Improving Care for Older Adults with Complex Needs “There’s No Place Like Home” Steven R. Counsell, MD Mary Elizabeth Mitchell Professor Director, IU Geriatrics Scientist, IU Center for Aging Research E-mail: scounsel@iu.edu IU Geriatrics

Disclosures Salary: Indiana University and IU Health Physicians President & Board of Directors, American Geriatrics Society Honoraria: Temple University, Health Dimensions Group, North Shore-Long Island Jewish Health System Grants and contracts: GRACE Team Care Implementation and Training: MetroHealth Cleveland, BCBS-Michigan, University of Michigan Health System, Atlanta VAMC, and Cleveland VAMC IU CoE in Geriatric Medicine: The John A. Hartford Foundation IU Geriatrics Workforce Enhancement Program: HRSA Medical Director, Division of Aging, State of Indiana

Objectives Identify unique aspects of geriatrics practice, characteristics of who benefits most from geriatric care, and clinical roles of IU geriatricians. Describe effective models of care for older adults with complex needs that include home visits as a key component. Discuss future directions and policy drivers for the care of older adults with complex needs.

Geriatrics Healthcare Professionals How are they different? When are they needed? Strive to optimize quality of life and independence Use an interdisciplinary team approach Integrate medical and social care Provide services in multiple settings Normal aging vs. disease Geriatric syndromes Multiple chronic illnesses with functional limitations Care transitions Primary care and consultation

Principles of Clinical Geriatrics Atypical and nonspecific presentation of illness Under-reporting of symptoms Communication issues Polypharmacy and adverse drug reactions Functional status Involvement of family and caregivers Level of care and housing alternatives Advance care planning and palliative care

Older People with Chronic Diseases and Functional Limitations Need more medical services and social supports Geriatric syndromes (e.g., dementia, depression, falls) Socioeconomic stressors, low health literacy, limited access and fragmented healthcare Have high healthcare costs Of community-dwelling adults 65 and over, the 20 percent with multiple chronic conditions and who receive help in instrumental or basic ADLs represent 40 percent of all healthcare spending.

Older Person with Chronic Diseases and Functional Limitations Multiple chronic illnesses: HTN, CHF, and DM Geriatric syndromes: dementia, falls, and ADLs Family and caregiver support needs Medicaid HCBS waiver case manager Primary and specialty care physicians Healthcare providers with limited geriatrics expertise Poor continuity and coordination of care

Clinical Role of the IU Geriatrician (The Nephrologist Analogy) Publish guidelines and teach about wellness and prevention of functional and cognitive decline Consult and co-manage older adults having geriatric syndromes in hospital and office settings Deliver primary care for elders dependent in ADLs Provide leadership for health system interventions to optimize care transitions and care coordination

Proven Models of Care with Home Visits as Key Component Acute/Subacute Care Hospital at Home Care Transitions Transitional Care Model Primary Care GRACE Team Care Geriatric Resources for Assessment and Care of Elders Home-Based Primary Care

Hospital at Home Acute/Subacute Care Patients Model of Care Qualifying Condition (Diagnosed with certainty in ED & low risk of decompensation) Pneumonia, UTI COPD, CHF, Dehydration DVT, Cellulitis Home Suitable Cleanliness Climate control Phone service Nurse assesses eligibility Physician evaluation in ED Patient transported home Accompanied by nurse Take needed equipment, medications, oxygen, etc. RN meets patient at home and implements care plan MD visits daily

Hospital at Home Acute/Subacute Care Outcomes Dissemination Fewer complications: Incident delirium Chemical restraints Greater patient and caregiver satisfaction Shorter LOS Lower hospital costs Reduction in mortality VA Medical Centers Boise, ID Honolulu, HI New Orleans, LA Philadelphia, PA Portland, OR Medicare Advantage Plan Presbyterian Health Systems Albuquerque, NM CMS Innovation Center Icahn School of Medicine at Mount Sinai, New York

Transitional Care Model Care Transitions Patients Model of Care ≥1 Risk for Poor Outcomes Age 80 years or older Inadequate support system Multiple Chronic Illnesses Depression Functional impairment Hospital admits ≥2, 6 months Hospital admit past 30 days Fair or poor self-rated health History of nonadherence to therapeutic regimen APN hospital visits Standardized protocol Patient/caregiver assessment Individualized care plan Collaboration with physician APN home visits 1st:48 hours, 2nd:7-10 days Additional as needed APN telephone contacts At least weekly Available 7 days per week

Transitional Care Model Care Transitions Outcomes Dissemination Improved physical function and quality of life Greater patient and caregiver satisfaction Reduced hospital readmission rates Fewer hospital days Lower costs 344 unique replications or adaptations (national scan) Health systems ACOs PCMHs Home health care

GRACE Team Care Primary Care Patients Model of Care Age 65 years or older Low-income Established PCP High risk of hospitalization (Probability of Repeated Admissions) Age Gender Perceived health Availability of caregiver Heart disease Diabetes Physician visits Hospitalizations Collaboration with PCP NP/SW initial home visit Geriatric assessment Individualized care plan GRACE protocols Weekly team conference (geriatrician, pharmacist, and mental health specialist) NP/SW home visits and telephone contacts Care transitions

GRACE Team Care Primary Care Outcomes Dissemination Improved quality of life Better quality of care High PCP satisfaction Reduced ED visits In High Risk Patients Reduced hospitalizations Fewer readmissions Lower costs Eskenazi Health, Indianapolis, IN UCSF Medical Center Medicare Advantage Plans HealthCare Partners Medical Group, CA Indiana University Health, IN Health Plan of San Mateo, CA Central Health Plan, CA Blue Cross Blue Shield of Michigan Accountable Care Organizations University of Michigan Health System MetroHealth System, Cleveland, OH VA Medical Centers Indianapolis, IN San Francisco, CA Atlanta, GA Cleveland, OH

Home-Based Primary Care Primary Care Patients Model of Care Impaired mobility Physical disability Functional limitation Inability to cope with clinic environment Cognitive impairment Mental health conditions Requires frequent medical visits to maintain stability End of life and hospice Comprehensive in-home primary care services Interprofessional team home visits Geriatric assessment Individualized care plan Weekly team conferences Frequent home visits and telephone contacts Urgent care

Home-Based Primary Care Primary Care Outcomes Dissemination Greater patient and caregiver satisfaction Reduced hospitalizations Reduced readmissions Reduced nursing facility days Lower costs All 139 VA Medical Centers 272 HBPC practices/non-VA (national survey) CMS Independence at Home Demonstration

Benefits of Home Visits Access to care improved and less burdensome for those with mobility, ADL and mental health issues More accurate and complete information obtained about the individual... “the rest of the story” Medications can be more thoroughly reviewed Living environment, social supports and safety are more accurately assessed Stronger and more trusting relationships are developed Care plan better personalized to an individuals preferences, capabilities and needs

Are Medical Home Visits Enough? Lesson Learned from a GRACE Replication HealthCare Partners Medical Group, Los Angeles, CA Patients in high risk chronic care program HBPC model with MD, NP and social worker No geriatrics healthcare professional involvement GRACE Enhancements and Results NP/SW geriatric assessment Individualized care plan using GRACE protocols Weekly team conferences with geriatrician, mental health specialist and pharmacist Reduced hospital, SNF, and ED utilization

Identifying Older Adults for Proven Models of Care Multiple chronic conditions and functional limitations Cognitive impairment Depression Low health literacy Inadequate social support Cultural and/or financial barriers High utilization of acute care services Lack of established primary care

Common Components of Proven Models of Care Home visitation by physician and/or APN Interprofessional team care Geriatric assessment and individualized care plan Special attention to geriatric syndromes Integration of medical and social care Implementation of care plan and follow-up Collaboration with patient’s physician(s) Decrease work or burden on patient Increase patient capacity for self-care

IU Geriatrics – Clinical Services Eskenazi Health Center for Senior Health Health Aging Brain Center Geriatrics Consultation Geriatrics Primary Care Specialty Consultation ABC Medical Home Senior Connection ACE Consult Service Extended Care Network GRACE Team Care House Calls for Seniors

IU Geriatrics – Clinical Services IU Health Indianapolis VAMC Senior Health Center Geriatrics Consultation ACE Consult Service Methodist Hospital West Hospital SNF Network GRACE Team Care Geriatrics Consult Clinic GeriPACT ACE Consult Service GRACE Team Care Home-Based Primary Care (HBPC)

Future Directions Integration between home and hospital settings Integration between medical and social care Community-based organizations Medicaid Community-Based LTSS Integrated care involving Medicare and Medicaid benefits for dual eligible enrollees Program for All Inclusive Care for the Elderly (PACE) State Option to Provide Health Homes for Enrollees with Chronic Conditions

Integration Between Home and Hospital Settings Hospital Medical Care by HBPC Providers HBPC Program, MedStar Washington Hospital Center Physicians follow patients in the hospital and in the home Fewer hospitalizations, SNF days, and ED visits Lower total Medicare costs ACE Plus GRACE Eskenazi Health, IU Health, Indianapolis VAMC ACE Consults by geriatrician/NP team with hospitalists Transitional care by GRACE team Reduced hospital readmissions

Integration Between Medical and Social Care HBPC and AAA Collaboration ElderPAC – Elder Partnership for All-Inclusive Care Penn’s In-Home Primary Care/Philadelphia Corp for Aging Serve Medicaid HCBS waiver clients Provide integrated care to emulate PACE Reduced hospital and NH utilization and total costs GRACE and AAA Collaboration Eskenazi Health GRACE Team Care Partnership with CICOA Aging & In-Home Solutions CICOA social worker serves as both GRACE social worker and HCBS waiver case manager Reduced hospital readmissions

Health Policy Drivers Value-Based Health Care Delivery and Payment Methods Bundled or episode-based payment Accountable Care Organizations Medicare Advantage and Special Needs Plans State Dual Eligible Demonstrations Independence at Home Demonstration Workforce Enhancement Initiatives Person-centered care

Take Home Message Improving Care for Older Adults with Complex Needs... Truly, “There’s No Place Like Home” Outcomes are best using a combination of home visitation and geriatric care principles. Both geriatrics as primary provider and geriatrics co-management models are effective. Our time has come!... Home Care Medicine and Geriatrics should lead the way in advancing the care of older Americans with complex needs.