Agenda for Workshop: Living Well while Old and Frail – at Lower Cost

Faculty:

·  Joanne Lynn, MD, MA, MS, Director, Center for Elder Care and Advanced Illness, Altarum Institute,

·  Dottie Deremo,

·  Ken Brummel-Smith,

8:30am – Introductions and goals

8:45am – The Frail Elder Cohort: Definition and significance

·  Ken – Definitions from the literature, current numbers, expected growth

·  Dottie – Insights from making it real

·  Joanne – Concepts and practical tips

·  Discussion around tables, questions and responses

9:45am – Individual care plans as the centerpiece of good care

·  Dottie – pointers from experience

·  Ken – Tools for “assessment”

·  Joanne – Concepts, evaluation possibilities

·  Discussion around tables, questions and responses

10:45am – break

11 am – Fixing the service delivery system

·  Ken – continuity, dementia or ADL disability as a defining diagnosis, planning ahead

·  Dottie – move services to home, 24/7 with care plan in hand, need for LTSS services

·  Joanne – testing performance with ability to make promises, expectations of feedback and reliable information fed-back, eventually requires deep changes (though all of us have to be doing some band-aid approaches first)

·  Discussion around tables, questions and responses

Noon – break

12:30pm – Measuring and managing –

·  Joanne – the argument for monitoring and managing locally; the measures that matter; the special role of care plans in guiding priorities; the current possibility for shared savings

·  Dottie – quality and cost measurement in practice now – what’s been useful, both internal to her program and those that affect (or could affect) her program

·  Ken – Quality and cost measurement at the federal level – challenges for this population, apparent direction – need for management with a scope that includes LTSS and health care (?)

·  Discussion around tables, questions and responses

1:30pm – Bringing it all together – MediCaring, a proposed shared savings, special purpose ACO for a community – Joanne – with discussion

2:00 pm – Bringing it all together – HOMe Support – a current practicing entity filling this gap –

2:30pm – Break

2:45pm - Getting underway – participants’ local projects and aspirations – working through the model and coaching, helping to solve problems, design tests – Ken and Dottie

·  The Target Population

·  Data to start with

·  Scaling up

·  Assuring adequate assessment

·  Building a cross-setting interdisciplinary team – special attention to the hospital dysfunction

·  Negotiating a care plan – honest prognostication of course with various options, process to get to a plan, documentation

·  Improving services – substitution (e.g. HBPC and HOMeSUPPORT), reforming existing, developing feedback, standardization across settings (CARE instrument),

·  Governing the system – data for management, arrangements that might work, financing

·  Workforce issues – direct care workers, professionals, unpaid “volunteer” caregivers

·  Others – as the participants suggest

3:45pm – evaluation, wrap up – IHI spring meeting on these topics (Andrea Kabcenell)