Senior Weak: Improving Professional Expertise in Integrated Care for Older

AdultsLauren N. DeCaporale-Ryan, PhD

Ian M. Deutchki, MDBarry J. Jacobs, Psy.D.

Janelle Jensen, MS. LMFTA

Collaborative Family Healthcare Association 16th Annual ConferenceOctober 16-18, 2014 Washington, DC U.S.A.

Session #A5bOctober 18, 2014

Faculty Disclosure

Please include ONE of the following statements:

• We currently have or have had the following relevant financial relationships (in any amount) during the past 12 months:– Part of Dr. Jacobs’ salary is paid by a proof of concept

grant through Independence Blue Cross

Learning Objectives

At the conclusion of this session, the participant will be able to:

• Describe the challenges to the American healthcare system of our rapidly aging population with increasing prevalence of chronic diseases

• Identify the key components for educating mental and physical health clinicians in family-oriented healthcare for older adults

• Describe three innovative, educational and clinical care programs in senior healthcare

Bibliography / Reference

• 1) US Agency on Aging website downloaded 9-20-14: http://www.aoa.gov/Aging_Statistics/

• 2) Redfoot, D, Feinberg, L, Houser A (2014). Baby boom and the growing care gap, AARP website downloaded 9-20-14: http://www.aarp.org/home-family/caregiving/info-08-2013/the-aging-of-the-baby-boom-and-the-growing-care-gap-AARP-ppi-ltc.html

• 3) Besdine, R., Boult, C., Brangman, S., Coleman, E. A., Fried, L. P, Gerety, M., . . . American Geriatrics Society Task Force on the Future of Geriatric Medicine. (2005). Caring for older Americans: The future of geriatric medicine. Journal of the American Geriatrics Society, 53(6), S245–256.

Bibliography (cont.)• 4) DeCaporale-Ryan, L.N., Cornell, A., McCann, R.M., McCormick, K.,

Speice, J. (2014). Hospital to Home: A geriatric educational program on effective discharge planning. Gerontology & Geriatrics Education, DOI: 10.1080/02701960.2013.858332.

• 5) Hayashi, J. L., Phillips, K. A., Arbaje, A., Sridharan, A., Gajadhar, R., & Sisson, S. D. (2007). A curriculum to teach internal medicine residents to perform house calls for older adults. Journal of American Geriatrics Society, 55, 1287–1294.

• 6) Matter, C. A., Speice, J. A., McCann, R., Mendelson, D. A., McCormick, K., Friedman, S., . . . Clark, N. S. (2003). Hospital to home: Improving internal medicine residents’ understanding of the needs of older persons after a hospital stay. Academic Medicine, 78, 793–797.

• 7) Thomas, D. C., Leipzig, R. M., Smith, L. G., Dunn, K., Sullivan, G., & Callahan, E. (2003). Improving geriatrics training in internal medicine residency programs: Best practices and sustainable solutions. Annals of Internal Medicine, 139, 628–634.

Bibliography (cont.)

• 8) Gawande, A (2011). The hot-spotters. The New Yorker, January 24 downloaded 9-20-14: http://www.newyorker.com/magazine/2011/01/24/the-hot-spotters

• 9) Coburn KD et al (2012). Effects of a Community-Based Nursing Intervention on Mortality in Chronically Ill Older Adults: A Randomized Control Trial, PLoS Medicine, 9(7), 1-14

Learning Assessment

• A learning assessment is required for CE credit.

• A question and answer period will be conducted at the end of this presentation.

Today’s Talk

• Implications of An Aging America• Key Components of Geriatric Education• University of Rochester Training Model

(DeCaporale, Deutchki)• A Frail Elderly, Super-Utilizer Program (Jacobs)• A Disease-Organization-Based Program of

Education and Collaboration (Jensen)

• 43% of current Medicare recipients have 3 or more chronic medical conditions (Federal Interagency Form on Age Related Statistics, 2010)

• Over 40% of adults over age 65 have a functional limitation

Key Components of Family-Oriented Geriatric Education

• Adult and family development• Common medical, social, psychological,

spiritual issues associated with aging (including cognitive changes, retirement, increased dependence, family caregiving)

• Exposure to older adults in multiple settings, including, office, hospital, nursing home, home, community

• Experience working on multidisciplinary teams

MODELS OF GERIATRIC EDUCATIONUniversity of Rochester Medical Center

Family Medicine

• Resources– 2 Geriatricians on faculty– Active Geriatrics fellowship – 566 bed nursing facility with a long tradition of

teaching

Family Medicine

• Aspects of curriculum– 4 week rotation during 3rd year of residency– 2 year longitudinal long-term care experience– Area of concentration– Within practice consultations– Didactic sessions

Clinical Psychology

• Lack of curriculum• Asking trainees to see older adults/caregivers

without specific training• Now offering 6-part luncheon series• Expanding to include Psychiatry Residents

Internal Medicine

• “Hospital to Home”• Standardized patients & geriatric discharge• Development of educational videos

A Super-Utilizer Program for Frail Elderly—Crozer-Keystone Health

System—Springfield, PA

What is an SU Program?

• Created by Jeff Brenner, MD

• (2011 CFHA plenary speaker)

• Family physician from Camden, NJ who focused on highest healthcare utilizers to bend the cost curve

1%5%

10%

50%

22%

50%

65%

97%

$26,767

$90,061

$40,682

U.S. Population Health Expenditures

$7,978

Distribution of Health Care Expenditures for the U.S. Population, According to Magnitude of Expenditure, 2009

The sickest 10% of patients account for 65% of the health care expenses. Dollar amounts are annual mean expenditures per patient. Data from the 2009 Medical Expenditure Panel Survey, adapted from the Commonwealth Fund.

Components of SU Interventions

• Data mining (sometimes across health systems and agencies) to create SU list

• Creation of collaborative multi-disciplinary teams: physicians, nurses, case managers, social workers, mental health consultants, pharmacists, community volunteers

• Assessment procedures and outcome measures• Relationship-building with other healthcare and social

service providers to improve care transitions and marshal community resources

• Strong emphases on social determinants of care, home visits and medical visit accompaniment

IBC Medicare Advantage SU Program

• Crozer-Keystone was approached by Independence Blue Cross in spring of 2013 to create a 1-year- proof of concept, super-utilizer intervention for IBC’s Medicare Advantage patients within the Crozer-Keystone Health System

• We drew on works of Ken Coburn, Dave Moen and Dan Hoefer

• Launched program in January 2014

Our Process

• Analyzed IBC and CK utilization data • Chose 13 patients on basis of utilization, cost to IBC,

losses to CK• Reached out to primary care physicians• Nurse case manager engages patients, conducts

assessments and weekly visits• Uses multidisciplinary team as advisors during

weekly Huddle• Includes family medicine fellows/residents;

psychology, social work, pharmacy students

• CO, 88 year old widow who lives in a multi-generational home.

• Co-morbidities include: DM, CHF, HTN, CAD, Obesity, Peripheral Neuropathy & edema

• Chaotic home environment• Patient having increased

episodes of confusion

0

1

2

3

4

5

6

7

8

LOS

9/4/13 11/4/13 1/4/14 3/4/14 5/4/14

Baseline utilization x 6 mos for CO

INPT

OBS

ER

Engagement

10/4/13 – Admitted for bilateral lower extremities cellulitis 11/20/13 – ER for Edema 11/24/13 – OBS for arm cellulitis 1/7/14 - Admitted pneumonia and CHF 2/5/14 – Admitted for change in mental status/Anemia/UTI Enrolled in Crozer Connections to Health Team program 2/12/14

Deep Dive

• Social milieu/uncoordinated care– Family refused to have homecare RN visits post-

hospitalization– Our team has great concerns about caregiver

burden and capacity, but the family didn’t want increased support services at this point

• Possible dementia versus delirium– Family concerned about increasing confusion

Interventions

• Weekly RN visits (and 3x/week phone calls with family)

• Weekly Psy.D. student behavioral health visits• Coordination of home PCP visit (through residency

program) and home lab draw• RN accompaniment to medical visits• Home medication reconciliation by pharmacists,

physicians, nurse• Supported decreased caregiver burden/increased

family organization

CO’S Outcomes Thus Far

• No hospitalizations from 1/14-8/14• 8/14: hospitalization for possible CVA; turned

out to be Bell’s palsy• Patient’s blood sugars are better controlled• Family has accepted home nursing for wound

care• Primary caregiver still contending with

burnout

Alzheimer’s Association:Western and Central Washington

ChapterPrograms and Services

Janelle Jensen, MS, LMFTACare Consultantjjensen@alz.org

National Programs:

• 24/7 Helpline Services – 800.272.3900– Available for all

consumers, including physicians and other health and mental health professionals

• Physician Outreach– Specific packets of

information for patients to give to PCP or specialist

– Alzheimer’s Disease Pocketbook App

– Healthcare professionals newsletter

Western and Central Washington -Chapter Programs

• Support Groups• Early-Stage Memory Loss• Education• Annual Conference• Family Caregiver Support Program -

Connections

Connections - Family Caregiver Support Program

• Offered to families in the 3 major counties surrounding Seattle, WA

• Funded through county and state grants• Master’s level clinicians deliver services• Collaborate with county respite programs• Services offered include ongoing:

– Emotional support, disease education, consultation, home visits

Moving forward….

• Local providers inviting our program to be part of existing collaborative models

• Clinic hours to be part of family meetings• Home visits• Providing clinical assessment to the team• Connect patient and families to other

association programs

Looking ahead

• Continued growth of our model into Geriatrics and Primary care

• Clients will have greater access to support; keeping caregivers healthy

• Allowing clients/patients to live in the community longer

• This disease is not going away, but the way we perceive and experience the disease process can improve

Session Evaluation

Please complete and return theevaluation form to the classroom

monitor before leaving this session.

Thank you!