit(s)

• Legislative proposals

• Advocacy with key decisionmakers across the spectrum• Policymakers

• Administration officials

• Providers

• Payers

Areas for Collaboration

• Information and Referral

• Care planning and assessment

• Family caregiver support

• Workforce education and training

• Payment innovations and barriers

• Advance care planning

Thank you!

For more information about the C-TAC – n4a Aging Network partnership project, contact:

Davis Baird, C-TAC Policy and Advocacy Manager at [email protected] or

Andrew MacPherson, C-TAC Senior Policy Advisor at [email protected] or

Brian Lindberg, Public Policy Advisor at [email protected]

mailto:[email protected]



BUILDING CAPACITY FOR SUSTAINABLE EDUCATION AROUND SERIOUS ILLNESS AND END OF LIFE CARE

Jessica Hausauer, PhD

Program Director

Live Well at Home Program

• Develop and/or provide services for older Minnesotans to live and age in the community of their choice

• Support home and community-based services

• Strengthen supports for solo agers, family, friends, and neighbors caregiving

• MNHPC funded 2014-2016; 2018-2019

• Lores Vlaminck, Principal, Lores Consulting, LLC

• Rivertown Communications, Inc.

• Area Agencies on Aging

Purpose:

1. Population is aging, growing more diverse

2. Living longer with complex, chronic health

needs

3. To effectively plan for serious illness and

end-of-life, older adults and their families

need information about advance care

planning, hospice, and palliative care

4. HCBS providers are on the front lines of care

and can play a role in sharing information

GOAL:

Increase the

availability of

consistent,

accurate, and

culturally relevant

information

regarding serious

illness and end-of-

life care to older

adults across the

state of Minnesota

Outcomes

2014-2016

• Trained 460 individuals across 16

locations

• In-person; 4 hours

• Fundamental level

• Developed consumer materials

2018-2019

• Trained 60 individuals across 4

locations

• In-person; 4 hours

• Intermediate level

• Developed on-line course

Training and Course Modules

• Health Care Directives

and POLST

• Palliative Care

• Hospice

• Payment

• Professional

Boundaries

Consumer Resources and On-line

Course Frequently Asked Questions

Consumer Guide

Videos and Radio Stories

The Basics of Serious Illness and End-of-Life

https://www.mnhpc.org/assets/docs/HospiceFAQ_General_lgtxt_8.5x11_ADA.pdf

https://www.mnhpc.org/the-hospice-stories-project

Attendees

Agencies

• AAAs

• County Public Health Departments

• Senior Living Communities

• DARTS

• Family Pathways

• Home care

• Hospice

• Lutheran Social Services

• Medica

• Wilder Foundation

Job Titles

• Community Living Specialist

• Senior Linkage Line Specialist

• Care Coordinators

• Home Health Aid

• Aging Care Specialist

• Caregiver Consultant

• Program Developer

• RN

Evaluation and Next Steps

Learnings and Next Steps

• Widespread need for education

• Veterans Benefits area of interest and need

• Phase II trainees = strong understanding of health care directives

• Gained most knowledge related to eligibility for palliative care and difference between hospice and palliative care

• Next: widespread dissemination of on-line course

Evaluation

Improving Advanced

Illness CareSharing Our Journey with Advance Care Planning &

Specialized Intervention

What is Advanced Illness?

Advanced illness is defined as one or more conditions

becoming serious enough that general health and

functioning begin to decline, curative treatment loses

its effectiveness, and care becomes increasingly

oriented towards comfort – this process extends to the

end of life.

Aging & In-Home

Services of NE

Indiana

Area Agency on Aging

Aging & Disability Resource Center

9 County Service Area (AAA & ADRC)

Strategic Priority for Growth – Integrated Care

CMS Demonstration CCTP (30 Counties; 10 Hospitals)

Partner – Development of Health IT Platform for Community Agencies and SDOH—Population Health Logistics

Partner – Preferred Community Health Partners, LLC & GroundGame Health™

PACE of NE Indiana, LLC

2019 Aging & In-Home Services of Northeast Indiana, Inc.

AIHS – Federal & State

Designated Area Agency on Aging


Client Population: Fee-for-service Medicare eligible patients 65 years of age and over

Service Area: Discharging to a home setting in one of 33 counties including Ohio and Michigan.

Initial admission diagnosis limited to: Acute Miocardial Infarction (AMI), Congestive Heart Failure (CHF), Pneumonia (PN), Chronic Obstructive Pulmonary Disease (COPD)

Referrals to Family Caregiver Program to support education on advanced illnesses and advance care planning

CMS Community-based Care Transitions Program (CCTP)


AIHS Involvement with

Advance Care Planning

Coalition formed in 2014 to address Indiana Physician’s Orders for Scope of Treatment form

Pilot Project using the Respecting Choices® model of Advance Care Planning

AIHS emerged as natural leader due to ability to work across health systems and organizations

Honoring Choices® Indiana formed in 2016

Respecting Choices® Advanced Steps Faculty on staff (1 of 2 trained in the State of Indiana)


Intent of Statewide Initiative

Promoting and sustaining advance care planning across the state to ensure individuals’ future

Health care preferences are discussed, documented, and honored


Honoring Choices® Indiana

Support structure for regional ACP coalitions/initiatives with the goal of speaking the same ACP “language” throughout the state

Initiatives Include:

Funding: Designated by a grant through the Indiana University School of Nursing for more than 5 years

Education for providers on ACP

state laws

Standardized training

tools/handouts (ACP Brochure)

Involvement in ACP legislative bills (identifying

issues & dissemination for comment)

Convening ACP groups together for discussion

and identifying best practices

within the state


The Role of Advance Care Planning

within our AAA Community

Incorporate ACP within Case Management & ADRC: fits with person-centered counseling

Division on Aging identifying ACP as an objective in the State Plan on Aging

Population Health and Care Transitions Programs

Regional and State Quality Improvement Initiatives

•Nursing facility groups, community care transition coalitions, and palliative care advisory council

Partnership with Healthcare Providers

•Health systems are becoming more aware of the need for improving ACP (bundled payments)

Partnership with Bar Association


Evolving Specialized Intervention

for Seriously Ill Clients

AIHS has been developing an evidence-informed,

specialized intervention for clients who have been

diagnosed with advanced serious illness.

Specializing our intervention began with the work we

did as part of our PCORI research partnership with Dr.

Lee Lindquist, Northwestern University to develop

PLANYOURLIFESPAN


5 Key Components of AIHS Specialized

Intervention for Seriously Ill Clients

Advanced Illness Trajectory

•Initiate discussions to fully understand the client diagnosis and utilize the trajectory of the illness to plan ahead for HCBS needs.

Interdisciplinary Care Team

•Encourage (and assist) client to develop their own multi-disciplinary “care team” to support them through this journey. (Medical, social, legal, etc.)

Family Caregiver Engagement

•Initiate relationship with Family Caregiver ASAP and ensure they are supported throughout their loved one’s illness.

Anticipated Care Transitions

•Plan ahead for additional Care Transitions support (if frequent or multiple hospitalizations are anticipated).

Advance Care Planning

•Emphasize importance of Advance Care Planning as a way of ensuring the individual’s wishes are respected.


2019 PCHP, LLC

How we

operate

PCHP utilizes a standardized evidence-informed care transitions and care coordination model fully aligned with NCQA principles for person-centered care.

PCHP does not replace the MCO Case Manager but extends their work into the member’s home and community.

Our technology platform is HITRUST certified and provides for the electronic transmission of data as well as analysis of outcomes.

2019 PCHP, LLC

PCHP / GroundGame Health™ Model

2019 PCHP, LLC

GroundGame Health™Commercial • Medicare • Medicaid

Preferred provider network of Preferred Community Health Partners, LLC. (PCHP)

2019 PCHP, LLC

Inter-operable Health IT Platform

Risk Stratification

Data Analytics

Predictive Capabilities

2019 PCHP, LLC

A “Smart Network”

NCQA

Evidence-Based & Evidence-

Informed Models

Continuous Improvement

Emphasis on Quality

2019 PCHP, LLC

National Aging & Disability NetworkPartners in Caring for Seriously Ill Patients

Across the Country

Supporting the Aging Network’s Role in

Improving Advanced Illness Care

Caroline Ryan

U.S. Administration for Community Living

Agenda

• Overview of the Administration for Community

Living (ACL)

• ACL Education and Advocacy Activities

• Principles for Person-directed Services and

Supports during Serious Illness

• Supporting the Aging Network Role/ Future

Opportunities

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ACL Organizational Chart

Administration on

Aging

Administrator &

Assistant Secretary

for Aging

Principal Deputy

Administrator

Chief of Staff

Center for

Innovation &

Partnership

Administration on

Disabilities

National Institute

on Disability,

Independent Living,

and Rehabilitation

Research

Center for Policy

and Evaluation

Center for Management

and

Budget

Office of External

Affairs

Center for Regional

Operations

Aging and Disability Service Network

Administration

on Aging

(Older Americans Act)

❖ 56 State Units on

Aging

❖ 629 AAAs

❖ 244 Tribal

organizations

❖ 2 Native Hawaiian

organizations

❖ 29,000 local service

providers•

Administration on Intellectual

and Developmental

Disabilities

(Developmental Disability Act)

❖ 56 State Councils on

Developmental Disabilities

❖ 68 University Centers for

Excellence in Developmental

Disabilities

❖ 57 Protection and Advocacy

programs

Independent Living

Administration

(Rehabilitation Act)

❖ 54 State Independent

Living Councils

❖ 354+ Centers for

Independent Living

Adapted from: Putnam, N. Bridging Knowledge in Long Term Care and Support: Crossing Network Lines. 200940

ACL Education and Advocacy Activities

• Advanced Care Fact Sheets

• Video Guide to Advanced Planning

• ACL Blogs

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Advanced Care Planning Fact Sheets

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https://eldercare.acl.gov/Public/Resources/Advanced_

Care/Index.aspx

Video Guide to Advanced Planning

43 https://longtermcare.acl.gov/how-to-decide/

ACL Blogs

44

Principles for Person-directed Services

and Supports during Serious Illness

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https://acl.gov/sites/default/files/Aging%20and%20Disability%20in%20America/Serio

us%20Illness%20Principles%208-30-17%20508%20compliant.pdf

Principles for Person-directed Services

and Supports during Serious Illness

• Were designed to:

• Promote choice and control for people with serious illness, while taking into account their unique life circumstances

• Help people plan for serious illness

• Help families, family caregivers, and service providers honor the choices of people with serious illness

• Assist people with serious illness in choosing and controlling services according to personal values, priorities, and goals

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Concepts Underlying Principles

• People need to be informed about their conditions and have the opportunity to express their preferences

• Service providers should respect those preferences and place individual choices at the center of treatment decisions

• Choices may be to accept or refuse treatment

• Service providers should honor the individual’s choices, help manage their symptoms, and provide needed emotional and spiritual supports to them and their families

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Principles1. Live with serious illness according to personal values and goals

2. Enable choice of services

3. Avoid discrimination

4. Enable choice of representative

5. Carry out person-directed planning and decision-making

6. Access to care coordination

7. Choose among services and supports

8. Deliver palliative care

9. Provide hospice care

10. Provide independent advocacy services

11. Educate and support providers

12. Support family caregivers

13. Address the concerns of older adults; people with disabilities, including those with developmental disabilities; and their family caregivers

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National Center on Advancing Person Centered

Planning, Practices and Systems (NCAPPS)

49https://ncapps.acl.gov/

Opportunities for the Aging Network

50

Contact Information:

Caroline Ryan

Administration for Community Living

[email protected]

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improving advanced illness care · •622 aaas nationwide, in every community •45-year history of...

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