1. Cross Cultural Strategies for Strengthening the Relationship between Hospital and Community Systems Robert J. Schreiber, MD Physician-in-Chief, Hebrew SeniorLife Clinical Instructor Of Medicine, Harvard Medical School February 17, 2011

2. The New Reality Healthcare consumes now 18% of GDP and will increase to 34% by 2040 79% of US healthcare $ spent on chronic care Medicaid expenditures are growing so rapidly that states can not meet demand Nursing home beds are decreasing in communities Health care reform is going to result in payment for outcomes and not service Are you part of the Healthcare system?

3. The IOM Quality report: A New Health System for the 21st Century “The current care systems cannot do the job.” “Trying harder will not work.” “Changing care systems will.”

4. IOM Report: Six Aims for Improving Health Systems Safe - avoids injuries Effective - relies on scientific knowledge Patient-centered - responsive to patient needs, values and preferences Timely - avoids delays Efficient - avoids waste Equitable - quality unrelated to personal characteristics

5. The Way Things Are

7. Need to be Bilingual or Trilingual Community organizations Physician Practices Health care systems Payers and/or Employers

8. The Community Perspective: Barriers to Health System / Community Integration Clinicians are very busy and are hard to engage Clinician behavior is regarded as relatively hard to influence and practice styles vary Changing clinician behavior presumably differs by behavior, including: prescribing behavior, referral behavior, communication style Lack of understanding of Aging Network benefits

9. Challenges Facing Medical Care Providers and Health Systems Payment for Quality, prevention and outcomes Penalized for bad outcomes Freezing of payments and/or cuts in Medicare payments Public Report Cards show a significant gap in best practice and the care delivered Being asked to restructure and redesign process of care Dong more with less

10. The Medical Provider Perspective: Barriers to Health System / Community Integration Lack of time Not my job to know or do Inadequate availability /understanding of services Question the outcomes and effectiveness CBOs have significant difficulty working with the medical care system Leveraging CBO reputation and connections will not work here

12. “Patient Protection and Affordable Care Act” Focus on 4 issues relevant to healthcare reform 1.Providers: ACOs and PCMHs 2.Self-Management 3.Care Coordination – requires three “I”s: information, infrastructure, and incentives 4.Research – Patient-Centered Outcomes Research Institute (PCORI) – Integration of the PCORI’s research findings with decision supports, guidelines, and other aspects of EHR

13. ACA Promoting Innovation Testing of programs that will lead to improvements in care coordination Expand beyond a narrow medicalized scope of practice toward connecting older adults in need of long-term care to supportive service in the community Transformation of payment and delivery system models of care such as ACO, medical health homes Bundling of payments for acute and post-acute services Funding to expand provider base to deliver long-term care services through direct workforce investments

14. AAAs/ADRCs are Part of the Solution to Solving Our Healthcare Crisis

15. Value Proposition Quality/Cost “Outcomes not service” is the new mantra for community based providers – Jim Firman CEO of NCOA Health system is transforming-what will be your role in it??? – Will you act or react? – Goal is to be relevant, add value

16. AAA Opportunities to Partner with Medical Community: Independent Living AL/SNF Long Term Care Primary Care Acute & Post-acute Acute/ Long-term Wellness, EBP Transitions/EBP Palliative Care/EOL health promotion Caregiver support Caregiver support EducationPCMH Transitions Dementia, Safety Upstream Midstream Downstream

17. Opportunity: Preventing Hospitalizations Preventing Readmissions-improving transitions from Hospital to Home – Care Transitions Program – STARR Program – Project RED – Project BOOST Avoidable hospitalizations through community interventions

18. Opportunity: Care Coordination Patient Centered Medical Homes Care Coordination/Integration Improve Healthcare Literacy Referral to EBP Community Prevention Programs – Hospitals – Postacute SNFs – Home Care

19. Opportunity: Building Healthy Aging Communities Involvement with dissemination of Evidenced- based Programs Building healthy communities through chronic care coordination, prevention and self- empowerment and efficacy Being part of the leadership solution for implementing a chronic care model in communities

20. Principle: WIIFM?

21. Before you proceed: Be prepared What is in it for me? (WIIFM?) Evidence (pay for performance, medical home) Prevent rehospitalizations Improve Quality outcomes

22. Before you proceed: Be prepared What do you want from the MD group? Referrals? Funding? Sites? Trainees? Support? All of the above? Are they the best partner? Are there other partners?

23. Before you proceed: Be prepared Can you deliver what they need? EBP: classes, variety of programs Partners in community to meet needs of patients and families Care coordination connections Can you meet the needs of their patients (language, vision, visual, transportation, evenings and weekends) How are you going to evaluate (aggregate and share outcomes?)

24. Talking Points: Why Should Medical Community Use AAAs? Medical Home Accountable Care Organizations EBP National initiative: AoA, CDC, AHRQ, CMS Posting of outcomes by payers Pay for Performance $ now attached to medical care practice IOM Report

25. The Value of Working with Aging Network Providers Dealing with care coordination for frail elders living in the community Extensive knowledge of community resources can be invaluable in arranging for in-home services. ADRC networks developing with goal of giving elders options to stay in their homes Move the “hospital into the community” concept

27. A Different Health System Evolving Self-management, self-determination, self- advocacy Community-based, collaborative solutions Prevention in delay of sickness and impairment Evidenced based outcomes, comparative effectiveness Development of Health Aging Communities Challenge ageism, health disparities

28. Concluding Remarks ACA has changed the playing field Financial Imperative for the country Critical role of Community Providers of Aging Network for care coordination, self- management and maintaining elders in the community Healthy Aging Communities should be a goal - bringing the hospital into the community