Dual Eligible Grant- Long Term Services and Supports Workgroup
October 21, 2011
Nursing Homes/ Adult care homes
Participants:Heather Burkhardt, Gay Joyner, Pam Ogoke-Llyod, Kim Sturkey, Raquel Rey, George Smith, Mary Bethel, Sandy Terry, Wendy Suase, Bill lamb, Scott TenBroeck, Sam Clark, Elise Bolda, Nidu Menon
NURSING HOME GROUP
Review of previous meetings
Introductions
Presentation by Wendy Sause – CC Western NC:
New program w/ 646 waiver program let them work w/ dual eligibles
Extended care physicians – practice that works w/ LTC medical directors and care managers is part of their network
Overall goal – LTC – preventing unneeded readmission & treatment in place (provides better quality care & saves all parties money). 3 care managers (2 in nursing homes/1 social worker capacity)
Chose facilities –
- Physicians – open to new project
- # of residents that were in 646 waiver range (extended care and dual eligible program)
- Willingness of facility to participate
First Meeting – looked at what would immediately help residents through:
- Advanced care planning and goals of care
- Communicate w/ family on (Medical Order Scope of Treatment (MOST form) or a similar form
- Physicians preferred MOST form
- Forms are being lost in process on both hospital and NH facility part; working w/ hospital on accountability of form tracking
- Extended Care Patients are reviewed on their diagnosis (geriatric consult team). Questions asked:
- Was this a preventable admission?
- Was the MOST form used?
- ECP/EMR systems are utilized to gather true diagnosis.
- Prescription drugs are reviewed
- Educate staff/physician on treating patients before sending them to the hospital
Retreat occurred with key players in industry to discuss the purpose of program and this can be an education that the facilities can eventually replicate and will no longer need the outside help.
Liability issues were discussed but there was not a resolution.
- Multiple readmissions from facility to hospital is prioritized and separated into a special file.
- Some hospital staff members have volunteered to help educate.
Data link access has all information for the patient in the hospital and can be accessed by any subscriber.
Facility > Community w/ practice that has community care imbedded; care manager will communicate all information to the physician at the practice (diagnosis, practice, etc)
Data from CMS is limited and care managers are working towards a more fluid system.
Starting to help adult care homes – looking at med reconciliation, training staff to use crisis care plan, lowering readmission to hospital. Problems still arise w/ no assessing due to lack of RN w/in assisted living.
Discussing what parts of this program should be a part of the transition team and other teams. Thoughts of some nursing home group ideas merging with medical home group.
New discussion raised on what are the problems with patients that have memory loss issues and end of life care conflicting with rehab (Nursing Homes trying to use Medicare dollars).
Concerns regarding nursing homes not having computer access. Response that rural N.H. are still functioning without advanced computer systems.
Request for analysis of behavior health problems. Elise comments that the focus should be on memory loss rather than the psychological diagnosis that don’t have memory loss issues.
Key items identified for further conversation:
- Advanced Directives/MOST Form (targeted approach within Assisted Living Facilities/Skilled nursing Facilities)
- General Public Awareness about Advance Directives/MOST ( utilizing community collaborative)
- Medication reconciliation ( standardization and avoidance of duplication in both the community and LTC)
- *Facility access to Electronic Medical Records
- Utilization of data link for continuity of care
- Care Plan segments for admission/discharge
- Communication with family and consumer; between facilities
- *Discharge from hospital to SNF (Rehab) when hospice is desired. Medicare won’t pay for Hospice and rehab- although beds are dually certified
- Dementia issues
Dual Eligible Grant- Long Term Services and Supports Workgroup
October 21, 2011
Living at Home/Community Living
Participants: Cynthia Temeshenko, Annette Lauber, Heather Burkhardt, Gay Joyner, Pam Ogoke-Lloyd , Kim Sturkey, Raquel Rey, George Smith, Mary Bethel, Sandy Terry, Wendy Sause, Scott TenBroeck, Cynthia Davis, Don Herring, Ursula Robinson, Elise Bolda, Nidu Menon
Wendy Sause provide a description of what activities were being done in the Community Care of Western NC
Transitions in care (hospital, home health agencies)
Care manager and pharmacist working within the hospital (Mission hospital). They review each patient: med reconciliation, reason for admission, talk to each patient, explain process of care manager.
Pharmacist looks at prescription history, method of taking pills, recommend community options for the patient to help in process.
Team observes each patient and what resources in the community that the individual could utilize. Care plan is written and the hospital and PCP has access to this plan with goal to have patient connected to community resources in an effort to reduce re-hospitalization and educate public.
Kim Sturkey – CMC care relayed info on her program and the relationship they have with physicians. They have to adhere to home health agencies qualifications. In addition the importance on communication with the physicians regarding discharge planning is important to the process.
Care Partners tries to coexist with Community Care and other agencies so there is not a duplication of services (i.e., Medication reconciliation).
Question/Concern was raised how you can provide services to an individual that Care Partners might not provide. Answer is to coordinate with CRC, disability partners and other agencies that can provide for their needs. It is the responsibility of the referral agency to know the community options.
All resources to community programs do not necessarily discharge them from the existing program as long as there is not a duplication of services to satisfy (grant, nonprofit and reimbursement) criteria.
Mary Bethel stated integration is key and had concerns about staffing in relations to cost efficiency.
Questions about getting services that might be outside the Medicaid waiver program (wheelchair ramps). How do you balance?
Answers: respite care for family care givers
How do you align money based upon people’s needs; parameters that can make that happen?
Elise brought up our focus should be:
How do figure out what resources can be used based on need?
How can you establish services for all the different demographics?
What are some the universal components that have to be intact to make this happen?
George asked why we aren’t merged together. Elise responded ‘there are too many topics for one group’
Social supports are key for the appropriate level of care
George asked who covers wheelchair ramps. Explanation was a portion is only paid by Medicaid to a certain $$ amount.
Medicaid will not pay for hands on ADL’s for home only. Any other issues refer client to SNF.
Heather closed by assumptive eligibility could be a focus for the group.
Elise asked group to focus on item that needs to be paid for and not who pays for it.
Three questions:
How do you figure out people’s levels of need? Resources?
How do you establish a variety of support approaches across the board?
What are the universal components that should be in place that allow a person to live in the community?
Key items identified for further conversation:
- “Dive deep” in looking at creating a system were individuals get the level of the services they need based on IADL and ADLs
- Allocate resources based on function/Align money based on need
- Collaboration with community based organizations
- Looking at the system to identify how some of the basic things that allow for successful living in the community happen ( a ramp, a magnified or speaking pill box)
- Care managers that follow a person to the community- or communication between a facility care manager and a community based one.
- This cannot be a free standing program – complete integration and coordination with everything else in the community
- Build in Self Direction, Flexibility, Assistance for family members
- Bundling of resources
- Examine ‘Presumptive Eligibility’