The Role of the RN Care Manager in the Geriatric Assessment Clinic Our Unique Medical Home Model for the Cognitively Impaired Lori Willis, BS, RN, CPHQ Hazel Torres, MN, RN

2 Florence Nightingale Quote “ So never lose an opportunity of urging a practical beginning, however small, for it is wonderful how often in such matters the mustard-seed germinates and roots itself. ”

3 Our “Practical Beginning”  One MD, one afternoon  Geriatric focus  To assist primary care providers  To improve utilization  To help the patients stay home

4 Dementia and Cognitive Impairment  Over 5.4 M Americans diagnosed  5 th leading cause of death over 65 years  80% of care delivered by (unpaid) family members – about $210 billion  Cost of Care about $183 billion annually

5 The Model

6 Our Journey  Our team – RN Care Managers – Geriatric MD – Social Worker – Pharmacist – Support staff  Services provided – Initial Consults and Assessment – Care Management by the RNs – Telehealth with extended hours – Neurology and Psychiatry services

7 When Change is Inevitable  When the home is no longer safe – Home Health – Referral and Placement into Long- Term Care facility  End of Life Care – Palliative Care – POLST

8 The RN Role CoordinateCommunicate Advocate Plan of care throughout the continuum For advice, support and consistency of care For the patient and the caregivers

9 Letter from Family Member — Ann, wife of former patient “ Throughout this whole adventure of Alzheimer’s, you have been my help, my support, my source of information and the people who knew and understood what he and I were going through and cared about.”

10 Where We Are Today 1500 patients being followed in our program Two interdisciplinary teams in place Focus on care coordination Resource to other providers and departments

11 Where We Are Today  Referral volume steadily increasing:

12 Where We Are Today – Program Strengths Comprehensive multidisciplinary consult Team conference with development of detailed treatment plan Geriatric staff availability

Geriatric Assessment Clinic Quality and Outcome Monitors

14 GAC Influenza Immunization Rates

15 GAC Pneumococcal Immunization Rates

16 GAC Annual Hospitalization Rates (per 1000 pts)

17 GAC Overall Satisfaction with Visit

18 GAC Satisfaction with Nursing Staff

19 Geriatric Assessment Clinic – A Win For All For the PatientFor the Department For the Organization  Treatment plan tailored to individual needs and situation  Improved compliance means better quality of life  Greater satisfaction knowing every aspect of care is addressed  High scores in patient satisfaction surveys  Increased staff satisfaction with team environment  Lower turnover rates and sick days  Improved utilization of emergency resources  Successful medical home; decreased hospital admissions  Greater patient & family satisfaction

20 The Geriatric Assessment Team …

The Role of the RN Care Manager in the Geriatric Assessment Clinic Our Unique Medical Home Model for the Cognitively Impaired Lori Willis, BS, RN, CPHQ Hazel Torres, MN, RN