Presentation is loading. Please wait.

Presentation is loading. Please wait.

Creative Approaches to Complex Patients

Similar presentations

Presentation on theme: "Creative Approaches to Complex Patients"— Presentation transcript:

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 ©AAHCM

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 ©AAHCM

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 ©AAHCM

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 ©AAHCM

5 High Spending on Health Care
Per capita data downloaded from OECD.StatExtracts. Available at ©AAHCM

6 Inclusion of social service spending
Source: OECD, Health at a Glance 2009: OECD Publishing ©AAHCM

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! ©AAHCM

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 ©AAHCM

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) ©AAHCM

10 Philanthropy 501c3 Families often want to give back
Volunteers—staff capacity Demonstrate need Oversight & Reporting Use of non-traditional vendors & contractors Outcomes ©AAHCM

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 ©AAHCM

12 Who benefits from social work services
Socially isolated Complex family/social systems Frail elders Burdened caregivers The community ©AAHCM

13 Social Work Services Our approach Stabilize Strengthen Empower
Crisis Intervention Conflict Resolution Strengthen Care Coordination Counseling Empower ©AAHCM

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 ©AAHCM

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 ©AAHCM

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 ©AAHCM

17 How to integrate social work services into your practice
Waiver program case manager Geriatric case manager-private pay Collaborative partnerships Grant opportunities ©AAHCM

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. ©AAHCM

19 Interventions for Mr. RM
Housing Food resources Medicaid Waiver Advocacy Equipment Bereavement Counseling Transportation ©AAHCM


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 ©AAHCM

22 Helpful websites For Caregivers For Housecall Providers
home- family/caregiving .org (National Association of Area Agencies on Aging) (National Association of Professional Geriatric Care Managers) ©AAHCM

23 Contact Information Julie Beecher MS, MPH Ruth Shea LICSW ©AAHCM

Download ppt "Creative Approaches to Complex Patients"

Similar presentations

Ads by Google