Fall Prevention Day 2016

Today is Falls Prevention Awareness Day, which is extremely important to us at InnovAge.

Canes
Canes

One piece of the puzzle that helps older adults live independently is reducing or eliminating falls, which account for 2.5 million emergency room visits for older adults every year.

Our clinical team is doing its part to help lower that number by performing research, and rolling out new programs that have reduced falls by 17 percent.

Read about it now and tell your friends.

 

 

 

 

Numbers Game: Care Management for Baby Boomers

By Maureen Hewitt

Statistics are one way to make a point; anecdotes are another. Both approaches are viable for examining the issues related to the overwhelming need for care management for older adults.

Defining the challenge through numbers is straightforward.

  • Life expectancy for Americans is 78.8 years, according to the latest from the National Center for Health Statistics.
  • Baby Boomers number 74.9 million as of 2016, according to the Pew Research Center.
  • Approximately 92 percent of older adults have at least one chronic disease, and 77 percent have at least two, according to the National Council on Aging (NCOA).
Maureen Hewitt
Maureen Hewitt

More of us are living longer and with multiple chronic conditions that require frequent treatment and continuing management. Couple this with the fact that 93 percent of all Medicare spending is for people with chronic illnesses, according to the Centers for Disease Control and Prevention, and the need for better care management is clear.

Whole Person Care

With care management, nearly every facet of the care continuum is integrated in a holistic way with a focus on personalized care, efficiency and efficacy. “Care coordination can help to improve care for this (older adult) population,” according to an issue brief published by the Eldercare Workforce Alliance, “and reduce the cost of treating them, if the most effective elements of care coordination models are identified, and challenges are addressed.”

At InnovAge, we see care management differently than other providers because we focus exclusively on the elderly through an interdisciplinary team approach. To successfully implement a holistic program, two pieces of information serve as the foundation of each personalized care management program:

  • A comprehensive patient assessment
  • A personal care plan

The information in these reports helps members of the interdisciplinary care team understand and address the care needs of each older adult as a unique individual. The personalized care plan may include medical and dental care; physical therapy and rehabilitation services; pharmacy; end-of-life care; and assistance navigating the complex healthcare system outside the care management program. This last piece ensures any external treatment plans and prescriptions are integrated into the larger care management system and delivered to the interdisciplinary team.

Baby Boomer Benefits

To ensure the interdisciplinary care team implements a holistic care management program for each of its patients, the group uses quality assessments to learn how they can better serve the older adult and improve the experience. Through this regular program reevaluation, the interdisciplinary team has an opportunity to make a lasting, positive impact on the health and wellness of older adults.

Eldercare providers now have a significant opportunity to help 74.9 million Baby Boomers by offering well-coordinated care management services, which can make a profound difference in their lives.

Maureen Hewitt is the President and Chief Executive Officer of InnovAge, a Denver-based provider of comprehensive healthcare services for older adults in California, Colorado and New Mexico. Hewitt has held this role since 2006 and has led for-profit and nonprofit health care organizations for 20 years. Hewitt’s experience includes leading skilled nursing/sub-acute care facilities and acute care and rehabilitation hospitals, as well as serving in volunteer board positions. Learn more at http://MyInnovAge.org and http://InnovAgeCares.com.

PACE: Effective Care Coordination for Dual Eligibles

By Maureen Hewitt

Care coordination, the use of an interdisciplinary health team to coordinate and provide patient care, sounds simple enough. So why does it remain so difficult to implement?

Technology has removed some of the borders found in medical care, making communication and data sharing faster and easier, which helps care coordination implementation. Nevertheless, bringing together care, communications and data remains a challenge and an ongoing goal for many healthcare organizations.

Older adults have the answer

Eldercare providers are always looking for better, more efficient ways to serve this population, which is often medically frail. The primary issue: many dual eligibles receive uncoordinated and expensive care through a fee-for-service model. These patients are kept “in ‘treatment silos’ connecting with one provider at a time—even when they have five doctors—and getting one prescription at a time—even when they take 15 different pills a day,” according to a 2009 report published by the Center for Health Care Strategies (CHCS).

Maureen Hewitt, InnovAge President and CEO
Maureen Hewitt, InnovAge President and CEO

Those in healthcare have discussed the necessity of care coordination for years to reduce or eliminate many of the issues associated with fragmented care as described by CHCS. Receiving care at multiple facilities and having medical data added to numerous electronic medical records that don’t “talk” is as much a concern for healthcare providers as it is for dual-eligible patients.

Bringing care under one roof has the benefit of eliminating the challenges inherent in siloed care. And supplementing it with a highly-proficient healthcare team has the benefit of mixing together the care and people necessary to improve the health and wellness of dual eligibles.

Care coordination demonstrations

In 2015, several states participated in demonstration projects designed to explore the usefulness of care coordination for dual-eligible beneficiaries. Eligible for Medicare and Medicaid, dual eligibles qualify for both government healthcare programs. There were nearly 10 million dual eligibles as of 2011, according to The Henry J. Kaiser Family Foundation. And while Medicaid is designed to assist low-income families, the program also helps older adults. Medicare focuses on older adults.

“Care coordination,” as a 2015 RTI International report funded by Centers for Medicare and Medicaid Services (CMS) aptly states, “generally include(s) an assessment of an individual’s medical, physical, and other social support needs, development of a personalized plan of care/action plan, monitoring and clinical management of people with complex care needs, and helping beneficiaries locate and obtain needed services.”

Care coordination should be implemented by an interdisciplinary team, including physicians, nurses, social workers and other healthcare professionals who ensure the continuity of competent and compassionate patient care.

RTI International found care coordinators generally needed more training to meet new care coordination responsibilities. In addition, the 2015 demonstration projects were fraught with delay as organizations attempted to provide the breadth and depth of services necessary for true care coordination.

While demonstration projects can provide important information about the successes and challenges of launching new programs, there exists an established, efficient program with decades of success in coordinating care for dual-eligible participants: the Program of All-inclusive Care for the Elderly (PACE).

PACE is an important CMS-supported program provides coordinated care every day to dual eligibles in 32 states, reports the National PACE Association.

Back to the future

For more than 40 years PACE has proven itself as an exceptional way to provide substantial care coordination services to frail dual eligibles. The interdisciplinary teams at PACE facilities around the country understand the challenges of participants, and have the processes and systems in place to provide a smooth care coordination experience.

The team develops a care plan for each participant and meets regularly to discuss the care of PACE participants, ensuring each receives the care he or she needs.

At InnovAge, for example, PACE care coordination has led to exceptional outcomes for dual-eligible participants:

  • Nursing home stays (typically long-term placements) are approximately 10 percent for PACE participants while 13 percent for all dual eligibles.
  • Skilled nursing facility stays (generally short-term placements) are approximately 50 percent as long for PACE participants compared to high-cost duals.
  • Inpatient hospital stays of a day or more are about 50 percent as much for PACE participants compared to high-cost duals.

With the goal of ensuring participants live on their own in the community, PACE brings coordinated care to the older adult to help make this independence a reality for the largest number of participants possible through a continuum that promotes the use of technology, constant communication and an interdisciplinary team focused on the health needs of older adults.

Maureen Hewitt is the President and Chief Executive Officer of InnovAge, a Denver-based provider of comprehensive healthcare services for older adults in California, Colorado and New Mexico. Hewitt has held this role since 2006 and has led for-profit and nonprofit health care organizations for 20 years. Hewitt’s experience includes leading skilled nursing/sub-acute care facilities and acute care and rehabilitation hospitals, as well as serving in volunteer board positions. Learn more at http://MyInnovAge.org and http://InnovAgeCares.com.