Improving Advanced Illness Care · •622 AAAs nationwide, in every community •45-year history of...
Transcript of Improving Advanced Illness Care · •622 AAAs nationwide, in every community •45-year history of...
Supporting the Aging Network’s Role in Improving Advanced
Illness Care
C-TAC NATIONAL SUMMIT ON ADVANCED ILLNESS CARE
Breakout Session IV
Thursday, October 10th1:30pm–2:45pm
Brian Lindberg, Public Policy Advisor, Coalition to Transform Advanced
Care
It is well-established that the quality of care for persons with an advanced illness
is tied to both the health care services and the community-based services and supports that they receive. If these and other factors are in sync, it is more likely
that the individual with an advanced illness will receive the care and treatment
that reflect his/her values and preferences.
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Why Partner with the Aging Network?
Often die in hospital, in pain and isolation
THE PROBLEM OF “THE BIG GAP”
Often unwanted, ineffective over-treatment
At great cost to families and the nation.
What People Want What They Get
Often recycled in and out of the hospital
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1. Coordinated care in the home
2. Have pain managed and “comfort” care
3. Be at home with family, friends
4. Avoid impoverishing families/being a burden
Why Partner with the Aging Network?
Why Partner with the Aging Network?
• Integrating health care and social services, such as meals and nutrition services, transportation, case management, and caregiver support, is particularly important for those facing advanced illness who typically live with multiple chronic conditions, pain and other symptoms, functional dependency, frailty, and significant family caregiver needs.
• The Aging Network, especially the country’s Area Agencies on Aging (AAAs), are THE experts on these kinds of social supports. The Network brings:
• Local knowledge and community trust
• Nationwide scale
• A long history of person-and-family centeredness
• Unrivaled experience delivering home and community-based services
• An ever-increasing business sophistication enabling healthcare partnerships
National Association of Area Agencies on Aging
Area Agencies on Aging
• 622 AAAs nationwide, in every community
• 45-year history of being the trusted resource on aging at the community level
• Older Americans Act is foundational for all AAAs, but because the law calls for local control and decision-making, AAAs adapt to the unique demands of their communities to provide innovative programs that support the health and independence of older adults
• AAAs leverage other funding and operate other programs, such as Medicaid HCBS
C-TAC & n4a Partnership Objectives
• Supporting the nation’s Area Agencies on Aging (AAAs) and others in the Aging Network to develop programmatic and legislative solutions to strengthen community-based organizations (CBOs) and their ability to deliver community-based care and support to those living with advanced illness and their families.
• Key Vehicles: • Older Americans Act (OAA) Reauthorization• Projects and tools to support aging network knowledge and services
• Working together with other key health care, social service, and policymaking stakeholder groups, including the Administration for Community Living (ACL) and the CMS Center for Medicare and Medicaid Innovation (CMMI), to develop avenues for reimbursement and integration of AAAs and other CBOs into new payment and delivery models (APMs).
• Key Vehicle: CMMI Payment Models
Roadmap for Success
• Establishing workgroups of n4a and C-TAC members to identify and prioritize key issues and strategies to move work forward.
• Pursuing a broad outreach and communications strategy to educate stakeholders on the value of Aging Network – Advanced Illness Collaboration
• Webinars (like this one!)
• Blogs (First in series : Pima Council on Aging’s advance care planning innovation)
• White papers (ex. A roadmap for AAAs and aging network providers on how to integrate advanced care principles and best practices.)
• Toolkit(s)
• Legislative proposals
• Advocacy with key decisionmakers across the spectrum• Policymakers
• Administration officials
• Providers
• Payers
Areas for Collaboration
• Information and Referral
• Care planning and assessment
• Family caregiver support
• Workforce education and training
• Payment innovations and barriers
• Advance care planning
Thank you!
For more information about the C-TAC – n4a Aging Network partnership project, contact:
Davis Baird, C-TAC Policy and Advocacy Manager at [email protected] or
Andrew MacPherson, C-TAC Senior Policy Advisor at [email protected] or
Brian Lindberg, Public Policy Advisor at [email protected]
BUILDING CAPACITY FOR SUSTAINABLE EDUCATION AROUND SERIOUS ILLNESS AND END OF LIFE CARE
Jessica Hausauer, PhD
Program Director
Live Well at Home Program
• Develop and/or provide services for older Minnesotans to live and age in the community of their choice
• Support home and community-based services
• Strengthen supports for solo agers, family, friends, and neighbors caregiving
• MNHPC funded 2014-2016; 2018-2019
• Lores Vlaminck, Principal, Lores Consulting, LLC
• Rivertown Communications, Inc.
• Area Agencies on Aging
Purpose:
1. Population is aging, growing more diverse
2. Living longer with complex, chronic health
needs
3. To effectively plan for serious illness and
end-of-life, older adults and their families
need information about advance care
planning, hospice, and palliative care
4. HCBS providers are on the front lines of care
and can play a role in sharing information
GOAL:
Increase the
availability of
consistent,
accurate, and
culturally relevant
information
regarding serious
illness and end-of-
life care to older
adults across the
state of Minnesota
Outcomes
2014-2016
• Trained 460 individuals across 16
locations
• In-person; 4 hours
• Fundamental level
• Developed consumer materials
2018-2019
• Trained 60 individuals across 4
locations
• In-person; 4 hours
• Intermediate level
• Developed on-line course
Training and Course Modules
• Health Care Directives
and POLST
• Palliative Care
• Hospice
• Payment
• Professional
Boundaries
Consumer Resources and On-line
Course Frequently Asked Questions
Consumer Guide
Videos and Radio Stories
The Basics of Serious Illness and End-of-Life
Attendees
Agencies
• AAAs
• County Public Health Departments
• Senior Living Communities
• DARTS
• Family Pathways
• Home care
• Hospice
• Lutheran Social Services
• Medica
• Wilder Foundation
Job Titles
• Community Living Specialist
• Senior Linkage Line Specialist
• Care Coordinators
• Home Health Aid
• Aging Care Specialist
• Caregiver Consultant
• Program Developer
• RN
Evaluation and Next Steps
Learnings and Next Steps
• Widespread need for education
• Veterans Benefits area of interest and need
• Phase II trainees = strong understanding of health care directives
• Gained most knowledge related to eligibility for palliative care and difference between hospice and palliative care
• Next: widespread dissemination of on-line course
Evaluation
Improving Advanced
Illness CareSharing Our Journey with Advance Care Planning &
Specialized Intervention
What is Advanced Illness?
Advanced illness is defined as one or more conditions
becoming serious enough that general health and
functioning begin to decline, curative treatment loses
its effectiveness, and care becomes increasingly
oriented towards comfort – this process extends to the
end of life.
Aging & In-Home
Services of NE
Indiana
Area Agency on Aging
Aging & Disability Resource Center
9 County Service Area (AAA & ADRC)
Strategic Priority for Growth – Integrated Care
CMS Demonstration CCTP (30 Counties; 10 Hospitals)
Partner – Development of Health IT Platform for Community Agencies and SDOH—Population Health Logistics
Partner – Preferred Community Health Partners, LLC & GroundGame Health™
PACE of NE Indiana, LLC
2019 Aging & In-Home Services of Northeast Indiana, Inc.
AIHS – Federal & State
Designated Area Agency on Aging
2019 Aging & In-Home Services of Northeast Indiana, Inc.
Client Population: Fee-for-service Medicare eligible patients 65 years of age and over
Service Area: Discharging to a home setting in one of 33 counties including Ohio and Michigan.
Initial admission diagnosis limited to: Acute Miocardial Infarction (AMI), Congestive Heart Failure (CHF), Pneumonia (PN), Chronic Obstructive Pulmonary Disease (COPD)
Referrals to Family Caregiver Program to support education on advanced illnesses and advance care planning
CMS Community-based Care Transitions Program (CCTP)
2019 Aging & In-Home Services of Northeast Indiana, Inc.
AIHS Involvement with
Advance Care Planning
Coalition formed in 2014 to address Indiana Physician’s Orders for Scope of Treatment form
Pilot Project using the Respecting Choices® model of Advance Care Planning
AIHS emerged as natural leader due to ability to work across health systems and organizations
Honoring Choices® Indiana formed in 2016
Respecting Choices® Advanced Steps Faculty on staff (1 of 2 trained in the State of Indiana)
2019 Aging & In-Home Services of Northeast Indiana, Inc.
Intent of Statewide Initiative
Promoting and sustaining advance care planning across the state to ensure individuals’ future
Health care preferences are discussed, documented, and honored
2019 Aging & In-Home Services of Northeast Indiana, Inc.
Honoring Choices® Indiana
Support structure for regional ACP coalitions/initiatives with the goal of speaking the same ACP “language” throughout the state
Initiatives Include:
Funding: Designated by a grant through the Indiana University School of Nursing for more than 5 years
Education for providers on ACP
state laws
Standardized training
tools/handouts (ACP Brochure)
Involvement in ACP legislative bills (identifying
issues & dissemination for comment)
Convening ACP groups together for discussion
and identifying best practices
within the state
2019 Aging & In-Home Services of Northeast Indiana, Inc.
The Role of Advance Care Planning
within our AAA Community
Incorporate ACP within Case Management & ADRC: fits with person-centered counseling
Division on Aging identifying ACP as an objective in the State Plan on Aging
Population Health and Care Transitions Programs
Regional and State Quality Improvement Initiatives
•Nursing facility groups, community care transition coalitions, and palliative care advisory council
Partnership with Healthcare Providers
•Health systems are becoming more aware of the need for improving ACP (bundled payments)
Partnership with Bar Association
2019 Aging & In-Home Services of Northeast Indiana, Inc.
Evolving Specialized Intervention
for Seriously Ill Clients
AIHS has been developing an evidence-informed,
specialized intervention for clients who have been
diagnosed with advanced serious illness.
Specializing our intervention began with the work we
did as part of our PCORI research partnership with Dr.
Lee Lindquist, Northwestern University to develop
PLANYOURLIFESPAN
2019 Aging & In-Home Services of Northeast Indiana, Inc.
5 Key Components of AIHS Specialized
Intervention for Seriously Ill Clients
Advanced Illness Trajectory
•Initiate discussions to fully understand the client diagnosis and utilize the trajectory of the illness to plan ahead for HCBS needs.
Interdisciplinary Care Team
•Encourage (and assist) client to develop their own multi-disciplinary “care team” to support them through this journey. (Medical, social, legal, etc.)
Family Caregiver Engagement
•Initiate relationship with Family Caregiver ASAP and ensure they are supported throughout their loved one’s illness.
Anticipated Care Transitions
•Plan ahead for additional Care Transitions support (if frequent or multiple hospitalizations are anticipated).
Advance Care Planning
•Emphasize importance of Advance Care Planning as a way of ensuring the individual’s wishes are respected.
2019 Aging & In-Home Services of Northeast Indiana, Inc.
2019 PCHP, LLC
2019 PCHP, LLC
How we
operate
PCHP utilizes a standardized evidence-informed care transitions and care coordination model fully aligned with NCQA principles for person-centered care.
PCHP does not replace the MCO Case Manager but extends their work into the member’s home and community.
Our technology platform is HITRUST certified and provides for the electronic transmission of data as well as analysis of outcomes.
2019 PCHP, LLC
PCHP / GroundGame Health™ Model
2019 PCHP, LLC
GroundGame Health™Commercial • Medicare • Medicaid
Preferred provider network of Preferred Community Health Partners, LLC. (PCHP)
2019 PCHP, LLC
Inter-operable Health IT Platform
Risk Stratification
Data Analytics
Predictive Capabilities
2019 PCHP, LLC
A “Smart Network”
NCQA
Evidence-Based & Evidence-
Informed Models
Continuous Improvement
Emphasis on Quality
2019 PCHP, LLC
National Aging & Disability NetworkPartners in Caring for Seriously Ill Patients
Across the Country
Supporting the Aging Network’s Role in
Improving Advanced Illness Care
Caroline Ryan
U.S. Administration for Community Living
Agenda
• Overview of the Administration for Community
Living (ACL)
• ACL Education and Advocacy Activities
• Principles for Person-directed Services and
Supports during Serious Illness
• Supporting the Aging Network Role/ Future
Opportunities
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ACL Organizational Chart
Administration on
Aging
Administrator &
Assistant Secretary
for Aging
Principal Deputy
Administrator
Chief of Staff
Center for
Innovation &
Partnership
Administration on
Disabilities
National Institute
on Disability,
Independent Living,
and Rehabilitation
Research
Center for Policy
and Evaluation
Center for Management
and
Budget
Office of External
Affairs
Center for Regional
Operations
Aging and Disability Service Network
Administration
on Aging
(Older Americans Act)
❖ 56 State Units on
Aging
❖ 629 AAAs
❖ 244 Tribal
organizations
❖ 2 Native Hawaiian
organizations
❖ 29,000 local service
providers•
Administration on Intellectual
and Developmental
Disabilities
(Developmental Disability Act)
❖ 56 State Councils on
Developmental Disabilities
❖ 68 University Centers for
Excellence in Developmental
Disabilities
❖ 57 Protection and Advocacy
programs
Independent Living
Administration
(Rehabilitation Act)
❖ 54 State Independent
Living Councils
❖ 354+ Centers for
Independent Living
Adapted from: Putnam, N. Bridging Knowledge in Long Term Care and Support: Crossing Network Lines. 200940
ACL Education and Advocacy Activities
• Advanced Care Fact Sheets
• Video Guide to Advanced Planning
• ACL Blogs
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Advanced Care Planning Fact Sheets
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https://eldercare.acl.gov/Public/Resources/Advanced_
Care/Index.aspx
Video Guide to Advanced Planning
43 https://longtermcare.acl.gov/how-to-decide/
ACL Blogs
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Principles for Person-directed Services
and Supports during Serious Illness
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https://acl.gov/sites/default/files/Aging%20and%20Disability%20in%20America/Serio
us%20Illness%20Principles%208-30-17%20508%20compliant.pdf
Principles for Person-directed Services
and Supports during Serious Illness
• Were designed to:
• Promote choice and control for people with serious illness, while taking into account their unique life circumstances
• Help people plan for serious illness
• Help families, family caregivers, and service providers honor the choices of people with serious illness
• Assist people with serious illness in choosing and controlling services according to personal values, priorities, and goals
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Concepts Underlying Principles
• People need to be informed about their conditions and have the opportunity to express their preferences
• Service providers should respect those preferences and place individual choices at the center of treatment decisions
• Choices may be to accept or refuse treatment
• Service providers should honor the individual’s choices, help manage their symptoms, and provide needed emotional and spiritual supports to them and their families
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Principles1. Live with serious illness according to personal values and goals
2. Enable choice of services
3. Avoid discrimination
4. Enable choice of representative
5. Carry out person-directed planning and decision-making
6. Access to care coordination
7. Choose among services and supports
8. Deliver palliative care
9. Provide hospice care
10. Provide independent advocacy services
11. Educate and support providers
12. Support family caregivers
13. Address the concerns of older adults; people with disabilities, including those with developmental disabilities; and their family caregivers
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National Center on Advancing Person Centered
Planning, Practices and Systems (NCAPPS)
49https://ncapps.acl.gov/
Opportunities for the Aging Network
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