Attachment A Minnesota DHS Community Service/Community Services Development

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1 Attachment A Minnesota DHS Community Service/Community Services Development Applicant Organization: First Plan of Minnesota Project Title: Implementing a Functional Daily Living Skills Assessment to Predict Service Needs and Care Delivery Management Systems for Seniors in Northeast Minnesota Submission Date: October 15, 2004 Counties in Project Service Area: St. Louis County, Lake County Applicant Organization is a not for profit organization PROJECT NARRATIVE Describe the overall design of the project. Include service package to be provided the characteristics of target clients and how many persons will be served. Older Adults are presented with many living environment options. The nursing home is the least preferred, but provides the highest level of care. The availability of assisted living environments has surged and the options available for an individual to continue living in their own home with services continue to increase. Unfortunately, the current health care model lacks an objective, standardized assessment for evaluation of an older adult s functional daily living skill level and safety needs. The current care delivery system lacks coordinated resource and care options and lacks competency standards for some senior services entities which result in gaps, inconsistencies and inequities in existing options and care delivery for older adults with physical and cognitive acute and chronic disease conditions. This project demonstrates a model of seamless care delivery for older adults which will provide the training, education, resources, case management and the objective assessment necessary to meet the health care and daily living needs of older adults. The strategic goal of this project is to prevent or slow decline of functional independence with the older adult population and prevent pre-mature admission or re-admission to a higher skilled living environment by effectively using health care dollars and integration of resources. To accomplish this First Plan will: Develop services, identify and collaborate with community resources that allow people to live independently and be active participants in their communities for as long as possible. Additionally, First Plan s obligations of completion of a risk assessment on enrollment and annually thereafter will be piloted through implementation of First Plan s Functional Daily Living Skills Assessment (FDLS). Components of the assessment include: Balance and Fall Risk, Activity of Daily Living Skill safety (includes driving and transportation), Nutrition and Medication Management, Behavior Management, Cognitive Performance, Case Management needs, Patient, Spouse and Caregiver needs and the identification of community and/or county based resources to sustain independence. The assessment will utilize standardized assessments and a team of health care professionals to evaluate and recommend the appropriate living environment, level of care and level of services necessary for a community living senior adult to maintain their daily living skill independence and safety in preferably the environment of their choice. Team members involved in the delivery 1

2 of the standardized assessments will include a Registered Physical Therapist, Occupational Therapist, Speech Therapist, Nurse, Pharmacist, Dietician and a Physician. Support for seniors, their families and other caregivers across the LTC system will occur through the development and implementation of a Successful Aging Resource Center in two Superior Health Medical Group community based clinic settings. Resource Center services will include the comprehensive FDLS, referral to skilled ancillary services if indicated, establishment of and referral to community and/or county resources which compliment each individuals functional independence maintenance needs as well as, education for caregivers and individuals and case management services. The resource center will serve as a "hub, one stop shop for seniors and their families and/or care partners to access information and services specific to the physical, medical and cognitive needs of a senior adult and individualized to that senior adult. In addition a relationship with one skilled nursing facility providing sub-acute rehabilitation or transitional care will be established through partnership with Superior Health Medical Group. Through this relationship care delivery standards, discharge criteria; services allocation and a case management system for efficient admission and discharge from the SNF will be developed. Components of the FDLS assessment will be utilized as an objective measure of progress toward discharge from the SNF. The fiscal benefits of this model will be evaluated based on the continued stay criteria, cost of services, functional outcomes achieved and sustained compared to discharge disposition. Through the delivery of an objective assessment, designed to meet the unique and complex needs of the older adult, the ability to align funding sources and effectively maximize resources will be possible. First Plan s relationships with formal and quasi formal partners and integration of those services will provide a seamless consumer experience, achieve coordinated management and reduce costs associated with fragmented or duplicated services and preventable decline in function (i.e. Fall which leads to hip fracture). By aligning existing resources and case managing services it is anticipated that the proportion of County, Federal and State long term care dollars spent on nursing facility vs. home and community based care will occur by providing solutions that directly prevent or delay nursing home placement. In addition the potential exists to move current nursing home residents into community settings. First Plan currently has 419 community dwelling seniors enrolled. Focus diagnostic groups will parallel diagnosis and intervention groups including individuals with Alzheimer s/dementia, Diabetes, COPD/Pulmonary Dysfunction, Cerebral Vascular Accident, Bacterial pneumonia, dehydration, urinary tract infection, adult asthma, Congestive Heart Failure and hypertension. Describe the need for systems change and how that was determined, cite the information used to determine the need. Based on a literature review and as observed in First Plan s current health plan enrollees and Minnesota Senior Care on the horizon, Older Americans use a proportionately large share of health care services provided by physicians, nurses, pharmacists, physical therapists, occupational therapists and other practitioners. Healthcare needs of the older adult are unique. 2

3 Older patients often have several chronic conditions, take multiple medications and respond to treatment and medications differently than do younger persons. Physicians often may not be trained or have adequate resources to recognize or address the unique and complex needs of the elderly nor are they able to perform an effective geriatric assessment. As a result, physicians often consider conditions like memory loss or incontinence to be expected side effects of aging. Hesitation in prescribing exercise regimens or cholesterol lowering strategies, even though patients could benefit occurs. Depression is often confused with the onset of cognitive impairment and is often undiagnosed. In addition many physicians either lack training or are limited by time to consider the social, environmental and psychological factors such as retirement, death of family and friends and isolation that can compound effects of a patient s illness or in some cases lead to a preventable injury or illness. Health care professionals who are trained in geriatrics can help to maintain the health and quality of life of older patients. The complex needs of older patients often require a team of health care providers with aging related expertise, with access to resources, to work together to assess the patient s physical and mental well being and to coordinate care in a variety of settings. Critical is the ability and availability of the team. Studies demonstrate that older patients who receive specialized geriatric care tend to be better than those that receive usual care as demonstrated by decreased hospital admissions and readmissions. Health care delivery teams trained in preventive and rehabilitative care, in prompt intervention, appropriate assessment and testing can impact (reduce) expenditure of health care dollars. Reduction in cost from avoidable hospitalizations and nursing home admissions not only reduces health care expenditures but also contributes to the quality of life of older patients. The Alliance for Aging Research estimates that proper geriatric care could reduce hospital, nursing home and home care costs by at least 10 percent a year, saving $50.4 billion in the year 2000 and $133.7 billion in Further, it has been estimated that medication related problems among the elderly, including improper dosing and adverse reactions, costs $20 billion a year in hospital stays. According to the Centers for Disease Control and Prevention fall related injuries could be reduced substantially through a prevention strategy of exercise, vision correction, medication review and home modifications, such as bathroom grab rails. Current reimbursement models make it difficult to compensate physicians for the time they spend working on care plans and coordinating geriatric care teams. Through this project an effective care delivery model and reimbursement model for geriatric assessments, allocation and identification of resource types and care coordination for older adults to live in the least restrictive, community based non-skilled nursing facility, environment feasible will be established and piloted. 3

4 Describe the strategic changes this project will make in the current long term care system; how will the project change the long-term care system? What are the intended system change outcomes? The primary strategic change that this project will make in the current delivery of long term health care services is moving from a reactive approach of care delivery to a preventive approach to care delivery. In addition it is anticipated that a comprehensive approach to assessment and case management will result in more coordinated management of chronic diseases, reduce costs with fragmented or duplicated services. The combination of traditionally fragmented a la carte services to a comprehensive and collaborative service team located at a single source will improve access, demonstrate higher quality outcomes, reduced utilization of skilled nursing facilities and health care dollar savings. Competency standards for service providers and care pathway and utilization standards for sub-acute rehabilitation/transitional care, currently not in place, will be developed and implemented throughout this pilot project and outcome data collected to support this care delivery model. The success of this program will be measured by the ability to demonstrate prevention or slow the decline of functional independence of older adults through the use of the comprehensive assessment, effective use of health care services and care management. Examples of measures will include Emergency Room visits, hospitalizations, and decline in function necessitating a higher skilled living environment. Describe how the new model will be financially sustainable. Include exiting and anticipated revenue sources used to achieve financial sustainability and when sustainability will be achieved. Assessments are performed by discipline, documentation is not interdisciplinary and is often not available or shared timely with a team. Services are eligible for ala carte reimbursement, but generally only for a notable change or significant change in condition or functional decline. Assessment is not allowed prospectively, consequently planning and intervention is always reactive to health decline rather than able to prevent such decline. Currently, there is not a bundled, preventive reimbursement model for the comprehensive Functional Daily Living Skills Assessment. Current reimbursement guidelines are unbundled, not coordinated and fragmented depending on the type of condition in which a patient presents. Through the pilot of this assessment, combined with a health care delivery team trained in preventive and rehabilitative care, in prompt intervention, identification and allocation of types of resources and care coordination a cost of this type of service delivery will be determined. Given these costs First Plan will be able to establish a fee structure and benefit structure for First Plan enrollees. In addition First Plan will be positioned to seek approval for reimbursement under DHS and public program guidelines based on the demonstrated outcomes of this project. Access to this type of information will be critical for effective implementation of Minnesota Senior Care. 4

5 Describe the role/s, expectations and resource contribution/s of each partner in the project. Memorandum of understanding among the partners is attached. Partners Responsibilities and Accountabilities. The roles of each project partner are as follows: First Plan of Minnesota will serve as fiscal agent and manager for the project. First Plan has developed and will pilot the Functional Daily Living Skills Assessment as the foundation of this project activity. First Plan will develop and pilot a case management system that will establish a seamless service and resource allocation system. First Plan will implement this through the development of a clinic-based resource center model (Successful Aging Resource Center). Superior Health Medical Group will provide physician oversight to the project and provide physical space and management support for the delivery of the Successful Aging Resource Center services. Community Partners will assist with the development of the seamless delivery care model through integration of quasi-formal caregiver resources and pilot implementation of assessment recommendations for people living independently in the community. Lake County will assist in developing an effective and efficient communication and case management system that will integrate the Functional Daily living Skills Assessment results and care management recommendations into County waivered service planning and allocation. St. Louis County will assist in developing an effective and efficient communication and case management system that will integrate the Functional Daily living Skills Assessment results and care management recommendations into County waivered service planning and allocation. Area Agency on Aging will collaborate as needed and provide technical assistance with evaluation activities. If applicable, provide the name and address of one nursing facility in the project s service area that has or is permanently closing beds under MS 256B.436 or closed NF beds after June 30, Nopeming Nursing Home, St. Louis County, closed Veteran s Home, Lake County, closed 2 beds 5

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