The GRACE Model Geriatric Resources for Assessment and Care of Elders

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1 Evidence-Based Care Transition Programs AoA, CMS, VA Grantee Meeting The GRACE Model Geriatric Resources for Assessment and Care of Elders Steven R. Counsell, MD Mary Elizabeth Mitchell Professor and Director, Scientist, IU Center for Aging Research School of Medicine Department of Medicine Division of General Internal Medicine and Geriatrics Center for Aging Research

2 Older People with Chronic Conditions and Functional Limitations Need more medical services and social supports, and have high healthcare costs 7 million Dual Eligibles living in the community 63% chronic conditions and functional limitations Older DE spent $14,000 per year on healthcare, close to 95 th percentile of healthcare spending Socioeconomic stressors, low health literacy, limited access and fragmented healthcare Geriatrics expertise of providers is limited

3 Background Older persons with multiple chronic illnesses and geriatric conditions: Often do not receive recommended standards of care Account for a disproportionate share of expenditures New models of care are needed that: Improve quality without increasing costs Optimize the roles of primary care and geriatrics healthcare professionals Integrate Medical and Social Care Institute of Medicine (IOM). Retooling for an Aging America. Washington, DC: The National Academies Press; 2008.

4 Background 3. PCPs have limited time and resources to provide comprehensive care to older patients GRACE Geriatric Resources for Assessment and Care of Elders

5 GRACE Intervention Geriatric Assessment Care Management Unmet health care needs Improved diagnosis of geriatric syndromes by primary care physician Improved quality of care and better outcomes Barriers System Providers Patient Barriers System Providers Patient

6 GRACE Project Partners GRACE Investigators and Research Group GRACE intervention staff and physicians ResNet: Primary Care Practice-Based Research Network IU Center for Aging Research Regenstrief Institute Wishard Health Services IU Medical Group Primary Care Senior Care at Wishard Older Adult Services, Midtown Mental Health Center CICOA Aging & In-home Solutions

7 Unique Features of GRACE Geriatric Resources for Assessment and Care of Elders In-home assessment and care management by NP/SW team in collaboration with the primary care physician Extensive use of specific care protocols for evaluation and management of common geriatric conditions Documentation in an integrated EMR Use of a Web-based care management tracking tool Integration with affiliated pharmacy, mental health, hospital, home health, and community-based services Counsell SR, et al. J Am Geriatr Soc 2006;54:

8 GRACE Model In-home comprehensive geriatric assessment by a geriatrics nurse practitioner and social worker

9 GRACE Model GRACE interdisciplinary team conference - Geriatrician - Mental Health Case Manager - Pharmacist - Community Resource Expert - Physical Therapist Care plan development using GRACE protocols for target conditions

10 GRACE Protocols for Targeted Conditions 1) Difficulty Walking/Falls 7) Memory Loss 2) Urinary Incontinence 8) Depression 3) Malnutrition/Weight Loss 9) Chronic Pain 4) Visual Impairment 10) Health Maintenance 5) Hearing Loss 11) Advance Planning 6) Medication Management 12) Caregiver Burden

11 GRACE Intervention Difficulty Walking / Falls PCP Review Confirm diagnosis and update EMR Evaluate and treat causes of falls Order lab evaluation Optimize pain management Consult physical therapy Routine Team Monitor orthostatic vital signs Increase fluid intake Prescribe walking program Provide patient education on falls prevention

12 GRACE Model NP and SW meet with PCP Implement care plan consistent with the patient s goals Provide ongoing care management Ensure continuity and coordination of care

13 GRACE Intervention Daily EMR notification to GRACE support team of ED visits, hospital admissions, clinic visits and orders.

14 GRACE Intervention Message to physician at time of hospital admit and discharge, ED visit, clinic visit and orders.

15 GRACE Transitional Care Home ED or Hospital Hospital or ED Home Hospital Nursing Facility Home No Assistance Medicaid HCBS Waiver Specialty Care Primary Care Primary Care Specialty Care

16 GRACE Transitional Care Communicate baseline status and care plan Collaborate in planning transition Deliver transitional care including home visit Proactive support of patient and family/caregiver Reconcile medications and provide new medication list Ensure post-discharge arrangements implemented Inform PCP and schedule follow-up visit Review in GRACE team conference

17 Process of Care Key Component of Intervention Implementation GRACE Protocols per Patient 5 (2-10) Team Suggestions per Patient 63 (33-131) Adherence after 12 Months 81% Patient Contacts 18 (1-65) Face-to-Face 39% Contacts for Coordination of Care 8 (0-68)

18 Advance Care Planning Health Maintenance Medication Management Difficulty Walking / Falls Chronic Pain Urinary Incontinence Depression Vision Loss Hearing Loss Malnutrition/Wt Loss Dementia Caregiver Burden GRACE Protocols 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

19 Physician Satisfaction Mailed Survey: 85% Response Rate (21 of 21 Faculty and 46 of 58 Residents) Satisfaction with resources without GRACE to treat elderly patients Very Somewhat Neither Somewhat Very Dissatisfied Dissatisfied Satisfied Satisfied Satisfaction with resources with GRACE to treat elderly patients Very Somewhat Neither Somewhat Very Dissatisfied Dissatisfied Satisfied Satisfied How helpful was the GRACE program in providing care? Very Somewhat Neither Somewhat Very Unhelpful Unhelpful Helpful Helpful The amount of care provided by the GRACE Support Team was? Not Enough Too Much Just Right

20 GRACE Trial Quality and Outcomes Better performance on ACOVE Quality Indicators General health care (e.g., immunizations, continuity) Geriatric conditions (e.g., falls, depression) Enhanced quality of life by SF-36 Scales General Health, Vitality, Social Function & Mental Health Mental Component Summary Counsell SR, et al. JAMA 2007;298(22):

21 GRACE Trial Resource Use and Costs GRACE Intervention in High Risk Patients Fewer ED visits Decreased hospital admissions Lower readmission rates Reduced hospital costs offset program costs Potential for cost savings Counsell SR, et al. J Am Geriatr Soc 2009;57:

22 Keys to Success 1. Created by collaboration of geriatrics and primary care 2. NP/SW team assigned by physician/practice site 3. Focused on geriatric conditions to complement care 4. Provided recommendations for care and resources for implementation and follow-up 5. Incorporated proven care transition strategies 6. Provided home-based and proactive care management 7. Integrated medical and social care 8. Developed relationships through longitudinal care

23 Aging with GRACE

24 2009 ADRC Discharge Planning Grant AoA Program Announcement Indiana FSSA Division of Aging CICOA Aging & In-Home Solutions, the largest ADRC and Area Agency on Aging in Indiana Wishard Health Services and IU Medical Group, safety net healthcare system (~7,000 seniors), a John A. Hartford Foundation Center of Excellence in Geriatric Medicine

25 ADRC Discharge Planning Project Goals 1. Integrate ADRC care managers into the hospital discharge planning process 2. Provide timely, on-site Options Counseling and Preadmission Screening 3. Improve coordination between hospital/adrc 4. Increase access to community-based LTC 5. Ensure linkages with physicians to prevent hospital readmission and NH placement

26 Indiana ADRC Linkage Model ADRC care manager based at hospital Serve as ADRC liaison to hospital staff Prioritize high risk and HCBS waiver clients Collaborate in discharge planning Link waiver case manager with PCP and facilitate patient follow-up with PCP Patient centered care transition, better care coordination, reduced readmissions and NH placement.

27 2010 ADRC Care Transition Grant The Patient Protection and Affordable Care Act, Section 2405 Funding to expand ADRCs AoA and CMS State Funding Opportunity: ADRC Evidence-Based Care Transition Programs Program Announcement and Grant Application GRACE included as eligible model

28 Indiana ADRC Integration Model ADRC care manager assumes GRACE social worker role with GRACE team Identify Medicaid waiver clients on admission Collaborate in discharge planning Provide GRACE transitional and ongoing care Assume HCBS waiver case management Patient centered care transition, better care coordination, reduced readmissions and NH placement.

29 Indiana ADRC Care Transitions Program Hospital Transitions Support Team Key Components 1) High risk patient identified on hospital admission 2) ADRC SW provides options counseling integrated with hospital discharge planning 3) Patient enrolled in GRACE Team Care if discharged home 4) ADRC SW & Medical Group NP provide GRACE transition home visit 5) ADRC SW & Medical Group NP provide GRACE care management w/ PCP 6) ADRC SW becomes Medicaid Waiver HCBS case manager Geriatric Resources for Assessment and Care of Elders (GRACE) Team Care Medicaid Waiver Home and Community Based Services (HCBS) Case Management

30 Indiana ADRC Care Transitions Program GRACE Primary Care GRACE Primary Care WHS Hospital Transition Team CICOA Aging & In-Home Solutions VA Hospital Transition Team

31 Affordable Care Act Initiatives Federal Coordinated Health Care Office in CMS Improve coordination and access to benefits for DE, and improve quality of health care and care continuity Center for Medicare and Medicaid Innovation (CMI) Test innovative payment and service delivery models, and implement successful models Medicare Shared Savings Program (ACOs) Providers work together to manage and coordinate care, and receive payments for shared savings

32 Affordable Care Act Initiatives Independence at Home Demonstration Test payment incentive and service delivery model using home-based primary care teams Community-Based Care Transitions Program Funding of community-based organizations to furnish improved care transition services Give priority to entities in program administered by AoA to provide care transitions

33 GRACE Implementation Geriatric Resources for Assessment and Care of Elders School of Medicine Department of Medicine Division of General Internal Medicine and Geriatrics Center for Aging Research

34 GRACE Dissemination Wishard Complete Care Indianapolis ADVANTAGE Health Solutions MA Plan HealthCare Partners Southern California The SCAN Foundation VA Healthcare System Indianapolis VHA Office of Geriatrics and Extended Care ADRC Evidence-Based Care Transition Programs ACA: U.S. Administration on Aging & CMS

35 GRACE Dissemination Opportunity in Dual Eligibles Evidence-based Flexible Integrated Reduces high cost utilization Infuses geriatrics principles Includes mental health Collaborative team approach Patients and physicians are highly receptive Implementation Support GRACE Website GRACE Training Manual GRACE Care Protocols Web-Based Care Management Tool GRACE Dashboard On-Site Training Consultation

36 A. AGREE B. BUILD C. COMMENCE D. DOCUMENT E. EVALUATE F. FEEDBACK G. GROW ABC s of Implementation

37 AGREE Agree on the need for GRACE by key stakeholders and that GRACE is a winning situation for patients, providers and the healthcare system. Proposal for better care and lower costs Presentations to key stakeholders Formation of GRACE Steering Committee Identify target patient population Develop GRACE Dashboard

38 BUILD Build the GRACE model with strong physician leadership and an interdisciplinary team approach to planning and development. Identify GRACE Champion and Medical Director Involve Geriatrician and Interdisciplinary Staff Assemble GRACE Implementation Team Develop GRACE model within the local healthcare system Review and customize assessment forms and protocols Institution specific GRACE Training Manual and training staff Monitor implementation using GRACE Dashboard

39 COMMENCE Commence GRACE model with a focus on patient-centered care and attention to provider issues. In-home geriatric assessment by NP/SW Individualized care plan development using protocols Weekly GRACE team conferences Collaboration with primary care physician Implementation of care plan Continuity and coordination of care

40 DOCUMENT Document implementation of the GRACE model to ensure changes in the process of care take place as planned. Record dates of enrollment and team conference Track collaboration with primary care physicians Use web-based system to track protocol adherence Monitor contacts for continuity and coordination of care with special focus on care transitions

41 EVALUATE Evaluate the GRACE program for anticipated benefits to the patients, providers and the healthcare system. GRACE Steering Committee Provider and patient satisfaction GRACE Dashboard ACOVE quality indicators ED and hospital utilization Healthcare costs

42 FEEDBACK Feedback is to be provided to key stakeholders to update them on the progress of the GRACE program for sustained support. Provide regular updates to healthcare system leadership and physicians Share GRACE Dashboard results GRACE Steering Committee develop business case

43 GROW Grow the GRACE model to serve more older patients cared for by the healthcare system. High risk seniors in primary care Transitional care Homebound seniors

44 A. AGREE B. BUILD C. COMMENCE D. DOCUMENT E. EVALUATE F. FEEDBACK G. GROW ABC s of Implementation

45 GRACE Team Care Geriatric Resources for Assessment and Care of Elders School of Medicine Department of Medicine Division of General Internal Medicine and Geriatrics Center for Aging Research

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