1. Staying Home Matters : Proactive Care Management Protocols for Medicaid Waiver Members Sharon Foerster, L.C.S.W. Director, Elder Independence of Maine ~ a division of SeniorsPlus, Area Agency on Aging May 21, 2010 Thanks: Atlantic Philanthropies and John A. Hartford Foundation Practice Change Fellows

2. Elder Independence of Maine (EIM) Care Management Model Coordinate in-home services Licensed nurses and social workers 3100 consumers throughout Maine Telephone-based and home visits Receive assessment, authorized plan of care from separate assessing agency

3. EIM Consumers and Programs Contract with Office of Elder Services Oversee 3 Medicaid and state-funded programs Out of the ~ 3100 on 3 programs, ~860 on Medicaid Waiver: 1915 (c) “elderly and adults with disabilities” Nursing facility level of care ~ Maine criteria most restrictive, high need ~ 450: 60 + ~ 153 of those with dementia

4. EIM Current Environment Challenging! Very tight state budgets Regulation Changes Proposed legislative actions All internal processes under review Care managers learning new practices, culture, new JD Readiness of staff to change practice drops But before all of this……just over one short year ago

5. Strategic Alignment EIM strategically seeking to update the care management model Use evidence-based practices, add value Allow for incorporation of chronic disease management Aligns with state’s initiative to rebalance community- based and facility care Practice Change project dovetailed with the organizational strategy Fundamental components to this project, but will move us forward in this waiver program in state of Maine

6. Nature of Problem Care management practice not based on proactive, evidence-based approaches with specified protocols Focus on service monitoring, in-home services Little attention to overall health conditions No risk level assignment or screening for risk factors No specific steps taken due to the medical diagnosis Caregivers not systematically approached; even though a key support, providing much care Missed opportunity to use proactive intervention based on diagnosis and evidence-based findings Consumers & caregivers coping with dementia are among those at highest risk : 5X greater risk of nursing home entry, increased use of medical services

7. Environmental Scan Dementia and long term care are major drivers of Medicaid long-term care costs Research demonstrates role of informal caregiver is key: influences well-being of consumer and nursing home entry decision Adverse outcomes for caregivers well documented: stress, depression Involvement of consumer & caregiver is key Identification of other models for dementia beneficiaries: Medicaid managed long term care (MA and WN) Partners in Dementia Care Model (VA and Alzheimer’s Association) Cleveland Alzheimer’s Managed Care Model: positive for clients and caregivers Validated Risk Appraisal Measurement (RAM) tool helps target interventions

8. Approach EIM current practice: not systematic nor evidence driven So – potential for real impact and change, but how? Build on previous success of EBP: this model used: Screening, education, linkage, action plan Concepts familiar to care managers New protocols fit in this known framework Example: Use Risk Screening tool (RAM), target the CM intervention Creates a focused question - guides a targeted intervention Six Domains: depression, burden, self-care and health behaviors, social support, safety, and patient problem behaviors Systematically include the caregiver

9. Project Approach Develop and standardize care management protocols, stemming from diagnosis, based on evidence to systematically carry out with all Medicaid waivers consumers and their caregivers Assign and Screen for Risk Assume high risk of the member with dementia Use a validated risk measurement tool (RAM) with caregiver and member to target the care management intervention and reduce risk Partner with the Maine Alzheimer’s Association to strengthen linkage of caregiver to this resource Provide educational materials Chose one chronic illness to start– dementia….

10. Target Population EIM data shows ~ 33 % - 37 % of our Med Waiver population has a diagnosis of dementia 134 female, 19 male 96% white, 2% Asian, 2% Black 85% live with a caregiver 54% caregivers adult children, 36% spouse Average length of stay on program is 18 months Many in rural areas Assume high utilizers of services (hosp, ER, readmissions) Assume most at-risk for institutionalization (5 x)

11. Process and Outcome Measures Measure risk level for caregiver and member Risk Appraisal Measure (RAM) given at baseline and then three month intervals Review length of stay Give a satisfaction survey to caregivers at baseline to measure care manager service Measure care manager process through chart review of Action Plans where intervention is captured

12. Anticipated Outcomes For each month of delayed NF placement, $3000 is saved per person; x153, $476,000 per month Reduction in risk levels Ease caregiver strain Safer environment for consumer Goals and targeted interventions met on Action Plan Increased average length of stay on program Policy considerations: (by-product) modernize policy to guide evidence-based practice (new practice inform policy)

13. Project Timeline Phase 1: through June 2010: Engaged stakeholders; champions, pioneers Partnered with Maine Alzheimer’s Association Developed Protocols, mini test Chose Measurement Tool, Trained staff on dementia, protocols Credential staff as Chronic Care Professionals Phase 2: May 2010 – March 2011: Begin measures Baseline survey and risk measures of caregivers Pilot protocols, carry out with 50 - 75 consumers and caregivers Review data at least monthly Phase 3: November 2010 – June 2011: Begin interpreting data to determine sustainability, need for change

14. Lessons Learned – to date Underestimated the process of developing a “new” model of standards and starting from scratch Leading a practice change during a time of unpredictability is extremely challenging; but also an opportunity Unlearning the old more difficult than learning the new Check out “WIIFM?” Financial savings to community-based care is significant; but to the person with dementia and the family, staying at home cannot be measured in dollars

15. Staying Home Matters “ One of the most precious things that happened as a result of Dad living with us is we make sure he spends lots of time with my two youngest nieces.”

16. Thank you ~ Q & A Audience Questions Suggestions for leading a practice change during a time of unforeseeable and unpredictable change? What one thing worked the best in your experience? Suggestions for leading culture change?