Building Effective Relationships among Home Care, Client, and Care Coordinator Presented by: Kathy Thurston RN PHN MA Director of Disability Care Coordination AXIS Healthcare May 2008

Objectives for Today’s Discussion Describe the AXIS Disability Care Coordination Model Understand the components of effective care coordination Identify ways that Care Coordinators can and should coordinate communication and care planning with home care providers Distinguish the difference between direct home care services and care coordination Articulate ways for creative collaboration among provider, client, and care coordinator

UM, DM, CM, CC… what’s the difference? DM (disease management) – Focuses on best clinical practices for specific diseases or chronic conditions; one-dimensional UM (utilization management) – Focuses on managing health care resources; reactive management CM (case/care management) – Focusing on identifying and addressing health care needs; proactive management CC (care coordination) – Relationship management; partnering with the consumer and their key providers to ensure a comprehensive plan of care

Home Care has led the way… Relationship based, person-centered care management has been a key element of home care and public health nursing for many years Home Care has been instrumental in helping people with chronic conditions and disabilities remain in the community Home Care helped establish a foundation for the development of effective care coordination

How People with Disabilities Describe the Health Care System  Islands of care & buckets of dollars resulting in one- dimensional services  Created and managed to serve the masses… resulting in barriers to access, limited service delivery flexibility and generic utilization controls  Medical Care is diagnosis or treatment based… resulting in avoidable acute episodes and/or progression of chronic conditions  Decisions and responsibility lie with the purchasers or providers… resulting in disempowerment of the individual needing services

AXIS Healthcare Created and owned by Sister Kenny Institute & Courage Center Strategy: To work in partnership with persons with physical disabilities, as well as their key providers and payers to address their needs by coordinating a high quality, cost effective network of specialized services, spanning the continuum of care and support.

The Mission of AXIS Healthcare RIGHT CARE: Preventive services and equipment, targeted interventions, clinical protocols, medications management, wound management, experienced providers RIGHT TIME Proactive delivery of care and supports, timely response to newly emerging episodes of illness, follow up on acute episodes to ensure safe transitions betweens sites of care, 24/7 RN triage RIGHT SETTING Most appropriate level and site of care, commonly in the home and community MOST COST EFFECTIVE MANNER Preventive care, risk stratification, home-based lab, support of health & wellness activities

AXIS Disability Care Coordination Guiding Principles PERSON-CENTERED: always seeks to identify the person’s individual desired outcomes and goals. INTEGRATED: incorporates all aspects of physical, social, and psychosocial needs, utilizing the skills and knowledge of each member of the care coordination team. COST-EFFECTIVE: seeks out the most efficient and effective options in order to achieve the person’s desired outcomes and meet his or her health and safety needs. GOAL-ORIENTED: incorporates quality of life and improved health outcomes that are measurable, through collaborative care planning and decision-making between members and their providers.

Effective Care Coordination Ensures delivery of the right care at the right time in the right place. Optimizing the opportunities for quality care and creative, cost-effective problem solving. Success starts and ends with the relationship developed with the person; where he or she is a face, not a disability, diagnosis or number

Characteristics of an Effective Care Coordination Relationship  Establish Trust  Build Confidence  Ensure Responsiveness  Clear Communication

Unique Competencies of AXIS Disability Care Coordinators  Assessment of risk factors unique to persons with disabilities  Clinical protocols, and management of high risk complications  Timely response to urgent health needs  Disability-competent care planning  Knowledge of providers with disability competency and commitment  Member-specific advocacy, health education and activation  Coordination across providers and sites of care

Outcomes of Effective Care Coordination Access to Care – Primary Care/Medical Home partnership Coordination – Management and support across all settings of care. Logistics of transportation and appointments. Organization of community-based supports. Community Living – Housing referrals and relocation, including more than 120 young people moved out of nursing homes. Advocacy – Assurance of appropriate and cost-effective medical benefits for people with disabilities. Ensures responsiveness of medical providers – Targeting pervasive problems of disability with a UTI Fast Track Plan, Pressure Ulcer Prevention Program and Nurse Practitioner initiatives.

Effective Care Coordination & Collaboration with Home Care Providers By building sustainable community support networks around members, AXIS Healthcare Coordinators help stabilize the person’s overall well- being and reduce the occurrence of costly and avoidable emergency room visits: Jane’s Story –Multiple complicating diagnoses including both mental and physical health concerns –Frequent ER & hospitalizations & at risk of losing independence –Referred by medical provider to AXIS for care coordination –AXIS team built community supports & services with Jane –Home Care was brought in to provide PCA support, weekly skilled nursing, and adult mental health rehabilitation services\ –After one year of support: no ER or hospital admissions

Effective Care Coordination & Collaboration with Home Care Providers Through a relationship of mutual trust and respect it is possible to provide the right care, at the right time, in the right place, which is key for effective health care Rudy’s Story –Progressive MS with Quadriplegia –Hospitalized with infection, developed pressure wounds –Admitted to SNF for a year +… lost his caregivers…“I was stuck” and wounds did not improve –Referred by medical provider to AXIS for care coordination –AXIS care coordinator provided effective liaison to ensure that appropriate home care services and other community based supports were in place & effectively implemented so that he could achieve his goal of returning to the community –Skilled nursing care weekly for skin inspections, assessments, etc. with regular/ongoing communication between SN and Care Coordinator –PCA support 14 hours/day –He is now working part time in his trained profession with no skin breakdown!

3 Ways to Receive AXIS Care Coordination MnDHO (Minnesota Disability Health Option) MnDHO is a partnership between the MN Department of Human Services, UCare and AXIS and is available at no cost to people who are on Medical Assistance, have a physical disability, live in the 7- county metro area, and are age AccessAbility AccessAbility is a SNBC plan with Medica and AXIS. It is available at no cost to people who are on Medical Assistance, have a physical or developmental disability, live in the 11-county metro area, and are age AccessAbility does not include waiver services; those must still be accessed through the county Private Pay We bill the member or family directly for our services based on a contract that we develop jointly.