Elder PAC Sewing a Program of AllInclusive Care

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

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

Elder PAC: Elder Partnership for All-Inclusive Care Ø Ø 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

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

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

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

UPHS In-Home Primary Care Program Ø Ø 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.

Elder. PAC Team Members Ø Case Manager from the Options/Waiver Programs of the Philadelphia Corporation for Aging Ø Social worker from Geriatrics Ø Geriatric Nurse Practitioners (GNP) Ø Physicians from Geriatric Medicine

Home Visit Activity Social Worker -- Makes initial contact -- Social/service map -- Usually bi-weekly contact Ø NP-Physician teams Ø 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) -

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

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

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

JW Ø Ø Ø Ø Ø 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 Ø Ø Ø Ø 491. 21 518. 83 327. 3 440. 2 585. 3 404. 11 416. 8 428. 3 427. 89 358. 8 274. 0 285. 29 721. 9 366. 9 530. 81 389. 9 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

JW Hospitalizations Pre/Post Housecall Management Start Housecall COPD/ICU 2004 2009 2005 COPD/ICU 2006 ED 2007 80 th birthday 2008

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