MediCaring - PowerPoint Presentation

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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

Slide2

By permission of Johnny Hart and Creators Syndicate, Inc.Slide3

Single Classic “Terminal” Disease

Onset

incurable

disease

Often

a few years, but decline usually

over a few months

Function

Time

Death

Mostly cancerSlide4

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 “suddenSlide5

Onset could be deficits in ADL, speech, ambulation

Function

Time

Death

Prolonged dwindling

Mostly frailty and dementia

Quite variable, up to 6-8 yearsSlide6

Customize services for frail elderly Generate care plansGeriatricize medical care

Include long-term services and supportsDevelop local monitoring and

management

Fund added services and management from medical efficiency

Channel the public’s

fear and frustration

into

the will to change

MediCaring™!

Key Components of ReformSlide7

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

>

65

Age

>

8

0

With Opt InSlide8

Discuss Useful category?Not setting, specific diagnosis, payment mode?Tolerable category? Better language?Slide9

PERSON-CENTEREDCARE PLAN

COMPREHENSIVE

EVALUATIONSlide10

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 honestPerson (and family) priorities, fears and hopesInvolvement of all key service providers Discussion/negotiation/compromise/accord

Time

and event triggers for re-evaluating

Document

10Slide11
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What about an "Advance Care Plan?"Lifespan and dying are naturally part of the care planInclude emergency plans like POLST

Designate surrogate decision-maker(s)Document along with care planUpdate and feedback as for other plan elementsFor frail elders, no advance care plan = serious errorSlide13

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?Slide14

Geriatricize Medical CareContinuityReliability, 24/7 to the end of lifeEnable self-management around disabilitiesRespect and include family and other caregiversReduce the burden of medical careMove services to the homePrevent falls, wrong actions

Enhance relationships, activities, meaningfulnessBe steadfast with dementia Slide15

2009 Health and Social Expenditures as Percentages of GDPSlide16

Ratio of Social to Health Service Expenditures Using 2009 Data Slide17

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 IntegratorSlide18

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?Slide19

Local level– not just state/federal (and provider)Frail elders are tied to where they liveLocal leadership responds to geography, history, leadershipLocalities can engender and use off-budget or less expensive services

Localities can address employer issues for caregiversLocal management is politically plausible nowSlide20

What will a local manager need?Tools for monitoring – data, metricsSlide21

Cincinnati Area Readmissions Over TimeSlide22

Patient- Reported Pursuit of GoalsUneven interval, multiple reporting strategies

DateScore

7/1/2012

2

8/3/2012

4

8/8/2012

3

10/12/2012

1

2/28/201343/2/201335/23/201306/1/201336/30/2013

4Slide23

What will a local manager need?Tools for monitoring – data, metricsSkills in coalition-building and governanceVisibility, value to local residents

Funding – perhaps shared savingsSome authority to speak out, cajole, create incentives and costs of various sortsA commitment to efficiency as well as qualitySlide24

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?Slide25

Frail Elderly People Need Some New Spending…Housing

NutritionPersonal CareCaregiver training, respite, income

New

drugs and other

treatments

Where will it come from?

$$$

$$$

$$$

$$$

$$$

$$$Slide26

My Mother’s Broken BackSlide27

“The Cost of a Collapsed Vertebra in Medicare”Slide28

A Winning Possibility: MediCaring ACOs…Four geographic communities - 15,000 frail elders as steady caseloadConservative estimates of potential savings from published literature on better care models for frail eldersYields $23 million ROI in first 3 years

Net Savings for CMS Beneficiaries

Yr 1

Yr 2

Yr 3

3-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/

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F costs per member per month

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29

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So – ~ half of expenditures saved – of 23% - if it costs half, 5% of Medicare is non-service profitsSlide30

Some options…Some ways to capture savings to invest in under-supplied supportive services – ACO, bundled payment, managed care, Pay4SuccessCreate 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 transportReduce low value tests and consultations and “rehab”Move some services to the homeMonitor and manage services – supportive and medicalConsider local social insurance for long-term care costsSlide31

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?Slide32

Customize services for frail elderly Generate care plansGeriatricize medical care

Include long-term services and supportsDevelop local monitoring and

management

Fund added services and management from medical efficiency

Channel the public’s

fear and frustration

into

the will to change

MediCaring™!

Key Components of ReformSlide33

We can have what we want and need

When we are old and frail

But only if we

deliberately build that future!