Medicaring enabling frail elders to live meaningfully and comfortably at a sustainable cost
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MediCaring – Enabling Frail Elders to Live Meaningfully and Comfortably at a Sustainable Cost. June 25, 2014 Joanne Lynn, MD, MA, MS Director , Center for Elder Care and Advanced Illness [email protected] By permission of Johnny Hart and Creators Syndicate, Inc.

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MediCaring – Enabling Frail Elders to Live Meaningfully and Comfortably at a Sustainable Cost

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Medicaring enabling frail elders to live meaningfully and comfortably at a sustainable cost

MediCaring – Enabling Frail Elders to Live Meaningfully and Comfortably at a Sustainable Cost

June 25, 2014

Joanne Lynn, MD, MA, MS

Director, Center for Elder Care and Advanced Illness

[email protected]


Medicaring enabling frail elders to live meaningfully and comfortably at a sustainable cost

By permission of Johnny Hart and Creators Syndicate, Inc.


Single classic terminal disease

Single Classic “Terminal” Disease

Mostly cancer

Time

Function

Death

Often a few years, but decline usually over a few months

Onset incurable disease


Long term limitations with intermittent serious episodes

Long term limitations with intermittent serious episodes

Mostly heart and lung failure

Time

Function

Death

2-5 years, but death often seems “sudden

Begin to use hospital often, self-care becomes difficult


Prolonged dwindling

Prolonged dwindling

Mostly frailty and dementia

Time

Function

Death

Quite variable, up to 6-8 years

Onset could be deficits in ADL, speech, ambulation


Medicaring key components of reform

MediCaring™! Key Components of Reform

  • Customize services for frail elderly

  • Generate care plans

  • Geriatricize medical care

  • Include long-term services and supports

  • Develop local monitoring and management

  • Fund added services and management from medical efficiency

    Channel the public’s fear and frustration

    into the will to change


Identification of frail elders in need of medicaring

Identification of Frail Elders in Need of MediCaring™

Unless Opt Out

AND one of the following:

>1 ADL deficit or

Requires constant supervision OR

Expected to meet criteria in 1-2Y

Age >65

Age >80

Want a sensible care system

Frail Elderly

With Opt In


Discuss

Discuss

Useful category?

Not setting, specific diagnosis, payment mode?

Tolerable category? Better language?


Medicaring enabling frail elders to live meaningfully and comfortably at a sustainable cost

COMPREHENSIVE

EVALUATION

PERSON-CENTERED

CARE PLAN


What s essential in developing a good care plan

What’s essential in developing a good care plan?

Thorough understanding of the person/family situation

Reasonable prognostication

Availability and acceptability of services

Effective communication, sensitive but honest

Person (and family) priorities, fears and hopes

Involvement of all key service providers

Discussion/negotiation/compromise/accord

Time and event triggers for re-evaluating

Document


What about an advance care plan

What about an "Advance Care Plan?"

Lifespan and dying are naturally part of the care plan

Include emergency plans like POLST

Designate surrogate decision-maker(s)

Document along with care plan

Update and feedback as for other plan elements

For frail elders, no advance care plan = serious error


Discuss1

Discuss…

Process for adequate understanding and negotiation of care plan – and revisions, and feedback?

Why so strongly resisted, or inadequate versions accepted? Why no demand?

How can care plans be used in system management?


Geriatricize medical care

Geriatricize Medical Care

Continuity

Reliability, 24/7 to the end of life

Enable self-management around disabilities

Respect and include family and other caregivers

Reduce the burden of medical care

Move services to the home

Prevent falls, wrong actions

Enhance relationships, activities, meaningfulness

Be steadfast with dementia


Medicaring enabling frail elders to live meaningfully and comfortably at a sustainable cost

2009 Health and Social Expenditures as Percentages of GDP


Ratio of social to health service expenditures using 2009 data

Ratio of Social to Health Service Expenditures Using 2009 Data


Disaster for the frail elderly a root cause

Disaster for the Frail Elderly: A Root Cause

  • Social Services

  • Funded as safety net

  • Under-measured

  • Many programs, many gaps

Inappropriate

Unreliable

Unmanaged

Wasteful “care”

No Integrator

  • Medical Services

  • Open-ended funding

  • Inappropriate “standard” goals

  • Dysfx quality measures


Discuss2

Discuss…

How to scale up good practices?

How to see services integrated across supports, medical treatments, housing, etc.?

Does overspending on health care provide an opportunity?


Local level not just state federal and provider

Local level– not just state/federal (and provider)

Frail elders are tied to where they live

Local leadership responds to geography, history, leadership

Localities can engender and use off-budget or less expensive services

Localities can address employer issues for caregivers

Local management is politically plausible now


What will a local manager need

What will a local manager need?

Tools for monitoring – data, metrics


Cincinnati area readmissions over time

Cincinnati Area Readmissions Over Time


Patient reported pursuit of goals u neven interval multiple reporting strategies

Patient- Reported Pursuit of GoalsUneven interval, multiple reporting strategies


What will a local manager need1

What will a local manager need?

  • Tools for monitoring – data, metrics

  • Skills in coalition-building and governance

  • Visibility, value to local residents

  • Funding – perhaps shared savings

  • Some authority to speak out, cajole, create incentives and costs of various sorts

  • A commitment to efficiency as well as quality


Discuss3

Discuss…

Is service delivery for frail elders best done with a strong component of local, geographic management?

What existing entities could grow into this function?

What are the political and other practical considerations?

Could willing communities be allowed to learn?


Frail elderly people need some new spending

Frail Elderly People Need Some New Spending…

$$$

$$$

$$$

Where will it come from?

$$$

$$$

$$$

  • Housing

  • Nutrition

  • Personal Care

  • Caregiver training, respite, income

  • New drugs and other treatments


My mother s broken back

My Mother’s Broken Back


The cost of a collapsed vertebra in medicare

“The Cost of a Collapsed Vertebra in Medicare”


A winning possibility medicaring acos

A Winning Possibility: MediCaring ACOs…

For more on financial estimates, see http://medicaring.org/2013/08/20/medicaring4life/

Four geographic communities - 15,000 frail elders as steady caseload

Conservative estimates of potential savings from published literature on better care models for frail elders

Yields $23 million ROI in first 3 years


Navih e alth pos t acute v alue proposition

naviHealthPost-AcuteValueProposition

Variationandoverutilizationofpost-acuteservicesoffersignificantopportunityto createbetterandmoreefficientoutcomes

Post-acuteutilization,inthefee-for-serviceMedicarepopulation,issubstantiallyhigherthan othermanagedmodels

BPCIopportunitycanintroducecoordinateddatadrivencaretoanotherwisefragmentedand

misalignedareaofhealthcare

AverageLTAC,SNF,IRFcostsper memberper month(PMPM)

$122

~50%lessthanFFS national average

$99

$67

$53

$42

MedicareAdvantageaverage

Topquartile

Nationalaverage

naviHealthaverage

naviHealthBest

(Fee-for-serviceMedicare)

So – ~ half of expenditures saved – of 23% - if it costs half, 5% of Medicare is non-service profits


Some options

Some options…

  • Some ways to capture savings to invest in under-supplied supportive services – ACO, bundled payment, managed care, Pay4Success

  • Create medical savings –

    • Much more advance care planning and arrangements that let more very sick, or very old people live the end of life on-island

    • Reduce medical transport

    • Reduce low value tests and consultations and “rehab”

    • Move some services to the home

  • Monitor and manage services – supportive and medical

  • Consider local social insurance for long-term care costs


Discuss4

Discuss…

Can we put it all together?

Can we have reliable services to support comfort and meaningful lives in the period of frailty, at an affordable cost, in another way?

What is appealing and what is appalling (or at least, implausible or underdeveloped!) in the MediCaring approach?

What people and organizations might be supportive or hostile?


Medicaring key components of reform1

MediCaring™! Key Components of Reform

  • Customize services for frail elderly

  • Generate care plans

  • Geriatricize medical care

  • Include long-term services and supports

  • Develop local monitoring and management

  • Fund added services and management from medical efficiency

    Channel the public’s fear and frustration

    into the will to change


We can have what we want and need when we are old and frail

We can have what we want and needWhen we are old and frail

But only if we

deliberately build that future!


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