Improve or maintain the health status of adults with multiple chronic illnesses and/or disabilities to remain at home

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1 ADSD Amy Vennett x1714 Program Purpose Improve or maintain the health status of adults with multiple chronic illnesses and/or disabilities to remain at home Program Information PM1: How much did we do? Program serves Arlington residents 60 years old or older with multiple chronic illnesses or adults age 18 to 59 with a permanent disability who require assistance managing health care needs and lack a sufficient support system. A community physician is required to order case management services. Brief client profile: More than 80% take more than seven medications; more than 70% live alone; 75% have a psychiatric diagnosis; 25% have some form of dementia Core services provided in client homes 1 to 4 times per month include: creating and updating care plans, assessing and monitoring health status, educating clients about health subjects, pre-pouring medications and referring to and collaborating with other providers. Additional services include: o Screening for nursing home level services and nursing assessments/ consultations with residents and DHS staff for clients who might benefit from services. o Delivering health presentations at congregate meal sites This is the only program of its kind in Virginia and is locally funded Staff Total 5.0 FTEs: o 0.5 FTE Supervisor o 4.5 FTE Nurses (75% of 6 FTEs) Customers and Service Total NCM Clients Served Ongoing Services Clients Clients receiving NCM intake assessments or consultations Clients screened for nursing home level care New Ongoing Services Clients Ongoing NCM Client Visits 3,302 3,261 2,968 Wellness Education Groups/Blood Pressure Screenings PM2: How well did we do it? 2.1 Caseload size 2.2 Care plans initiated and updated quarterly PM3: Is anyone better off? 3.1 Clients who have maintained or improved their health status in the last year: blood pressure, medication adherence and emergency room (ER) visits Page 1

2 Number of Clients Measure 2.1 Caseload size Monthly Average Ongoing Caseload With Assessments and Screenings Target caseload: FY 2016 (proj) Ongoing Caseload Assessments Screenings The caseload ratio for on-going clients, as well as assessments and prescreenings, are both presented. The average ongoing caseload in was 21 with 1 assessment and 2 screenings on average per nurse each month. The average caseloads are calculated by averaging the end-of-month censuses from across the year. Monthly average caseloads per nurse did not increase as forecasted. However, the total caseload (with assessments and pre-screenings) was 24 in. Program has implemented efficiencies to increase capacity of staff to reach the 25 monthly target of ongoing cases in FY 2016: o Manager partnered with local pharmacies that bubble-pack medications in. For clients willing to use bubble-pack medications, this increases nurse efficiency by reducing time spent on medication monitoring. Page 2 Continue to implement efficiencies and analyze program for additional improvements. Program will research workload and productivity measures in FY 2016 with the goal of identifying a measure that better represents the depth of the workload and productivity of staff.

3 o o Manager clarified staff roles of nurses and aides to ensure nurses were able to focus on complex medical issues and medication management and spend less time on activities such as accompanying clients to medical appointments. Nurses cluster home visits when possible to ensure travel time is as efficient as possible. The new electronic documentation continues to require more staff time than the prior paper-based system. Manager is working closely with vendor to address changes to the system. Staff changes including one nurse moving to a new role in that does outreach for new referrals and initial assessments. Her cases were absorbed by the other nurses. It is anticipated that the monthly average caseloads will increase in FY 2016 as a result. FY 2016: Caseload size will average 25 in the last half of FY Vendor adjusted electronic documentation system to make it more user friendly. Changes were effective in the first month of FY Manager will continue to address systems issues when possible with the vendor to improve efficiency. Manager will monitor caseloads on a monthly basis of nurse case managers. Continue to train and monitor nurse in her new role as the lead for outreach and assessment. Page 3

4 Percent of Care Plans Percent of Care Plans Measure 2.2 Care plans initiated with 10 days and updated quarterly Care Plans Initiated Within 10 Business Days 80% Target: 40% 20% 0% 39/39 Charts 28/28 Charts 24/24 Charts 29/30 Charts Care Plans Updated Quarterly 80% Target: 40% 79% 20% 0% 50/63 Charts 73/73 Charts 70/70 Charts 60/62 Charts of charts had care plans initiated within 10 days of admission. Manager reviews all new charts to determine if care plans were initiated within 10 business days. Manager reviews a random sample of 15-20% of active cases each quarter to determine if care plans were updated quarterly. is collected each month and tracked on a spreadsheet. Care plans were consistently initiated within 10 days of case opening. Manager will continue to closely monitor the initial and ongoing care plans to Page 4

5 Quarterly compliance has been maintained after staff adjusted to the new expectation in. Program developed a quality assurance plan that was implemented in July 2015 that established and documented ongoing quality assurance mechanisms, including monthly chart reviews that review timeliness of care plans. With these mechanisms in place, the program expects to continue to achieve its timeliness goals. ensure this measure continues to be achieved. FY 2016: Rate of compliance will be at least for both initiating new care plans within 10 days and updating care plans quarterly. Page 5

6 Percent of Clients Measure 3.1a Clients who have maintained or improved their health status in the last year: Blood pressure for clients with high blood pressure diagnosis Clients Within and Outside Normal Limits for Blood Pressure: Quarterly Average 90% 80% 70% 50% 40% 30% 20% 10% 9% 9% 9% Target: 10% 90% 91% 91% 91% 90% 81/89 Clients 78/86 Clients 68/74 Clients 72/80 Clients BP Clients Within Normal Limit BP Clients Outside Normal Limit Clients within normal limit have blood pressure within norm for at least 80% of visits during the quarter. The number of clients within normal limits is then averaged each quarter to get an annual average. (74/123) of NCM clients have a diagnosis of high blood pressure. For these clients, data was collected at each visit and pulled into a report each quarter, using the electronic documentation system. In, 91% of clients with a diagnosis of high blood pressure were within normal limits each quarter. This has been consistent for the last three fiscal years. Percent of NCM clients with blood pressure in normal limits is significantly higher than national survey that indicated 50.5% of older adults with a high blood pressure diagnosis had blood pressure within normal limits (U.S. National Health and Nutrition Examination Survey ( ) The new national standard for normal blood pressure is 80% of the time blood pressure is less than 150/90 for clients over 60, less than 140/90 for those under 60, and less than 140/90 for clients (all ages) with diabetes or chronic kidney disease (Eighth Joint National Committee) NCM intervention is effective in helping people manage blood pressure. Nurses will continue to monitor blood pressure at each visit and report findings. Nurses continue to educate clients on healthy activities and diets that can lead to improvements in blood pressure. FY 2016: At least 90% of clients with high BP will maintain blood pressure within normal limits. Page 6

7 Measure 3.1b 100.0% 90.0% 80.0% 70.0% 60.0% 50.0% Clients who have maintained or improved their health status in the last year: Medication adherence for clients who have medication pre-poured Client Adherence to Medication Regimen: Quarterly Average 4.6% 3.0% 3.0% 3.0% Target for 22.0% 20.0% partial /full 22.0% 27.7% adherence: 40.0% 30.0% 20.0% 10.0% 67.7% 75.0% 77.0% 75.0% 0.0% 65 Clients 66 Clients 51 Clients 60 Clients Fully Adherent Partially Adherent Nonadherent 77% of clients for whom nurses pre-poured medications into a pill box or pre-filled insulin syringes fully adhered to medication regimen as prescribed. Total of 97% had partial or full adherence. An average of 51 clients per quarter had medications pre-poured. was recorded at each visit and pulled into a report each quarter using the electronic documentation system. Nurses reported if clients were adherent partially adherent or non-adherent at each visit. Quarterly and annual averages were calculated. Nurses record medication adherence based on a 2005 New England Journal of Medicine article: 80% to of medications taken is adherent; 50% to 79% is partially adherent; below 50% is not adherent. Percent of NCM clients fully or partially adherent to medication regimen exceeds a national study indicating 68% of adults fully or partially adhered to treatment regimens (2013 US National Report Card on Adherence) Began to partner with local pharmacies to place medications in a bubble-pack to NCM intervention is effective in helping people manage adherence to medications. Nurses will continue to pre-pour and monitor medication adherence. Program will work with local pharmacies to place medications in bubble-packs when possible. Page 7

8 improve the nurses ability to assess medication adherence Program will analyze any changes in adherence levels over time. 97% of clients for whom the nurse pre-pours medication or pre-fills insulin syringes will demonstrate full or partial adherence in FY Page 8

9 Measure 3.1c 90% 80% 70% 50% 40% 30% 20% 10% Clients who have maintained or improved their health status in the last year: Decreased client ER visits Emergency Room Visits for New Clients who had Visits Before Admission 52% 19% 29% 38.5% 23% 38.5% 0% 25% 75% Target: > 15% 25% 0% 31 Clients 26 Clients 8 Clients 23 Clients Fewer visits Same number of visits More visits : Eight clients (33% of new clients) had unplanned emergency room (ER) visits in the three months prior to admission. o 75% (6) of these clients had fewer unplanned visits in each of the first four quarters of being served. This is a significant increase over and 2014 data. ER visits are recorded based on self-reports of clients, family members, caregivers and referrers. Staff records the number of admissions in the quarter prior to admission and during the first four quarters of service. Exceeded goal: 75% percent of clients had fewer ER visits. Sample size was small. Fewer clients had ER visits reported prior to admission to program. data may be an anomaly due to small sample size. While the same number of visits stayed relatively level there was a very large jump in fewer visits. Client factors such as falls, unstable physical or mental health conditions, and client preferences contribute to unplanned emergency room use. Research an alternative measure for future use that may better reflect NCM s impact on health, hospital utilization and ability to continue to live in the community. Sample size will be a consideration when developing a new measure. Program will continue to emphasize client education about alternatives to ER use. of clients with unplanned emergency room visits prior to admission will have fewer unplanned visits during FY Page 9

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