1 / 15

University of Pennsylvania Jean Yudin, CRNP, Jeanette Gallagher, MSW

ElderPAC: Sewing a “Program of All-Inclusive Care for the Elderly” Quilt from Community-Based Patches. Campaign for Better Care Webinar June 30, 2010. University of Pennsylvania Jean Yudin, CRNP, Jeanette Gallagher, MSW Philadelphia Corporation for Aging (PCA)

liora
Download Presentation

University of Pennsylvania Jean Yudin, CRNP, Jeanette Gallagher, MSW

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

  1. ElderPAC: Sewing a “Program of All-Inclusive Care for the Elderly” Quilt from Community-Based Patches Campaign for Better Care Webinar June 30, 2010 University of Pennsylvania Jean Yudin, CRNP, Jeanette Gallagher, MSW Philadelphia Corporation for Aging (PCA) Susan Meyer, MSW, Wendi Botnick, MSW

  2. Long Term Care: Deconstructing a Nursing Home Complex Health Management Independence at Home HCBC waivers Supportive Living Services Housing

  3. Elder PAC: Elder Partnership for All-Inclusive Care • Combines community-based Long Term Care (CB-LTC) services (through Philadelphia Corporation on Aging), the local Area Agency on Aging (AAA) with medical care (In-Home Primary Care Program) in an integrated academic health system. • Links to Home Health Agency services through both AAA and CMS funding • Now includes the Waiver, Options,Family Caregiver Support, and Bridge programs • Service Bundle varies by program– from $14,000-$34,000 /year as caps– average is $23,000/year

  4. Pre-Elder PAC 3 Nurse Practitioners 39 Case Managers 180 patients at PCA Case Manager 60 PCA consumers 50 providers

  5. Elder-PAC Philadelphia Corporation for Aging Senior Centers Elder Caregivers In-Home Primary Care Program Home Health Agencies

  6. Integrated Service Delivery • Primary Care • Acute, Rehab, LTC • Home Health Services • AAA / Aging Network • Care Management

  7. UPHS In-Home Primary Care Program • Active census of 130 homebound elderly patients in In-Home Program; 19 homebound elderly patients in Medicare Advantage • Primary Care provided by NP/SW/MD teams • Majority of patients receiving PCA services when they enter the In-Home Program • Majority of patients receiving skilled home health services, including chronic care coordination.

  8. ElderPAC Team Members • Case Manager from the Options/Waiver Programs of the Philadelphia Corporation for Aging • Social worker from Geriatrics • Geriatric Nurse Practitioners (GNP) • Physicians from Geriatric Medicine

  9. Home Visit Activity • Social Worker -- Makes initial contact -- Social/service map -- Usually bi-weekly contact • NP-Physician teams • see patients every 6-8 weeks (6 NP/2 MD visits/yr) • Physical exams, diagnostic studies • Home environmental modifications • Evaluate and strengthen social supports • Ensure contact with appropriate community agencies -- CONSUMER CHOICE (sort of) • Weekly team meeting /monthly with community agencies 2009 average 7.5 visits/pt (6 NP:1 MD)

  10. Supportive Living Service Integration • Environment • Information for modification and repair programs • Durable medical equipment • Stairglides • Transportation • Shared Ride SLS • Non-Emergency Ambulance • MA / Wheels

  11. Socialization • Information, lists and application process for: • Senior Centers • Adult Day Care • Senior Companion • Friendly Visiting • Counseling / Mental Health • Community Mental Health Center / Base Service Units • Home Health Aides / Personal Care Aides • Safety • Emergency Response Systems • Locks / Windows Program • Financial Management • Older Adult Protective Services

  12. Medical / Health:Switching between AAA and CMS • Home Health Agencies • Registered Nurse • Physical Therapist • Occupational Therapist • Speech Therapist • Home Health Aide • Incontinence Specialists

  13. 78 yo AA woman, Lives independently in neighborhood for past 50 years 2-story row home Son involved but lived 20 miles away Oxygen dependent Held and personally catered annual block party Multiple cats with fleas Medicare risk score 4.6 Personal goal to survive to 80th birthday 491.21 COPD 518.83 Resp Fail 02 327.3 Sleep Apnea 440.2 PVD 585.3 CKD 404.11 HTN c CKD and HF 416.8 Pulmonary Htn 428.3 Diastolic CHF 427.89 SVT 358.8 Neuropathy 274.0 gout 285.29 anemia 721.9 Cervical spondylosis 366.9 cataract 530.81 GERD 389.9 Hearing loss JW

  14. JW Hospitalizations Pre/Post Housecall Management 2004 2005 2006 2007 2008 2009 Start Housecall COPD/ICU COPD COPD COPD/ICU COPD/ICU COPD/ICU 80th birthday ED

  15. Conclusions • All-Inclusive management of medically complex, homebound patients can result in substantial savings compared to similar Medicare beneficiaries. • Independence At Home can provide funding for housecall practices caring for medically complex patients by guaranteeing a share in those savings.

More Related