1. Developing a Patient Centric Geriatric Home Based Care Management Model Presented by: Gail Silver, MS, APRN, GNP, BC

2.  Chronically ill, nursing home eligible patients in the program utilize a disproportionate amount of high-cost medical services.  ~ 80% of LTHHCP patients experience one hospitalization annually.  Fragmented service delivery impacts patients’ quality of life.  Financial impact to organization, federal and state programs. (Medicare and Medicaid)  LTHHCP multicultural workforce with varied educational, skill levels, and knowledge of geriatric best practice.  Current model of care delivery does not utilize the core values of patient self-care management that VNSNY is interested in spreading as a care standard across the organization. Nature of the Problem

3.  In 2011 baby boomers start to turn 65 creating multiple challenges for healthcare system 1.  Chronic illness  Increased healthcare services  Increased longevity  Racial and ethnic diversity  Workforce shortage  Inadequately trained work force  Healthcare utilization outcomes for patients experiencing poor transitional care include returning to the emergency room or being readmitted to the hospital. Coaching interventions during care transitions may reduce reduce rates of rehospitalization 2.  Home health care is uniquely positioned to improve transitional care and outcomes for the growing population of older adults with continuous complex needs 3. Environmental Scan 1-Retooling for An Aging America: Building the Healthcare Workforce (2008), Broad of Health Care Services, Institute of Medicine/ National Academies, 2-Coleman EA, Smith JD, Frank JC, Min SJ, Perry C, Kramer AM, Preparing patients and caregivers to participate in care delivery across settings: The care transitions intervention. J Am Geriatr Soc. 2004;52: 1817 - 1825 3-Naylor, MD (2006). Transitional care: a critical dimension of the home healthcare quality agenda. Journal for Healthcare Quality, 28(1), 48-54.

4. Project Goals  Develop a patient-centric home care management model for the geriatric population.  Promote patient knowledge and self management through CTI, TCC and risk stratification activities.  Optimize patient outcomes while generating increased revenue and billable days through reducing hospitalizations and emergency room visits.  Enhance clinician critical thinking skills; increase staff efficiencies and care delivery; improve staff satisfaction  Support interdisciplinary collaboration between nurses and other healthcare providers.

5. Target Population Pilot with three teams in one region of program Patient Demographics  100% Medicaid eligible; 70% Medicare Eligible  Average age is 70 years  ALOS on program – 1.5 years  Average 4.1 co- morbidities per patient  Average number of medications- 10 per patient  57% some level of cognitive impairment  Average 2-3 ADL deficits Full rollout will serve the 3,700 LTHHCP patients

6. Project Approach and Timeline

7. Key Stakeholders This new care model will benefit: 1. Patients—activated, engaged, and fewer adverse events 2. Care team—training, mentoring, collaboration, and critical thinking skills in care transition interventions 3. Physicians—referral base, increased collaboration to manage highly complex patients 4. VNSNY—increase staff efficiencies, enhance staff satisfaction, and generate positive revenue. 5. Medicaid/Medicare—reduce unnecessary costs

8. Process and Outcomes Measures Reduce unnecessary hospitalizations and ER visits LTHHCP electronic scorecard (monthly report) VNSNY Information Systems Improve staff efficiency and staff satisfaction CMAT risk tool — track CMAT completion at specified intervals, professional utilization of multi-disciplinary services based upon patient risk, patient medication adherence / plan of care adherence (monthly report) VNSNY Human Resource reports — staff retention and turnover at target, and lower recruitment expenses (monthly report) Increase billable visits and home health aide hours VNSNY Information Systems (monthly report)

9. Facilitators/Barriers Facilitators: VNSNY Information Systems Center for Home Care Policy and Research LTHHCP’s APRN’s in geriatrics. Organization support and current TCC initiatives Implementation of a geriatric education pilot for ANCC certification VNSNY sponsor: Sr. Vice President of Specialized Service Operations Barriers: Organizational culture of productivity Reimbursement for LTHHCP program Cultural variation and co- morbidities of the population served Varied and inconsistent knowledge base for geriatric clinical practice among staff Current clinical system does not have structure to monitor clinical adherence to a new care management model.

10. Sustainability  This model is in line with organizational strategies to develop initiatives grounded in the CTI and TCC approach.  Improved patient outcomes and revenue generated from lower hospitalization rates and increased billable days.  Enhanced staff satisfaction, which will result in improved staff retention rates and lower recruitment expenses.  Broad applicability for this change model beyond the LTHHCP program as this model will reduce unnecessary healthcare utilization for the Medicaid/Medicare population.

11. Video and Discussion