1. Community-Based High Risk Care Management Sandee Ferguson Area Agency on Aging, 10B

2. Nature of Problem In order to improve care while enhancing overall efficiency, we must invest in development of new techniques and infrastructure in the changing long term care landscape. Investment needs to be made in new and more sophisticated methods of integrated medical care management in the home, instead of service management. By maintaining an older Ohioan at home rather than in the NF, we save the state $32,049 annually per member making the high risk care management initiative a vital investment and good policy.

3. Environmental Scan Other countries, such as United Kingdom and Australia, have literature for high risk in community care. Literature is primarily disease management (Acute Care or Insurance based) and does not include integration with community Care Managers. A NEW APPROACH TO COMMUNITY- BASED CARE MANAGEMENT

4. Approach The project will be an effort to introduce medical integration with protocol application: INTERVENE AVERT THE DECLINE RECOGNIZE

5. 4 County Region Frail, chronic illnesses, 60+ adult NF Level of Care Receives Home and Community-based Waiver High Risk Screening Tool Logit Model: Based on univariate analysis, a total of 30 predictors were identified Target Population

6. Process and Outcome Measures Member data (assessment and ongoing)- protocol and risk measurement/ stratification ↑ length of stay on program ↓disenrollments to NF ↓ hospitalizations ↓ emergency Dept. visits ↑ member satisfaction Transition to community from NF and remain in community = SUCCESS

7. Project Timeline Year 1 Risk Stratification Methodology and application process for HRCM Development of Care Plan Protocols & Policies Development of Software Evaluation Year 2 HRCM Manual and information package Expand to HRCM Consultation Introduced and Integrated Statewide by State Policy and Standards

8. Implementing the Program In AAA 10B Our Strategic Vision: High Risk Care Management is in alignment with our vision and mission. 12 AAAs in Ohio: Opportunity Key Stakeholders: 3500+ members, Care Managers, Hospitals, Physicians, Provider Network Engaging is Involving!

9. Perceived Facilitators/Barriers FACILITATORS Partners: Hospitals Physicians Community Organizations State Policy Provider Network AAA Network Insurance Plans Education/Research Nursing Facility BARRIERS Nursing Facility Nursing Shortage Cultural Change Consistency and uniformity

10. Preliminary Data Preliminary Data Stratification by risk level.pdf Stratification by risk level.pdf

11. Keep It Going After 2 yrs!  Data and Outcome Success $Ohio’s Medicaid Nursing Facility Costs  State Policy and Practice Change for Waiver Members.

12. Thank you