Integration of Care Coordination: Building Bridges Between ......2014/03/14 · Integration of Care...
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Integration of Care Coordination: Building Bridges Between Community and the Disease Centric Islands of Care National Health Policy Forum March 14 2014 Kyle Allen, DO AGSF VP Clinical Integration Medical Director Geriatric Medicine and Lifelong Health Riverside Health System Newport News VA
Transcript of Integration of Care Coordination: Building Bridges Between ......2014/03/14 · Integration of Care...
Integration of Care Coordination: Building Bridges Between
Community and the Disease Centric Islands of Care
National Health Policy Forum
March 14 2014
Kyle Allen, DO AGSF
VP Clinical Integration Medical Director Geriatric Medicine and Lifelong Health
Riverside Health System Newport News VA
Key Issues
• Policy, traditional medical model, history and financial incentives have created chasms in care delivery and true coordinated care
• For those with chronic illness and functional impairment the system woefully inadequate, unsafe and poor quality.
• Change will require “radical” transformational change of the health system and integration of community based services
Health-service and social-services expenditures for OECD countries, 2005, as ratio
BMJ Qual Saf 2011;20:826e831.
US level
Health Care Utilization Experience for Patients with Chronic Conditions: Current Health Care System
Poor care transitions planning and advance care
decisions (often by the family) and failure to link to care transitions program or
community programs at transition/discharge
Community-dwelling chronically ill patient with poor symptom control and coordination of care, whose
goals and advance care wishes are rarely asked or documented, and
who rarely engages in self management programs or learning
Exacerbation of chronic illness leading to ED visit and hospitalization with inherent
hospital risks for further decline and associated disability
The Expanded Chronic Care Model: Integrating Population Health
Promotion
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Source: The Expanded Chronic Care Model, Barr, Robinson, Marin-Link, Underhill, Dotts, Ravensdale, & Salivaras, 2003
We Need Bridges and “Boundary Spanners”
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Summa Health System Akron, Ohio
Case Study
A Comprehensive “System” Approach: The Foundation for ACO for those with Complex Illness
Summa Health System
• Serves a five county region in Northeast Ohio
• Seven owned, affiliated and joint venture hospitals
• SNF Network • Regional network of ambulatory
centers • 240+ employed multi-specialty
group • A 150,000+ member health plan • A System-level foundation • 10,000+ employees • Total Net Revenue of $1.6
Billion • Total Discharges of 61,000
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Enhanced Care Management
Improving Care through Collaboration: Integration of the Aging Network and Acute and Post
Acute Medical Care Services
Area Agency on Aging 10B.Inc
The SAGE Project The AD-LIFE Trial
AHRQ# R01 HS014539
The PEACE Trial National Palliative Care Research Center
SummaCare Insurance Co.
The Enhanced Care Management Program
Summa Health System
Care Coordination Network
Summa Health System Care Coordination Task Force
• 26 active participating facilities (now 39) • Initial meetings to define the problems:
– Identified that 99.9% of problem was communication – Collaborative development of work plan – Commitment to 2-hour work sessions every 2 weeks – Shared learning experiences
• Developed memorandum of understanding (MOU) to formalize network
• Use meetings to advance quality, problem solving, new learning, and innovations
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NE Ohio Regional Impact
• Universal transitional care form created by CCN
• Instituted in 19 regional hospitals • Phase II was creation of SNF “change in
condition” form – Involved EMS and EM physicians and staff – Used by CCN facilities
• http://www.innovations.ahrq.gov/content.aspx?id=2162 • http://www.innovations.ahrq.gov/content.aspx?id=186
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Newport News Virginia
A Health System Approach for Improving Care for Older Adults with
Complex Illness
Integrated Delivery System
Riverside Health System
ACUTE Riverside Medical Group
Lifelong Health
Engineering Health System for Older Adults and Those With Advanced Chronic Illness
Nurses Improving Care of Health System Elders
Acute Care for Elders Meeting the Challenge of Providing Quality and Cost-Effective Hospital Care to Older Adults
Programs of All-Inclusive Care for the Elderly
Transformation of Institutional Nursing Home to Household Person- Centered Care
ACE Acute Care for Elders
Hospice
Palliative
Care
POST
• All adults with progressive illness
• Projects complications • Normalizes ACP for future
decisions
Advance Care Planning *http://www.capc.org/capc-resources/capc-poster-sessions/capc-texas-2008/abstracts/posters/01-full.jpg
*NIH/National Institute of Nursing Research, R01 NR009784
Community Partnerships In Eastern Virginia and Beyond
• Hampton Road Chronic Disease Self Management Coordination Coalition
• Eastern Virginia Care Transitions Partnership • Tidewater Advance Care Planning Coalition
Chronic Disease Self Management Coalition
Provided by
and
Eastern Virginia Care Transitions Partnership: A community partnership of health systems, area agencies on aging, independent
physicians’ groups and other public and private health and human service providers.
HEALTH SYSTEMS Riverside Health System
Bon Secours Mary Washington Healthcare
Rappahannock General Hospital Sentara Health Care
AREA AGENCIES ON AGING Bay Aging – Lead Community Based Organization
Eastern Shore Area Agency on Aging and Community Action Agency, Inc. Peninsula Agency on Aging, Inc.
Rappahannock Area Agency on Aging, Inc. Senior Services of Southeastern Virginia
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Tidewater Advance Care Planning Coalition
• Respecting Choices Model • Supported by 4 Regional Health Systems • Administered through the local AAA • Supports Executive Director and Programing • Moving ACP upstream into the community
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Scaling to a state model for care transitions?
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Conveners Department of Aging and Rehabilitation Services Virginia Health System and Hospital Association Virginia QIO- VHQC
Model to Scale 1. Expanding the Eastern Virginia Care Transitions Partnership 2. Western Virginia- Appalachia AAA Care Transitions Program 3. Both using Coleman CTI
MediCaring4LIFE: Making Local Improvement for Frail Elders
• CMMI Proposal 2014 • Altarum Institute’ s Center for Elder Care • 4 Communities
– Akron Area Agency on Aging & Summa Health System, Akron ,Ohio
– Riverside Center of Excellence for Aging and Lifelong Health, Williamsburg Virginia
– Providence Health, Milwaukie Oregon – North Shore –LIJ Health System, New York
Challenge: Medically Complex Patients Answer: Geriatric and Palliative Care Medicine
If geriatrics/palliative care can implement its vision: • Patients don’t get care they don’t want • Patients don’t get care which can’t benefit them • Patients suffer fewer adverse events • Patients experience fewer transitions • Caregiver burden is reduced • Costly care of marginal utility is eschewed • Society meets its responsibilities to vulnerable
population—and has money left over for other good things
Kyle R. Allen, D.O. , AGSF
Riverside Lifelong Health Services Across the Continuum
Independent 24 hour care End of life Needing
Assistance Senior Care Navigation
Wellness & Fitness Centers Inpatient Rehabilitation Center Outpatient Rehabilitation
Continuing Care Retirement Communities – Life Care at Home
Assisted Living
Memory Support
LTACH – Skilled Nursing - Care Residences
In-Home Technology
Home Health – In-Home Private Duty – Pharmacy – Home Medical Equipment PACE
Adult Day Care Hospice
Provider Group - Care Coordination - CEALH - Clinical Initiatives
