Jeffrey B. Klein, FACHE President & CEO

Jeffrey B. Klein, FACHE President & CEO

THE ROAD TO REVOLUTION

How serious will the trajectory of demographic shifts and the effects of the health care delivery system change be on America s most vulnerable populations?

PROGNOSIS: Social and health care delivery will be forced to function as a society in revolution including resource shifts, dramatic changes in order and an unsettled postrevolutionary era The entire American society will be drawn in as well as the participants

1965: Three Important Programs Enacted Medicare Medicaid Older Americans Act Every State and every community can now move toward a coordinated program of services and opportunities for our older citizens. President Lyndon B. Johnson, July 1965

Increasingly aged population Greater functionality with chronic conditions Living longer, yet sicker Bottom Line: necessity of high quality transitional care and care coordination

Innovations in the Last Five Years in Health Prevention Two-thirds of 66% of Medicare spending is for beneficiaries with five or more chronic conditions. Historical/Ongoing: Preventive Health Services (OAA Title III-D) formula grants, including medication management appropriations language requirement. Evolving to evidence-based prevention, incorporating and disseminating latest science from AHRQ, NIH, CDC, and others. The Evidence-based Prevention Program served more than 24,000 people last year in approximately 24 states. The Evidence-based Prevention Program includes, but is not limited to, chronic disease self- management, falls prevention programs, programs for people with mental illness, and exercise programs.

The Last Five Years of Health & Long- term Care Reform: Branching Out In New Directions AoA innovation activities come out of the core programs in selected states and then are used to strengthen the core programs nationwide. Aging and Disability Resource Centers MIPPA & Medicare Part D enrollment Care coordination with the Department of Veterans Affairs (VA) Care Transition Activities Community Innovations for Aging in Place Medicare fraud detection Senior Medicare Patrol Prevention and health promotion Evidence-based programs

The Next Five Years: Health & Long- term Care Reform Serving an escalating senior population Enhancing care coordination/hospital discharge planning Reducing hospital readmission rates through ACA demo opportunities Health care reform Outreach Long-term services and supports Elder justice Caregiver service demand for paid/formal caregivers Expanding supportive services model to reach veterans of all ages Housing collaboration

Recent Health Initiatives Evidenced-based programming Chronic disease self-management Caregiver support Community Living Program (AoA/CMS) Evidence Based Care Transitions (AoA/CMS) Veteran s Directed Home & Community Based Services Program (VD-HCBSP)

UNMANAGED COORDINATED CARE PATIENT CENTERED Fee For Service Accountable Care Integrated Health Inpatient focus Poor access & quality Low reimbursement Little Oversight No organized networks Focus on paying claims Little Medical Management Organized care delivery Integrated Provider Networks Focus on Cost Avoidance & Quality Performance Medical home Care management Patient Care Centered Personalized care Multiple integrated network & community resources Deployment of best practices Client & provider interaction

Payment & Service Model Innovation Program & Policy Redesign Delivery System Reform & Transform 2012-2019 2014-2019 2011-2019

INITIATIVES

Affordable Care Act calls for the establishment of community-based care transitions programs 5 year program to provide $500,000/year to fund hospitals and community based organizations Partnerships to improve care transitions services for high-risk Medicare beneficiaries

Medicare Shared Savings Program creates incentive for establishment of ACOs Networks of physicians & other providers Share savings resulting from the ACO s coordinated care Reduced Medicare expenditures Improved beneficiary health outcomes

Medical Homes Encouraging Medical Homes Interdisciplinary teams contracting with primary care physicians to provide supportive services to 125 eligible patients: Care coordination Case management Health promotion Transitional care Patient and family support Referral to community services 18

Bundled payment pilots start 2013 Single Medicare payment will cover all services for an episode of care to be distributed among providers: Acute hospital services Physician services Post-acute community-based services Care coordination & transitional care services

Reducing 30-Day readmissions Reductions in CMS payments Excess readmissions for high volume or high expenditure conditions & procedures Public report of readmission rates for Medicare participating hospitals on the internet

Community Supports Healthcare Services Community Based Services

INTEGRATED SERVICES ENVIRONMENT Hospital Home Health Patient/ Caregiver Care Coordinator Community Physician ADRC Care Coordination Community- Based Organizations

NEVADA CARE CONSORTIUM NO WRONG DOOR SYSTEM ENTRY Community Living Support Caregiver Support Housing Advocacy Nevada Care Consortium Info & Referral, Case Management Healthcare Services Transportation Nutrition

Identify community agencies that already perform the services required Aging Network providers Home and community-based services Social workers Community and social service agencies Academic medical centers and schools Build direct referral relationships and collaboration to address gaps in care

What Does It Take To for Us to Partner? Community-Based Services Commitment to partnering, respect, valued outcomes Healthcare Commitment to partnering, respect, valued outcomes Shared project leadership Qualified leader with dedicated time In kind personnel time Shared project leadership Planning/writing proposals In kind personnel time Referrals to/from program Planning/writing proposals Team meetings IRB/compliance Training program personnel in CB Team meetings protocols Data systems support Data extraction from CB systems Employer of record, new HR positions Software licenses, space Contract management Commitment to evaluation Flexibility in timeline for unfamiliar processes (e.g., IRB) and processes Commitment to evaluation not interfering with service delivery Commitment to the health of the 80 community 26

Collaborate on well-defined projects Build on incremental success Give each partner a stake Identify champions to nurture the relationship & encourage others Leverage partner strengths Define short- & long-term markers of success Forward looking Remain flexible to partner roles & responsibilities

Partners NV Aging & Disability Services Division Nevada Senior Services Helping Hands of Nevada Southern Nevada Senior Law Program ADRCs Senior Centers Alzheimer s Association Elder Protective Services Nevada Hand HUD Public Housing RTC & Transportation Agencies Personal Care Services/Home Care Agencies Catholic Charities Academic Partners Local Government Many other partners Services Available Information & Referral Transportation Adult Day Health Care Respite Care Case Management Chronic Disease Self-Management Personal Care Accessible Affordable Housing Legal Assistance Nutrition Meals On Wheels Eligibility/Benefits Counseling Care Partner Support Health Care Screening Many other services

Consortium Members Community-based organizations Nevada Senior Services- Adult Day Health Care/Specialty Day Programs Catholic Charities Nevada Hand Helping Hands of Nevada ADRCs Personal Care Agencies Southern Nevada Senior Law Program Transportation (RTC/ITN/Silver Riders) Healthcare Nevada Senior Services Geriatric Assessment, Therapy, CDSMP Cleveland Clinic Lou Ruvo Center for Brain Health Alzheimer s Disease Hospitals Physicians

Consortium Members Research, Evaluation & Policy Nevada Aging & Disability Services Division Nevada Office of Consumer Health Assistance University Nevada Las Vegas (UNLV) Cleveland Clinic Lou Ruvo Center for Brain Health Education & Care Partner Support Alzheimer s Association MS Society Heart Association Cleveland Clinic Lou Ruvo Center for Brain Health Nevada Senior Services - REACH

Empowers on-going long-term coordinated planning & decision-making Streamlines access to public & private services Links pathways to long-term services & supports Collaborates to secure grant funding for demonstration programs Offers evidence-based programs to support engagement of persons with needed services Provides a trusted resource for information & resources for consumers & professionals Is a one-stop no wrong door resource connecting services for aging and disabled persons in the community

DIMENSION Reach Effectiveness Adoption Implementation Maintenance KEY QUESTIONS Is the program serving the priority population? What proportion enrolls from community vs hospital? Does the program impact Quality of life, health Nursing home placements Caregiver capacity Hospital readmissions Are service providers fully engaged? Are consumers creating/using plans? Is the Intervention delivered as designed? Can/should the program be sustained? Does the impact last?

NEVADA CARE CONSORTIUM CASE MANAGEMENT PROCESS REFERRALS (MULTIPLE SOURCES) Screen & Enroll Baseline Evaluation Information, Referral & Interventions Formal Support Services Diagnostic & Clinical Caregiver Education & Support Services Community Based Services Re-Evaluation Intervals *Post-Service * 6 Month *12 Month

CENTRAL TEXAS PARTNERSHIP Scott & White Healthcare Central Texas Department of Aging & Disability Services Central Texas Area Agency on Aging ADRC: Single point of entry system

Accountable for the health, quality of life, and value of care in their community

Ethnicity/Race Hispanic 3% Black 10% Caucasian 87% Living Arrangement Alone 25% With children 14% With spouse 50% Other 11% MMSE M=18.9 (7.8) Number of ADLs Impaired 2 1% 3-4 16% 5+ 73% Unknown 10% Income as % FPL 100-199% 25% 200-249% 49% 250-299% 19% 300% 3% Unknown 4%

AREAS OF CAREGIVER SUPPORT Home Safety Using Social Support Managing stress Healthy Living Relating Memory Loss to Behaviors Legal & Medical Information Navigating services EXAMPLES OF SERVICES Respite, Adult Day Services Homemaker, Personal Care Medication Management Minor Repairs Occupational & Physical Therapy Assisted Transportation Home Delivered Meals Emergency Response

80 60 40 20 0 Percent Receiving

Baseline 6-Month Mean (SD) or % Mean (SD) or % CES-D (Depressive Symptoms) 8.5 (6.3) 7.4 (6.9) (0-30) Self-Rated Health Excellent 8% 34% Good 28% 31% Fair or Poor 58% 35% Healthcare Utilization in previous 6 months (CR Reported) ER Visits 1.2 (1.4) 0.5 (0.9) Hospital Stays 1.2 (3.7) 0.4 (0.8) Physician Visits 6.8 (5.9) 5.6 (4.7)

Baseline 6-Month Mean (SD) or % Mean (SD) or % CES-D (Depressive Symptoms) 6.3 (4.4) 6.2 (4.9) (0-30) Self-Rated Health Excellent 8% 34% Good 28% 31% Fair or Poor 58% 35% Zarit Burden Scale 15.4 (7.0) 13.1 (7.6) (0-88, higher = more burden) Healthcare Utilization in previous 6 months (CR Reported) ER Visits 0.3 (0.8) 0.2 (0.5) Hospital Stays 0.2 (0.5) 0.1 (0.3) Physician Visits 3.2 (3.9) 2.5 (3.5)

Reaching older adults through community-healthcare partnerships is feasible Most avoided nursing home placements Caregiver burden was reduced Families were satisfied with services Consumer ER/hospital utilization was reduced

Organizations that blindly attempt to repair, adjust or tinker with everything may be in worse shape afterward, assuming that they survive at all, than those who adjust and come through the revolution changed and refocused.

The change to a revolutionary mentality and the resultant dislocations will bring innovation, new ideas and fresh service delivery concepts.

There is nothing more difficult to take in hand, more perilous to conduct, or more uncertain in its success, than to take the lead in the introduction of a new order of things. - Niccolo Machiavelli, The Prince

Like all revolutions, the opportunity brings with it the echoes of the ancient Chinese curse: May you live in interesting times. However, through proper planning, a courageous and open attitude, and the will to succeed, we can create a better future for all.

Jeffrey B. Klein, FACHE President & CEO 702.648.3425 www.nevadaseniorservices.org