Agenda

1. ASSURING Quality in Geriatrics Practice-A changing EnvironmentGeorgia GAPNA and Arkansas GECMarch 1, 2013Jennie Chin Hansen, RN, MS, FAAN-CEOwww.americangeriatrics.org#geriatrics #3ormore

2. Agenda • Current Environment • Present Situation of Workforce • Public Perception of Need • The Health Policy and Payment Environment Alignment • What Innovations are Happening to Improve Care and their Diffusion • The Need, Our Opportunity and New Context

3. Evolving Directions in Framing Health and Care of Older Adults • There is speed in the momentum of reimbursement and delivery system changes in health care • Focus on improving quality and those areas most expensive has become a new culture • There are more concrete population health initiatives that go beyond the hospital and facility settings • Health care payors and providers are learning to expand their consideration of “patient” to “older adult”

4. “How Does It Feel?” • Survey designed to understand the health care experience of older patients • Do you have a regular doctor? Are you satisfied with their clinic and hospital-based care? • Are your doctors asking you about ADLS, IADLs, medications, falls, mental health problems? • Are they recommending non-medical resources? • Do you think better training in geriatrics might help? John A Hartford Foundation 04.12

5. Methodology • Partnered with Lake Research Partners • National survey of 1,028 adults 65 and older • Fielded February 29 through March 3, 2012 • Margin of Error: + 3.1 percentage points John A Hartford Foundation 04.12

6. Majority Satisfied with Primary Care John A Hartford Foundation 04.12

7. Majority Satisfied with Primary Care

8. Attitudes Toward Geriatric Training John A Hartford Foundation 04.12

9. Awareness of Shortage 40% of adults 65+ with a college degree or higher have heard of the shortage. John A Hartford Foundation 04.12

10. 10 Things Aging Americans WantU.S. News & World Report Finance 1. Dependable and fair Social Security 2. Bring back traditional pensions. 3. Higher interest rates Aging in Place 4. Good public transportation 5. Walkable neighborhoods 6. Universal design Healthcare 7. Home-based healthcare 8. More geriatricians Technology 9. Self-driving cars 10. Intuitive Technology products Source: Moeller, Philip, http://money.usnews.com/money/blogs/the-best-life/2012/08/06/10-things-aging-americans-want U.S. News & World Report August 6, 2012.

11. From Our Core Knowledge of Geriatrics Syndromes To.. • Population Based Segmentation • Well Older Adults, Chronic Conditions, Advanced Illness and Complexity, Frailty • Use of Prevention Based Evidence and greater self care • Self Management and Care Coordination • Risk Management and Care Transitions • Palliative Care • Management of Complexity • Care and Management of Frailty

12. The Triple Aimfor the Older Adult • Hospital-Quality and Safety • ACE-Acute Care for Elders • Transitions Programs-Naylor, Coleman, Boost, Project Red • NICHE • Value Based Purchasing • Partnership for Patients Better Health Lower Costs Better Care Save $$$ for consumer/family, payors, society-Medicare, Medicaid Maintain best function and engagement in home and community: prevention, self care, coordination

13. Examples of Innovative Practices • CMS-Center for Innovations and Other ACA Enabled Efforts • Partnership for Patients • Long Term Quality Alliance • Coalition example of best practice • Independence at Home • ACA Section 3024 • Hospital at Home (Johns Hopkins!)

14. Innovation Center PortfolioLong-Term Care Involvement in Many Areas Primary Care Transformation • ● Comprehensive Primary Care Initiative (CPC) • ● Multi-Payer Advanced Primary Care Practice (MAPCP) Demonstration • ● Federally Qualified Health Center (FQHC) Advanced Primary Care Practice Demonstration • ● Independence at Home Demonstration • ● Graduate Nursing Education Demonstration ACOs • ● Medicare Shared Savings Program • ● Pioneer ACO Model • ● Advance Payment ACO Model • ● PGP Transition Demonstration Bundled Payment for Care Improvement ● Model1: Retrospective Acute Care ● Model 2: Retrospective Acute Care Episode & Post Acute ● Model 3: Retrospective Post Acute Care • ● Model 4: Prospective Acute Care • Capacity to Spread Innovation • ●Partnership for Patients • ● Community-Based Care Transitions • ● Million Hearts • ● Innovation Advisors Program • ● Health Care Innovation Challenge Initiatives Focused on the Medicaid Population • ● Medicaid Emergency Psychiatric Demonstration • ● Medicaid Incentives for Prevention of Chronic Diseases • ● Strong Start Initiative • Dual Eligible Beneficiaries • ● State Demonstration to Integrate Care for Dual Eligible Individuals • ● Financial Models to Support State Efforts to Integrate Care • ● Demonstration to Reduce Avoidable Hospitalizations of Nursing Facility Residents Source: CMMS 2012

15. Partnership for PatientsTen Priority Areas of Focus • Adverse Drug Events • Catheter-Associated Urinary Tract Infections • Central Line Associated Blood Stream Infections • Injuries from Falls and Immobility • Obstetrical Adverse Events * • Pressure Ulcers • Surgical Site Infections • Venous Thromboembolism • Ventilator-Associated Pneumonia • Reducing Readmissions Source: CMMS 2012 * Only area that would not relate to older adults

16. Community Based Care Transitions Program (CCTP)-Section 3026 • Provide Payment for Care Transitions Services to Improve Health and Reduce Readmissions • An Engine & Asset to Connect Hospitals and Communities to Help Patients • 47 Sites in Place with Many More on the Way • Buttressed by Hospital Engagement Networks, QIOs, AAAs, ADRCs and Many Other Resources to Reduce Readmissions CMS 2012

17. System Features Enabling Older Adults with Complex Conditions to Live at Home Status: Robust Linked Services Status: Progressive Frailty Coordinated Services Status: End of Life Fully Integrated Services Home and Community-based Services Frailty Care Services (at home) Clinic-based Services Frailty Care Settings Hospital-based Services Geriatrics principles embedded in all services and programs Connected by an integrated, informed, accurate, and available information system System measurement and monitoring across the continuum of care Warren Wong, MD Kaiser Permanente 2012

18. Long Term Quality Alliance Initial Best Practices • Cathedral Square Corporation (Housing Corporation) • Evolved from landlord role to advocate monitoring health and coordinating services help resident stability- • 1 year outcome-22% falls reduction, 19% reduced risk reduction of those of moderate risk; physically inactive residents reduced by 10% • July 2011-112 housing projects added • Estimated $40million w health care • Savings to Medicare

19. Independence at Home (IAH) • 2009 HB 2560 (Markey) + S 1131 (Wyden) • 2010 ACA section 3024 • Medically-led interdisciplinary team (MD or NP) • House calls, with technology • Portable diagnostics, telemedicine • 24-7-365 availability • Electronic health record • Expertise and experience with model • Keep + use existing Medicare benefits (A,B) • Savings (gain-sharing) • First 5%  Medicare; then 80% IAH • 10,000 beneficiary cap in current demo

20. Why Independence At Home (IAH) • Immobile, complex population is better served at home • Patient and family centered • Better insight into illness and needs, better care plan • More timely response when getting sick • Real opportunity for near term cost savings • Targets highest cost subset with a viable solution that people prefer

22. Header • Hospital at Home®: Disseminating an Innovative Health Service Delivery Model into Practice • Bruce Leff, MDProfessor of MedicineJohns Hopkins University Schools of Medicine & Public Health

23. How Hospital at Home Can Help How it Helps Case Studies Why We Need It Spreading Success Hospital at Home®

24. Less CG stress Better function High provider satisfaction How it Helps The Future Why We Need It Spreading Success • 61% chose HAH care • HaH is feasible and efficacious • High-quality care • Fewer complications • Higher satisfaction • Lower costs of care Ann Intern Med. 143:798-808, 2005. J Am Geriatr Soc. 54:1355-1363, 2006. J Am Geriatr Soc. 2008;56(1):117-23. Am J Manag Care. 15:49-56, 2009. J Am Geriatr Soc. 2009;57(2):273-8. Medical Care, 47(9):979-85, 2009. Hospital at Home®

25. Takeaway themes • Incentives for all are moving in the direction of the “whole person” over time-geriatrics knowledge and quality of care (e.g.transitions of care) • Treating segments of population with the most appropriate health and health care in settings that are most conducive to effectiveness • Consider the whole environment of the person as an asset to health and chronicity maintenance • Engagement and enabling capacity of the person/patient toward health and well being • Enlargement of the caring provider roles-i.e. not just the professionally licensed

26. Current Heightened Opportunities • Health Systems, Hospitals, Post acute and Community Settings • Health Systems-segmentation: focus on most complex , at risk • Hospitals: reduction of infections and readmissions, focus on falls, pressure ulcers, medication reconciliation • Post Acute-transfers between hospitals and nursing homes • Community-hospitals working with community orgs

27. Implications of Our Changing World • Others are Paying Attention-there are specific needs for “older adults”: boomers and those who “show up for care” • Traditional: hospitals, post acute and long term care • New: e.gACOs, patient centered medical homes, convenient care clinics, telehealth, Federally Qualified Health Centers, Naturally Occurring Retirement Communities (NORCs) • Other “Providers” • Housing • YMCAs • Entrepreneurs

28. Game Changers • From Outside Our Usual Players • Mathematicians-using voice technology to help diagnose Parkinson’s disease (10 mins)-implications for neurologists (CNN ”Next” Innovators) • Chronic Disease-Tackled by National Networks (YMCA, OASIS) at 25% of usual cost (adult diabetes) • Aging 2.0-social entrepreneurs

29. Geriatric Leaders, Catalysts and Facilitators • Framing a value that function reigns supreme • Person’s (family) goals, confidence and capacity matter (knowledge, capability and resources) • A plan of health, health status and well being is necessary • Multiple conditions need competent team management • Evidence we have needs to be used • Advancing understanding and appreciation of quality of life while living with disability* • Advancing the known “science and best practice” to that of new inputs that “improve best practice and advance science” Perceptions of Successful Aging Among Diverse Elders with Late-Life Disability, Romo et al,Gerontologist: Dec 2012

30. Roles We Can Contribute in Geriatrics Clinical Expert/Care Provider in institutions and home Consultant in Acute, Outpatient, Post Acute, LTC Clinician and Academic Researcher-classic and applying new adaptive models Systems Designer in Various Settings including the Community Consultant-a bridge to Those Who “Discover” geriatrics (GEC) Diffusion Expert of Evidenced Models

31. Conclusion and Discussion • The need and opportunity for our framing of care, along with our knowledge and skills, is high and will continue to grow • Hold to our values of assuring dignity, respect, voice of our older person and family • Assuring the best competency and quality possible from ourselves and those we enable as teachers, researchers and facilitators • Engage in awareness: • Geri-Pal Blog • New York Times: New Old Age Blog

32. Thank you Visit us at: www.americangeriatrics.org Facebook.com/AmericanGeriatricsSociety Twitter.com/AmerGeriatrics linkedin.com/company/american-geriatrics-society