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ElderPAC: Sewing a “Program of All-Inclusive Care for the Elderly” Quilt from Community-Based Patches University of Pennsylvania Jean Yudin, CRNP, Jeanette.

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Presentation on theme: "ElderPAC: Sewing a “Program of All-Inclusive Care for the Elderly” Quilt from Community-Based Patches University of Pennsylvania Jean Yudin, CRNP, Jeanette."— Presentation transcript:

1 ElderPAC: Sewing a “Program of All-Inclusive Care for the Elderly” Quilt from Community-Based Patches University of Pennsylvania Jean Yudin, CRNP, Jeanette Gallagher, MSW Philadelphia Corporation for Aging (PCA) Susan Meyer, MSW, Wendi Botnick, MSW Campaign for Better Care Webinar June 30, 2010

2 Long Term Care: Deconstructing a Nursing Home Long Term Care: Deconstructing a Nursing Home Complex Health Management Complex Health Management Independence at Home Home HCBC waivers Supportive Living Services Housing

3 Elder PAC: Elder Partnership for All-Inclusive Care  Combines community-based Long Term Care (CB-LTC) services (through Philadelphia Corporation on Aging), the local Area Agency on Aging (AAA) with medical care (In-Home Primary Care Program) in an integrated academic health system.  Links to Home Health Agency services through both AAA and CMS funding  Now includes the Waiver, Options,Family Caregiver Support, and Bridge programs  Service Bundle varies by program– from $14,000- $34,000 /year as caps– average is $23,000/year

4 Pre-Elder PAC 3 Nurse Practitioners 39 Case Managers 3 Nurse Practitioners 39 Case Managers 180 patients at PCA Case Manager 60 PCA consumers 50 providers

5 Elder-PAC Elder Caregivers Philadelphia Corporation for Aging Home Health Agencies Senior Centers In-Home Primary Care Program

6 Integrated Service Delivery  Primary Care  Acute, Rehab, LTC  Home Health Services  AAA / Aging Network  Care Management

7 UPHS In-Home Primary Care Program  Active census of 130 homebound elderly patients in In- Home Program; 19 homebound elderly patients in Medicare Advantage  Primary Care provided by NP/SW/MD teams  Majority of patients receiving PCA services when they enter the In-Home Program  Majority of patients receiving skilled home health services, including chronic care coordination.

8 ElderPAC Team Members  Case Manager from the Options/Waiver Programs of the Philadelphia Corporation for Aging  Social worker from Geriatrics  Geriatric Nurse Practitioners (GNP)  Physicians from Geriatric Medicine

9 Home Visit Activity  Social Worker -- Makes initial contact -- Makes initial contact -- Social/service map -- Social/service map -- Usually bi-weekly contact -- Usually bi-weekly contact  NP-Physician teams - see patients every 6-8 weeks (6 NP/2 MD visits/yr) - Physical exams, diagnostic studies - Home environmental modifications - Evaluate and strengthen social supports - Ensure contact with appropriate community agencies -- CONSUMER CHOICE (sort of) - Weekly team meeting /monthly with community agencies 2009 average 7.5 visits/pt (6 NP:1 MD)

10 Supportive Living Service Integration  Environment Information for modification and repair programs Information for modification and repair programs Durable medical equipment Durable medical equipment Stairglides Stairglides  Transportation Shared Ride SLS Shared Ride SLS Non-Emergency Ambulance Non-Emergency Ambulance MA / Wheels MA / Wheels

11  Socialization Information, lists and application process for: Information, lists and application process for: Senior CentersSenior Centers Adult Day CareAdult Day Care Senior CompanionSenior Companion Friendly VisitingFriendly Visiting  Counseling / Mental Health Community Mental Health Center / Base Service Units Community Mental Health Center / Base Service Units  Home Health Aides / Personal Care Aides  Safety Emergency Response Systems Emergency Response Systems Locks / Windows Program Locks / Windows Program Financial Management Financial Management Older Adult Protective Services Older Adult Protective Services

12 Medical / Health: Switching between AAA and CMS  Home Health Agencies  Registered Nurse  Physical Therapist  Occupational Therapist  Speech Therapist  Home Health Aide  Incontinence Specialists

13 JW  78 yo AA woman,  Lives independently in neighborhood for past 50 years  2-story row home  Son involved but lived 20 miles away  Oxygen dependent  Held and personally catered annual block party  Multiple cats with fleas  Medicare risk score 4.6  Personal goal to survive to 80 th birthday  COPD  Resp Fail 02  Sleep Apnea  PVD  CKD  HTN c CKD and HF  Pulmonary Htn  Diastolic CHF  SVT  Neuropathy  gout  anemia  Cervical spondylosis  cataract  GERD  Hearing loss

14 JW Hospitalizations Pre/Post Housecall Management COPD COPD/ICU COPD Start Housecall ED 80 th birthday

15 Conclusions  All-Inclusive management of medically complex, homebound patients can result in substantial savings compared to similar Medicare beneficiaries. Medicare beneficiaries.  Independence At Home can provide funding for housecall practices caring for medically complex patients by guaranteeing a share in those savings.


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