1. Integrating Family Caregivers Into Primary Care to Improve Outcomes WellMed Medical Management Inc. WellMed Charitable Foundation San Antonio, Texas

2. Disclosures It is the policy of the AAFP that all individuals in a position to control content disclose any relationships with commercial interests upon nomination/ invitation of participation. Disclosure documents are reviewed for potential conflicts of interest and if identified, they are resolved prior to confirmation of participation. Only these participants who have no conflict of interest or who agree to an identified resolution process prior to their participation were involved in this CME activity. All individuals in a position to control content for this activity have indicated they have no relevant financial relationships to disclose.

3. Objectives Upon completion of this session, the participants should be able to: Describe how family caregivers can be integrated into a health care setting. Determine if the tools used for caregiver assessment and referral would be pertinent in their care setting. Determine if the program described during this presentation could be adapted to their care setting.

4. Agenda WellMed Organizational Overview The Case for Integrating Caregiver Services into Primary Care Caregiver SOS – A New Approach Integration of Caregiver Support Pilot in the WellMed Care Model

5. WellMed Organizational Overview Dr. George M. Rapier III founded WellMed in San Antonio, TX in 1990 as a single primary care practice Dr. Rapier grew WellMed into a diversified healthcare company to serve Medicare-eligible Seniors: Primary Care Clinics Medical Management Services UM, Case Management, Disease Management Transportation Services

6. Organizational Overview 56 primary care clinics (in-house lab, x-ray, pharmacy) with more than 100 physicians in Texas and Florida.

7. Organizational Overview Primary Care Centric Medical Group (Family Practice, Internal Medicine + added Podiatry, Dermatology, Cardiology, Oncology, Pain Medicine) Manages Full-Risk Capitated Insurance Contracts Specialize in Medicare-eligible Seniors – responsible for 87,000 lives Contracts for all Medical Services (Specialty, Hospital, Ancillary, Hospice) Fully functional primary care centric, patient centered medical home (PCMH) functioning as an accountable care organization (ACO)

8. Chronic Care Model

9. WELLMED CARE MODEL ACCESS TO CARE & INFO Health care for all After-hours access coverage Accessible patient & lab info PRACTICE-BASED SERVICES Comprehensive care for both acute & chronic conditions Prevention screening & services Ancillary diagnostic services CARE MANAGEMENT Wellness promotion Disease prevention Patient engagement and education CARE COORDINATION Collaborative relationships–ER, Hospital care & Specialist care Care Transition PRACTICE MANAGEMENT Disciplined financial management Cost-Benefit decision-making Facilities management HEALTH INFO TECHNOLOGY Electronic medical record Electronic orders & reporting Evidence-based decision support QUALITY & SAFETY Evidence-based best practices Medication management Quality improvement PRACTICE-BASED CARE TEAM Provider leadership Effective communication Patient participation Source: TransforMED.com

10. The Case for Integrating Caregiver Services Into Primary Care

11. The Background One in four US adults are caregivers caring for an adult family member, partner or friend with chronic conditions or disabilities. The average caregiver is a 49 year old working woman who provides 20 hours per week in care. The presence of a family caregiver during physician visits has been shown to facilitate communication and increase patient satisfaction.

12. Medical or Health Care Home The medical home, in reality, is the home of the person with chronic care needs cared for by a family caregiver L Feinberg, SC Reinhard, A Houser, and R. Choula, Valuing the Invaluable, 2011 Update – the Growing contributions and costs of Family Caregiving, AARP Public Policy Institute INSIGHT on the Issues (Washington, DC: AARP, 2011

13. Home Alone: Family Caregivers Providing Complex Chronic Care A new study from the United Hospital Fund and the AARP Public Policy Institute released in October 2012 46% of caregivers perform “medical” or “nursing” tasks

14. Medication Management 78% managed many different kinds of medications –5-9 prescriptions each day –Intraveneous fluids and injections 60% learned how to manage at least some of these on their own 47% never received any training of any kind Caregivers are afraid of making a mistake and harming their family member

15. Wound Care 35% of caregivers provide wound care –Ostomy care –Pressure sores –Application of ointments and bandages for skin care 66% found this very hard 47% were afraid of making a mistake 36% received some training, usually from home health organization

16. Heavy Medical Burden Those caregivers who performed 5 or more medical tasks were more likely to feel depressed They believe they are helping their family member avoid being placed in a nursing home. 57% felt they had no choice

17. “How has doing these medical/nursing tasks affected your own quality of life?” Caregiver Answers: “In the last year and a half, I have developed high blood pressure, diabetes, and weight gain so now I have sleep apnea.” “What life?”

18. Care Transitions High levels of caregiver burden and/or depression are associated with problematic discharges. Risk of re-hospitalizations occurs when the family caregiver feels unprepared for care in the home. Between 40 and 50 percent of re-admissions are linked to social problems and lack of community resources.

19. Positive Interventions Involving family caregivers in discharge planning during care transitions may improve quality of care and lessen risk of readmission. Goals: ◦ Understand instructions for medication and self care ◦ Recognize symptoms that signify complications ◦ Make and keep follow-up appointments ◦ Engaged and activated caregivers as members of the health care team

20. Person/Family Centered Approaches In 2008, the American College of Physicians endorsed ethical guidance to physicians emphasizing the importance of the patient- caregiver-physician relationship. United Hospital Fund initiative to improve quality of care by regularly recognizing, training, and supporting family caregivers. Programs with a combination of education, skills training, coping techniques, and counseling show positive results.

21. The Costs of Doing Nothing 17-35% of caregivers have significant chronic health issues, such as heart disease, diabetes, sleep problems, and increased use of psychotropic drugs. Caregivers of persons with dementia were more likely to have an emergency room visit or hospitalization.

22. Involving family caregivers in a meaningful and practical way, and supporting their own health care needs, should be a key component in all new models of care to promote better care, improve the experience of care, and reduce costs.

23. A New Approach: The Caregiver SOS Program

24. What is Caregiver SOS? A caregiver support program that provides:  Wellness-activity programming to support the physical and mental health of caregivers  Information-assistance with care planning and referral to local community resources  Support – groups that foster connections to other caregivers  Education- Education on caregiver topics Developing WISE caregivers!

25. Caregiver SOS Locations San Antonio –Alicia Trevino Lopez Senior One Stop Center –Northern Hills Edinburgh –Hidalgo County Harlingen –Harlingen Senior Center Corpus Christi –Lindale Senior Center

26. Evidence Based Programming Assessments and Care Planning Tools Better Choices/Better Health (CDSMP) Diabetes Self Management Program Stress-busting Program for Family Caregivers A Matter of Balance

27. Has been highly beneficial for many family caregivers 209 Alzheimer’s caregivers –162 females and 47 males –128 spousal caregivers, 78 adult children caregivers, 3 others –149 white (non-Hispanic) caregivers, 53 Hispanic caregivers Stress-Busting Program Results of Phase 2

28. Perceived Stress Baseline 4 weeks End 2 Months Intervention

29. Depression Baseline 4 weeks End 2 Months Intervention

30. Anxiety Baseline 4 weeks End 2 Months Intervention

31. Stress-Busting Program Summary of Results Decreases inImprovements in Stress Depression Anger/Hostility Anxiety Quality of life Sense of control

32. Other Assessment Tools C.A.R.E Tool (Short Version) ◦ Caregivers Aspirations, Realities, and Expectations ◦ N. Guberman, J. Keefe, P. Fancey, L. Barylak Caregiver Risk Screen (Guberman, Keefe, Fancey, Nahmiash, Barylak, 2001)

33. Integration of Caregiver Support Pilot in the WellMed Care Model

34. Chronic Care Model for Caregivers caregivers

35. Clinic Integration Utilizing 4 question Zarit caregiver burden scale as initial screening. Initial clinic site is co-located with a Caregiver SOS site Clinic staff administer the screening with the caregiver. The results are given to the Caregiver SOS specialist who contacts the caregiver.

36. Clinic Integration Caregiver SOS specialist works directly with the caregivers to assess needs, and offer appropriate programming. Referrals to community agencies are made as indicated by the screening and interview Feedback provided to clinic staff Goal: Make the caregiver part of the Care Team.

37. Referral Mechanisms Desktop Icon Zarit 4 Question Survey in Clinics Self Referral of Caregivers

39. Intervention Average Zarit score = 7.7 Contact required within 48 hours Referrals include support groups, evidence based programs, community programs 60% of caregivers are now participating in SOS programming

40. Future Evaluation Metrics Reduced hospitalizations Reduced hospital re-admissions Reduced emergency department usage Reduced cost per member per month Tie patient acuity rating to caregiver wellbeing

41. Questions Yet to Be Answered What training is required with the health team to ensure they have the skills to integrate a caregiver as a member of the health team? What changes in procedure are required to leverage an activated and engaged caregiver? What policy changes would allow all health care providers to engage caregivers?

43. An Interview with Bob Phillips, MD, MSPH Bob Phillips, MD, MSPH Director, Robert Graham Center Policy Studies in Family Medicine & Primary Care “What is primary care going to look like in 20 years and who is going to be providing it?” http://www.youtube.com/watch?v=dx3rzWE- 9u4&feature=youtu.be

44. Contact Information Cynthia Henderson, RN, CCM Director, Clinical Programs WellMed Medical Management, Inc. chenderson@wellmed.net Debbie Billa, Grants Manager WellMed Charitable Foundation dbilla@wellmed.net