1. Geriatrics Patient Centered Medical Home Audrey Chun, MD Mount Sinai School of Medicine

2. Nature of Problem Traditional primary care model: Traditional primary care model: Fragmented care without reimbursement for non-procedure care.Fragmented care without reimbursement for non-procedure care. Staff and physician burnout.Staff and physician burnout. Patient dissatisfaction with healthcare system.Patient dissatisfaction with healthcare system. Department and Medical Center mission: Department and Medical Center mission: Explore models to improve the care of older adults and those with serious illness.Explore models to improve the care of older adults and those with serious illness. Improve patient satisfaction.Improve patient satisfaction.

3. Results of Environmental Scan Potential models of care: Potential models of care: Chronic care modelChronic care model Guided care modelGuided care model Disease based team management (CHF, IMPACT- depression)Disease based team management (CHF, IMPACT- depression) Hospital at homeHospital at home Geriatrics models: GRACE, home-based primary care, PACEGeriatrics models: GRACE, home-based primary care, PACE Patient centered-medical homePatient centered-medical home

4. Results of Environmental Scan Potential models of care: Potential models of care: Chronic care modelChronic care model Guided care modelGuided care model Disease based team management (CHF, IMPACT- depression)Disease based team management (CHF, IMPACT- depression) Hospital at homeHospital at home Geriatrics models: GRACE, home-based primary care, PACEGeriatrics models: GRACE, home-based primary care, PACE Patient centered-medical home (PCMH)Patient centered-medical home (PCMH) Potential reimbursement Potential reimbursement Fit into our current model of care/resources Fit into our current model of care/resources Adaptable for geriatrics care Adaptable for geriatrics care

5. 2nd Environmental Scan PCMH PCMH Primary Care Collaborative (PCC)Primary Care Collaborative (PCC) National Committee for Quality Assurance (NCQA)National Committee for Quality Assurance (NCQA) Geriatrics Geriatrics AGS subcommitteeAGS subcommittee ACOVEACOVE

6. Approach to the Problem Update/transform the existing primary care delivery model in our outpatient geriatrics practice to align with the patient centered medical home (PCMH) model with an emphasis on care for older adults. Update/transform the existing primary care delivery model in our outpatient geriatrics practice to align with the patient centered medical home (PCMH) model with an emphasis on care for older adults.

7. Target Population Academic geriatrics practice Academic geriatrics practice 2,500 community-dwelling older adults2,500 community-dwelling older adults Average age 85 yearsAverage age 85 years 1/3 Medicaid eligible1/3 Medicaid eligible 1/3 identify themselves as Hispanic1/3 identify themselves as Hispanic 25% as African-American25% as African-American Border of Upper East Side and East HarlemBorder of Upper East Side and East Harlem No full time providers (fellows, academic geriatricians) but dedicated full time staff (SW, NP, RN, MA, registrars)No full time providers (fellows, academic geriatricians) but dedicated full time staff (SW, NP, RN, MA, registrars)

8. Process and Outcome Measures Patient satisfaction Patient satisfaction Outsourced (Press-Ganey) surveyOutsourced (Press-Ganey) survey Patient “rounding”Patient “rounding” Staff satisfaction, affective performance: Staff satisfaction, affective performance: surveys, 360 evals, physician report cardssurveys, 360 evals, physician report cards QI from ACOVE (screen + appropriate action) QI from ACOVE (screen + appropriate action) FallsFalls urinary incontinenceurinary incontinence memory loss screening and treatmentmemory loss screening and treatment # Hospital admissions # Hospital admissions Costs (by CMS data) Costs (by CMS data)

9. Project Timeline Resource/needs assessment: August, September Resource/needs assessment: August, September Faculty/staff development: Quarterly, starting in September Faculty/staff development: Quarterly, starting in September Staged implementation of QI, patient satisfaction, care coordination initiatives 2009-2010 Staged implementation of QI, patient satisfaction, care coordination initiatives 2009-2010 Application for CMS demonstration project if NY region qualifies. Application for CMS demonstration project if NY region qualifies.

10. Implementing the Program Leverage Leverage Funding from Medicare Demonstration projectFunding from Medicare Demonstration project Initiative to improve patient satisfaction/care qualityInitiative to improve patient satisfaction/care quality Opportunities Opportunities Hospital QIHospital QI Stakeholders Stakeholders PatientsPatients ProvidersProviders StaffStaff Departmental and Hospital AdministrationDepartmental and Hospital Administration Medical school and studentMedical school and student

11. Perceived Facilitators/Barriers Facilitators Facilitators Department Chair as advocateDepartment Chair as advocate MD and nursing championsMD and nursing champions Patient demand and appreciation of current carePatient demand and appreciation of current care Barriers Barriers Culture changeCulture change Healthcare unionHealthcare union Limited financial resources to add additional FTEs or support additional supportLimited financial resources to add additional FTEs or support additional support Increasing demand for services greater than supplyIncreasing demand for services greater than supply

12. Patient Satisfaction

14. Staff Satisfaction

15. QI Falls Falls 30% screening documentation30% screening documentation Initiated reminder for screening documentation and decision pathway for assessment/treatment planInitiated reminder for screening documentation and decision pathway for assessment/treatment plan

16. Hospital and Emergency Room by Coffey Geriatrics Patients ED Use Inpatient Admissions None 58% 1 adm. 24% 2+ adm. 18% 2+ visits 9% None 72% 1 visit 19%

17. Sustaining the Program Improvements in any of the outcomes areas would be considered “successful” to maintain current resources and FTEs. Improvements in any of the outcomes areas would be considered “successful” to maintain current resources and FTEs. Additional funding would provide incentive for expansion to meet needs. Additional funding would provide incentive for expansion to meet needs. Exportable deliverables regarding practice design for older adults. Exportable deliverables regarding practice design for older adults.

18. What I am Learning Even with a supporting environment, culture change is challenging. Even with a supporting environment, culture change is challenging. Theory to practice is not always so obvious. Theory to practice is not always so obvious.

19. Questions Which would have more meaningful impact in the care older adults? To model a patient centered medical home that incorporates geriatrics within the current guidelines.To model a patient centered medical home that incorporates geriatrics within the current guidelines.OR To model a geriatrics patient centered medical home separate from the existing structure that would better meet the needs of older adults.To model a geriatrics patient centered medical home separate from the existing structure that would better meet the needs of older adults.