1. Maryland’s ADRC Evidence Based Transitions Grant Project: the Guided Care Model Ilene Rosenthal Deputy Secretary Maryland Department of Aging

2. Project Partners Johns Hopkins Community Physicians Baltimore City Aging and Disability Resource Center (Maryland Access Point) Maryland Department of Aging

3. Key Elements Builds on Maryland’s: – Person Centered Hospital Discharge Program – Money Follows the Person Demonstration – Older Adult Waiver Program – Aging and Disability Resource Center Program Expanded Guided Care Program ADRC nurse working collaboratively with Johns Hopkins guided care physicians and nurses ADRC case manager extending the community- based services available to Guided Care patients

4. Target Population Individuals eligible for Medicare and Medicare with complex chronic conditions – Discharging from hospital or nursing homes – Coming into a HCBS waiver from the community – Transitioning from nursing homes into a HCBS waiver Baltimore City residents

5. How this Will Improve Care Identify people at high risk of hospital and nursing home readmissions and emergency room use Empower individuals or families to self-manage chronic conditions Provide one on one support in the community – Medication education – Provide post acute oversight – Early intervention for post acute episodes Facilitate access to community-based services with additional case management from the ADRC Coordinate care among providers

6. Other Benefits Reduce costs – Reduce emergency room admissions – Reduce hospital and nursing home readmissions Expand the number of patients that can be served by a Guided Care Nurse Higher consumer and provider satisfaction Fewer physician visits Demonstrates rationale for making this a paid benefit under insurance including public payers

7. Current Status Preparing to hire ADRC Guided Care Nurse Developing evaluation criteria and goals Determining assessment instruments and process Defining partnership roles Developing a protocol for cross referrals Determining data requirements and access to data Planning on-line training and cross training for ADRC Guided Care Nurse Developing a rolling method to identify at least 25 individuals

8. Challenges and Issues Getting cost data over time on Medicare patients Forging new partnerships Location of ADRC Guided Care Nurse How to institutionalize and broaden this option How to embed this option in the ADRC program