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  491.21 COPD  518.83 Resp Fail 02  327.3 Sleep Apnea  440.2 PVD  585.3 CKD  404.11 HTN c CKD and HF  416.8 Pulmonary Htn  428.3 Diastolic CHF  427.89 SVT  358.8 Neuropathy  274.0 gout  285.29 anemia  721.9 Cervical spondylosis  366.9 cataract  530.81 GERD  389.9 Hearing loss

14. JW Hospitalizations Pre/Post Housecall Management 2004 2005 2006 2007 2008 2009 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.