1. Medical Home Visits: After the Physician Team Leaves Cindy Hasz, Director Grace Care Management November 10, 2004

2. Physician Team to Care Manager –Referral from Physician Team to Community Care Team –Assessment, ID needs, Care plan, care coordination, on-going reassessment –Multidisciplinary team –Feedback system

3. ACUTE SYSTEM - Long Term Care - CHRONIC SYSTEM Vertical Horizontal Institution centered - Starting Point - Patient centered Facility-Stationary Residence-Mobile Crisis based Maintains Normalcy Single-system based - Method of Delivery- Partnership based Managed Care Care Management RIGID - Character of System - DYNAMIC Fixed-Slow-Inefficient Flexible-Fast-Efficient Emergency Resolved - Functional Outcome - Health Level Sustained SHINING A LIGHT ON TWO SYSTEMS CURRENT MEDICAL SYSTEM COMMUNITY CARE MANAGEMENT

4. When Necessary, Patient Enters Acute System Emergency Resolved, Patient Returns to Chronic Care Community Care Management Allows for the Best Utilization of Both Systems ACUTEACUTE CHRONIC

5. Community Care Management provides “Circulation” necessary for the appropriate care for the patient

6. Chronic Care Management: n Proactive: stabilize at home n Prevents acute care use & $$ n Based on Quality of Life: dignity, choice n Need for recognition of value by Public funding sources n Private sources: LTC insurance, families, private pay n Improved outcomes

7. Client Referral Patterns

9. Mr. Z n 92 yo, lives alone, only son out of state n HTN, dementia, risk for “undue influence” n APS referral, has assets, at risk for self- neglect n Cognitively unable to follow treatment plan n Needed assist w/ADLs and IADLs n Placement vs. home care?

10. Mr. Z today n In-home care carries out tx plan n Controlled HTN, adequate nutrition, safety, “Gracie”, companionship n Cost is $60/day or $2000/month n Mr. Z is happy and healthy at home!

11. Community Care Management: Choice Dignity Quality of Life. Inland Comprehensive Health Care Community Care Management, Serving the Unincorporated, Rural Regions of San Diego County