1. Creative Approaches to Complex Patients
MedStar Washington Hospital Center
Geriatric Medicine—Medical Housecall Program
Julie Beecher, Director of Strategy & Operations
Ruth Shea LICSW, Social Worker
Financial Disclosure: No relevant financial relationships
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2. Who We Are Non-profit academic hospital
Non-profit academic hospital setting
Started in 1999 by Drs. De Jonge & Taler
Embedded in Dept of Medicine--Medical Housecall Program (active census—618 patients)
Serve 9 zip codes in Washington DC
90% Medicare FFS; 40% Medicare/Medicaid
~20 FTEs (5 geriatricians ~50% effort; 5 nurse practitioners; 4 social workers; 1 office nurse; 4 support staff ;1 administrator)
~$2 million operating budget
Who We Are
Non-profit academic hospital
Serve 9 zip codes in DC; housecall census 618 patients
Team-based care (20 FTEs)
90% Medicare FFS & 40% Medicare/Medicaid
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3. Mr. RM 74 yrs old Multiple chronic diseases
2009: hospitalized, then to SAR. In process, his toes were amputated; lost his housing; limited mobility; and would have been institutionalized in LTC
Became our patient in January 2010
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4. Programmatic interventions for Mr. RM
Use of the state Elderly & Persons with Disability (EPD) Waiver
Philanthropy for uncovered services and subsidy of social work FTEs
Screening & Intake process
Linkages to other community resources
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5. High Spending on Health Care
Per capita data downloaded from OECD.StatExtracts. Available at stats.oecd.org
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6. Inclusion of social service spending
Source: OECD, Health at a Glance 2009: OECD Publishing
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7. How the money flows for elderly supports
Federal Programs
Agriculture
Health & Human Services
Housing & Urban Development
Social Security Administration
Veterans Affairs
Medicare
Medicaid
Home Energy Assistance
Administration on Aging
Subsidized senior housing & Section 8 housing vouchers
Low-interest loans & rehab grants
Reverse mortgages
Food stamps (SNAP)
Supplemental Security Income
Pioneer in home-based primary care teams!
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8. More on money… Most federal $ thru state/tribal governments
State Health Finance Division
State Aging Services Division
State & Local Housing Authorities
Food programs
Caregiver assistance
Adult Protective Services
Legal Aid
Transportation
Burial Assistance
Medicaid (budget match & administration; for low income)
Medicaid waivers
Programs of All Inclusive Care for Elderly (PACE)
Long Term Care Ombudsman
Senior housing assistance (for low income; long wait lists)
Good link
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9. The Basics of Elderly & Persons with Disablity (EPD) Waiver
What is a state waiver?
Mechanism for states to test new ways to deliver and pay for services within Medicaid
How do I find out what’s in my state?
Search by your location
Benefits to our program
1915(c) Home & Community-Based Waiver: Uses Medicaid $ to provide long term care services in home/community setting rather than institutional settings
Often provide a combination of standard medical & non-medical services (case management, homemaker, personal care aide, adult day care & respite services)
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10. Philanthropy 501c3 Families often want to give back
Volunteers—staff capacity
Demonstrate need
Oversight & Reporting
Use of non-traditional vendors & contractors
Outcomes
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11. Intake Intake Team approach Program Expectations
Patient/caregiver engagement
Intake
Overview of how we work together—the team
Foundation for engagement; helpful if safety i& family issues later
Consents, release of records, expectations
Specialty appointments & transportation
Labs & mobile diagnostics
Equipment, supplies, home-delivery pharmacy if needed
Office nurse introduction (Triage; medical emergencies; after-hours coaching)
Social Work services if needed
Orientation packet (resources, forms) and best contact number to the home
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12. Who benefits from social work services
Socially isolated
Complex family/social systems
Frail elders
Burdened caregivers
The community
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13. Social Work Services Our approach Stabilize Strengthen Empower
Crisis Intervention
Conflict Resolution
Strengthen
Care Coordination
Counseling
Empower
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14. Key tools & skills
Culturally sensitive psycho/social/spiritual assessment
Develop a comprehensive plan
Knowledge of resources and how to access
Advocate for patient/family benefits
Monitor needs
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15. Caregivers- the silent patient
Assess
Interventions
Caregiver’s support system
Respite
Support Groups
Caregiver Burden Interview
Counseling
Depression screening if indicated
Assess the CG
Make sure they have some type of support for every patient assess CG support
CG burden interview
Depression screening CG if indicated
CG support system
Respite
Suport groups
counseling
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16. Outcomes of Social Work Intervention
Patient’s perspective
Quality of Life
Caregiver’s perspective
Empathic ear
Supportive resources
Team’s perspective:
Reduce psychosocial barriers to care
Improved coping
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17. How to integrate social work services into your practice
Waiver program case manager
Geriatric case manager-private pay
Collaborative partnerships
Grant opportunities
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18. Home at last
If it takes a village to raise a child, sometimes it takes a village to keep a senior in his/her own home.
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19. Interventions for Mr. RM
Housing
Food resources
Medicaid Waiver
Advocacy
Equipment
Bereavement Counseling
Transportation
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21. “I would rather die than live in a nursing home… You have a good little club with a whole lot of love. And when there ain’t no love, there ain’t no home. Your people have given me a home.” RM
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22. Helpful websites For Caregivers For Housecall Providers www.alz.org
home- family/caregiving
g.org
.org
(National Association of Area Agencies on Aging)
(National Association of Professional Geriatric Care Managers)
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23. Contact Information
Julie Beecher MS, MPH Ruth Shea LICSW
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