medical home visits: after the physician team leaves cindy hasz, director grace care management...
TRANSCRIPT
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Medical Home Visits: After the Physician Team Leaves
Cindy Hasz, Director
Grace Care Management
November 10, 2004
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Physician Team to Care Manager
– Referral from Physician Team to Community Care Team
– Assessment, ID needs, Care plan, care coordination, on-going reassessment
– Multidisciplinary team– Feedback system
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ACUTE SYSTEM - Long Term Care - CHRONIC SYSTEM
Vertical Horizontal
Institution centered - Starting Point - Patient centered
Facility-Stationary Residence-Mobile
Crisis based Maintains Normalcy
Single-system based - Method of Delivery- Partnership based
Managed Care Care Management
RIGID - Character of System - DYNAMIC
Fixed-Slow-Inefficient Flexible-Fast-Efficient
Emergency Resolved - Functional Outcome - Health Level Sustained
SHINING A LIGHT ON TWO SYSTEMS
CURRENT MEDICAL SYSTEM
COMMUNITY CARE
MANAGEMENT
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When Necessary, Patient Enters Acute System
Emergency Resolved, Patient Returns to Chronic Care
Community Care Management Allows for the Best Utilization of Both
Systems
ACUTE
CHRONIC
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Community Care Management provides “Circulation”
necessary for the appropriate care for the patient
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Chronic Care Management: Proactive: stabilize at home Prevents acute care use & $$ Based on Quality of Life: dignity, choice Need for recognition of value by Public
funding sources Private sources: LTC insurance,
families, private pay Improved outcomes
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Client Referral Patterns
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Mr. Z
92 yo, lives alone, only son out of state HTN, dementia, risk for “undue influence” APS referral, has assets, at risk for self-
neglect Cognitively unable to follow treatment plan Needed assist w/ADLs and IADLs Placement vs. home care?
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Mr. Z today
In-home care carries out tx plan Controlled HTN, adequate nutrition,
safety, “Gracie”, companionship Cost is $60/day or $2000/month Mr. Z is happy and healthy at home!
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Community Care Management:
Choice
Dignity
Quality of Life.Inland Comprehensive Health Care Community Care Management, Serving the Unincorporated, Rural Regions of San Diego County