1. Altarum Institute integrates independent research and client-centered consulting to deliver comprehensive, systems-based solutions that improve health and health care. A nonprofit, Altarum serves clients in both the public and private sectors. For more information, visit www.altarum.org MediCaring – Enabling Frail Elders to Live Meaningfully and Comfortably at a Sustainable Cost June 25, 2014 Joanne Lynn, MD, MA, MS Director, Center for Elder Care and Advanced Illness Joanne.Lynn@Altarum.org

2. 2 By permission of Johnny Hart and Creators Syndicate, Inc.

3. 3 Single Classic “Terminal” Disease Onset incurable disease Often a few years, but decline usually over a few months Function Time Death Mostly cancer

4. 4 Begin to use hospital often, self-care becomes difficult Function Time Death Long term limitations with intermittent serious episodes Mostly heart and lung failure 2-5 years, but death often seems “sudden

5. 5 Onset could be deficits in ADL, speech, ambulation Function Time Death Prolonged dwindling Mostly frailty and dementia Quite variable, up to 6-8 years

6. 6 1.Customize services for frail elderly 2.Generate care plans 3.Geriatricize medical care 4.Include long-term services and supports 5.Develop local monitoring and management 6.Fund added services and management from medical efficiency Channel the public’s fear and frustration into the will to change MediCaring™! Key Components of Reform

7. 7 Identification of Frail Elders in Need of MediCaring™ AND one of the following: >1 ADL deficit or Requires constant supervision OR Expected to meet criteria in 1-2Y Unless Opt Out Frail Elderly Want a sensible care system Age >65Age >80 With Opt In

8. 8 Discuss  Useful category?  Not setting, specific diagnosis, payment mode?  Tolerable category? Better language?

9. 9 PERSON-CENTERED CARE PLAN

10. 10 What’s essential in developing a good care plan?  Thorough understanding of the person/family situation  Reasonable prognostication  Availability and acceptability of services  Effective communication, sensitive but honest  Person (and family) priorities, fears and hopes  Involvement of all key service providers  Discussion/negotiation/compromise/accord  Time and event triggers for re-evaluating  Document 10

12. 12 What about an "Advance Care Plan?"  Lifespan and dying are naturally part of the care plan  Include emergency plans like POLST  Designate surrogate decision-maker(s)  Document along with care plan  Update and feedback as for other plan elements  For frail elders, no advance care plan = serious error

13. 13 Discuss…  Process for adequate understanding and negotiation of care plan – and revisions, and feedback?  Why so strongly resisted, or inadequate versions accepted? Why no demand?  How can care plans be used in system management?

14. 14 Geriatricize Medical Care  Continuity  Reliability, 24/7 to the end of life  Enable self-management around disabilities  Respect and include family and other caregivers  Reduce the burden of medical care  Move services to the home  Prevent falls, wrong actions  Enhance relationships, activities, meaningfulness  Be steadfast with dementia

15. 15 2009 Health and Social Expenditures as Percentages of GDP

16. 16 Ratio of Social to Health Service Expenditures Using 2009 Data

17. 17 Disaster for the Frail Elderly: A Root Cause Social Services Funded as safety net Under-measured Many programs, many gaps Medical Services Open-ended funding Inappropriate “standard” goals Dysfx quality measures Inappropriate Unreliable Unmanaged Wasteful “care” No Integrator

18. 18 Discuss…  How to scale up good practices?  How to see services integrated across supports, medical treatments, housing, etc.?  Does overspending on health care provide an opportunity?

19. 19 Local level– not just state/federal (and provider)  Frail elders are tied to where they live  Local leadership responds to geography, history, leadership  Localities can engender and use off-budget or less expensive services  Localities can address employer issues for caregivers  Local management is politically plausible now

20. 20 What will a local manager need?  Tools for monitoring – data, metrics

21. 21 Cincinnati Area Readmissions Over Time

22. 22 Patient- Reported Pursuit of Goals Uneven interval, multiple reporting strategies

23. 23 What will a local manager need?  Tools for monitoring – data, metrics  Skills in coalition-building and governance  Visibility, value to local residents  Funding – perhaps shared savings  Some authority to speak out, cajole, create incentives and costs of various sorts  A commitment to efficiency as well as quality

24. 24 Discuss…  Is service delivery for frail elders best done with a strong component of local, geographic management?  What existing entities could grow into this function?  What are the political and other practical considerations?  Could willing communities be allowed to learn?

25. 25 Frail Elderly People Need Some New Spending… $ Housing $ Nutrition $ Personal Care $ Caregiver training, respite, income $ New drugs and other treatments Where will it come from?

26. 26 My Mother’s Broken Back

27. 27 “The Cost of a Collapsed Vertebra in Medicare”

28. 28 A Winning Possibility: MediCaring ACOs…  Four geographic communities - 15,000 frail elders as steady caseload  Conservative estimates of potential savings from published literature on better care models for frail elders  Yields $23 million ROI in first 3 years Net Savings for CMS Beneficiaries Yr 1Yr 2Yr 33-Yr Before Deducting In- Kind Costs -$2,449,889$10,245,353$19,567,328$27,362,791 After Deducting In- Kind Costs -$3,478,025$8,463,101$17,629,209$22,614,284 For more on financial estimates, see http://medicaring.org/2013/08/20/medicaring4life/http://medicaring.org/2013/08/20/medicaring4life/

29. 29 Average LTAC, SNF, IRF costs per member per month (PMPM) $122 $99 $67 $53 $42 Top quartileNational average Medicare Advantage average naviHealth averagenaviHealth Best naviHealth Post-Acute Value Proposition Variation and overutilization of post-acute services offer significant opportunity to create better and more efficient outcomes ~50% less than FFS national average (Fee-for-service Medicare) 29  Post-acute utilization, in the fee-for-service Medicare population, is substantially higher than other managed models BPCI opportunity can introduce coordinated data driven care to an otherwise fragmented and misaligned area of healthcare  So – ~ half of expenditures saved – of 23% - if it costs half, 5% of Medicare is non-service profits

30. 30 Some options…  Some ways to capture savings to invest in under- supplied supportive services – ACO, bundled payment, managed care, Pay4Success  Create medical savings –  Much more advance care planning and arrangements that let more very sick, or very old people live the end of life on-island  Reduce medical transport  Reduce low value tests and consultations and “rehab”  Move some services to the home  Monitor and manage services – supportive and medical  Consider local social insurance for long-term care costs

31. 31 Discuss…  Can we put it all together?  Can we have reliable services to support comfort and meaningful lives in the period of frailty, at an affordable cost, in another way?  What is appealing and what is appalling (or at least, implausible or underdeveloped!) in the MediCaring approach?  What people and organizations might be supportive or hostile?

32. 32 1.Customize services for frail elderly 2.Generate care plans 3.Geriatricize medical care 4.Include long-term services and supports 5.Develop local monitoring and management 6.Fund added services and management from medical efficiency Channel the public’s fear and frustration into the will to change MediCaring™! Key Components of Reform

33. 33 We can have what we want and need When we are old and frail But only if we deliberately build that future!