1. Courtney Davis, MHA HOME CARE + Program Manager January 14, 2015

2. Centers for Medicare and Medicaid Health Care Innovation Award Improved Health Improved Care Reducing Costs through improvement Home Care + is supported by Funding Opportunity Number CMS-1C1-12-0001 from Centers for Medicare and Medicaid Services, Center for Medicare and Medicaid Innovation. Its contents are solely the responsibility of the authors and do not necessarily represent the official views of HHS or any of its agencies.

3. Mission and Vision MISSION To ensure optimal health and care of each Home Care + participant to successfully remain at home. Person-centered coordination across care settings Appropriate support and care at the appropriate time Actively engaging the Home Care + participant and family VISION Home Care + will be the leader in community-based care coordination.

4. Person-Centered Community-based Care Coordination Relationship-building Engaging participant/family in care and decision making Collaborative Problem Solving Team Approach – Client/Family – Home Care Consultant (RN or LPN) – Home Care Specialists – “Trusted Source” – Home Care Specialist Trainer – Physician – Discharge Planners and Others – CLTC Case Manager Negotiated Plan of Care Chronic Disease Management Training for Personal Care Aides HOME CARE + Innovations

5. HOME CARE + Model Home Care + Participant Home Care Consultant Home Care Specialists PCPA Trainer Personal Health Record On-Call Support Team Approach Internal External PCPAs is the hub

6. HOME CARE + Key Areas to Support Self-Care Relationship with participant/family Medications Management Follow-up care with physicians Chronic disease education and warning signs that a condition is worsening Use of Personal Health Record

7. Home Care Specialist Certification 12 modules Enhance knowledge of chronic conditions Increase the ability of the home care worker to recognize a change in condition that could prevent the need for an acute care transfer Upon the completion of each 1-hour module, a certificate of completion will be provided Completing 12 modules will result in a Home Care Specialists Certificate

8. HCS Training Modules 1.Intro to the Role of Home Care Specialist 2.Congestive Heart Failure 3.Dehydration 4.Pneumonia 5.Incontinence and Urinary Tract Infections 6.Heart Attack 7.Chronic Obstructive Pulmonary Disease 8.Hypertension 9.Stroke 10.Diabetes 11.Mental Status Changes/Dementia 12.The Final Phase of Life

9. Lessons Learned Careful selection of Home Care Consultant Impact of Trust Relationships are critical

10. Preliminary Outcome Data - $130,386.00 -$918.21/pp

11. Preliminary Outcome Data

12. Stories from the Field Mr. Clark Ms. James Ms. Cook

13. Where is HOME CARE + ?

14. Advantages of HOME CARE + Model Point of Contact in the community Home Care Consultant in Provider Network Established relationship with participant/family and Personal Care Aide Engaged participant/family Personal Care Aide in participant’s home 2-5 times/week (“eyes and ears”) Personal Care Aide trained on “red flags” of signs and symptoms of worsening condition that could lead to avoidable ER visit

15. Contact Information Courtney Davis, MHA HOME CARE + Program Manager (803) 777-5336 daviscb@sc.edu