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.”

Thank you ~Q & A

Audience Questions

Suggestions for leading a practice change during a time of unforeseeable and unpredictable change?What one thing worked the best in your

experience?Suggestions for leading culture change?