Program Purpose Program Information PERFORMANCE PLAN ADSD Amy Vennett x1714 Improving and maintaining the health status of adults with multiple chronic illnesses and/or disabilities, so they may successfully age in place at home. Program serves Arlington residents 60 years old or older with multiple chronic illnesses, or adults age 18 to 59 with a permanent disability, all of whom who require assistance managing health care needs yet lack a sufficient support system. A community physician is required to order case management services. Brief client profile: More than take more than seven medications; more than 70% live alone; 51% have a psychiatric diagnosis; 35% have some form of cognitive deficiency. Core services provided in client homes 1 to 4 times per month include: Initiating and updating care plans focused on individual needs Assessing and monitoring health status and care needs Educating clients about health and wellness needs Pre-pouring medications if pharmacy bubble-packing is not available Referring to and coordinating with other providers and services Additional services include: Screening for nursing home level services to include placement and community based care Assessing clients for in-home services This is the only program of its kind in Virginia. It is primarily locally funded, with approximately 9% revenue generated from client fees and state reimbursements for screenings for nursing home level services. PM1: How much did we do? Staff Total 5 FTEs: 0.50 FTE Supervisor 4.5 FTE Nurses (88% of 6 FTEs) Customers Units of Service Total NCM Clients Served 303 446 439 Ongoing Services Clients 123 103 114 Clients receiving NCM intake assessments or consultations 49 180 102 Clients screened for nursing home level care 131 163 223 New Ongoing Services Clients 24 22 25 Ongoing NCM Client Visits 2,968 2,840 2,468 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 improved or maintained their health status in the last year: blood pressure, medication adherence and emergency room (ER) visits Page 1
Number of Clients PERFORMANCE PLAN Measure 2.1 Caseload size 35 30 25 20 2 1 Monthly Average Workload 3 4 3 2 Target workload: 29 4 3 15 10 21 21 21 22 5 0 24 clients 27 clients 27 clients Ongoing Caseload Assessments Screenings FY 2018 (proj) 29 clients The workload ratio for on-going clients, as well as assessments and prescreenings, are both presented. The average ongoing caseload in was 21 ongoing clients with 2 assessments and 4 screenings per nurse each month. The average workloads are calculated by averaging the end-of-month censuses from across the year. What is the story behind the data? Monthly average on-going caseload per nurse did not increase from 21 to 25 as forecasted. The total workload of all clients served (including assessments and pre-screenings) remained at 27 in. The team was down 0.5 FTE for six months due to FMLA and a vacancy due to a retirement. This resulted in fewer visits. To cover vacancies, the assessment and coordination nurse took on a caseload. Therefore, there were fewer assessments. There was a 37% increase in clients receiving screenings for nursing home level care because the demand was higher. FY 2018: Workload size will average 29; on-going caseload will average 22. Change the target on-going caseload from 25 to 22. Continue to implement efficiencies and analyze program for additional improvements. Explore additional methods for measuring acuity of client needs, such as visit frequency. Manager will monitor caseloads and workloads on a monthly basis. Orient two new nurses in FY 2018 due to two retirements. Full staffing will allow the team to serve more clients in FY 2018. Page 2
Percent of Care Plans Percent of Care Plans PERFORMANCE PLAN Measure 2.2 Care plans initiated within 10 days and updated quarterly Care Plans Initiated Within 10 Business Days Target: 95% 95% 0% 24/24 Charts 22/22 Charts 25/25 Charts 24/25 Charts Care Plans Updated Quarterly 98% Target: 95% 95% 70/70 Charts 63/64 Charts 64/64 Charts 61/64 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. of charts reviewed had care plans updated quarterly. Manager reviews a random sample of 20-25% of active cases each quarter. What is the story behind the data? Care plans were consistently initiated within 10 days of case opening. Quarterly compliance has been maintained. Manager will continue to monitor the initial and ongoing care plans to ensure this measure continues to be achieved. Explore development of a measure to assess documentation quality. Page 3
PERFORMANCE PLAN FY 2018: Rate of compliance will be at least 95% for both initiating new care plans within 10 days and updating care plans quarterly. Page 4
Percent of Clients Measure 3.1a 70% 50% 30% 10% 0% PERFORMANCE PLAN Clients who have improved or maintained 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 9% 4% 8% 10% Target: 91% 96% 92% 68/74 Clients 68/71 Clients Clients Within Normal Limit 61/66 Clients Clients Outside Normal Limit 63/70 Clients Clients within normal limit have blood pressure within norm for at least of visits during the quarter. The number of clients within normal limits is then averaged each quarter to get an annual average. 58% (66/114) 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 What is the story behind the curve? In, an average of 93% of clients with a diagnosis of high blood pressure were within normal limits each quarter. This is a slight decline from the last fiscal year. Several new clients in the third and fourth quarters had less optimal blood pressure control. The percentage of NCM clients with blood pressure within normal limits is significantly higher than a national survey that indicated 50% of older adults with a high blood pressure diagnosis had blood pressure within normal limits (CDC Vital Signs 2016). The national standard for normal blood pressure (Eighth Joint National Committee) is of the time blood pressure is: o 150/90 or less for clients over 60 o less than 140/90 for those under 60 NCM intervention is effective in helping people manage blood pressure. Nurses will continue to monitor blood pressure at each visit and report findings. Nurses will continue to educate clients on healthy activities and diets that can lead to improvements in blood pressure. Page 5
PERFORMANCE PLAN o less than 140/90 for clients (all ages) with diabetes or chronic kidney disease FY 2018: At least of clients with high BP will maintain blood pressure within normal limits. Page 6
Percent of Clients Measure 3.1b 70% PERFORMANCE PLAN Clients who have improved or maintained their health status in the last year: Medication adherence for clients who have medication pre-poured or bubble-packed 3% 77% Client Adherence to Medication Regimen: Quarterly Average 1% 9% 6% 5% 15% Target for partial and full 79% adherence: 95% 75% 50% 30% 10% 0% 51 Clients 37 Clients 49 Clients Fully Adherent Partially Adherent Nonadherent 50 Clients 79% of clients for whom nurses monitored pharmacy bubble-packed medications, pre-poured medications into a pill box, or pre-filled insulin syringes fully adhered to medication regimen as prescribed. Total of 94% had partial or full adherence. An average of 49 clients per quarter had medications monitored or pre-poured by nurses. 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 evaluate medication adherence based on a 2005 New England Journal of Medicine article: to of medications taken is adherent; 50% to 79% is partially adherent; below 50% is not adherent. What is the story behind the data? 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) NCM intervention is effective in helping people manage adherence to medications. Nurses will continue to use pharmacies that can bubble-pack medication, pre-pour if bubblepacking is not available, and monitor medication adherence. Page 7
The percentage of clients fully adherent was lower than in, but consistent with data from prior fiscal years. In, some clients with bubble-pack medications were inadvertently excluded from data collection. In, data was collected consistently for both pre-poured and bubble-packed medications. of clients in the first quarter met the target. New clients in following quarters included several younger adults with lower levels of adherence. PERFORMANCE PLAN Continue nursing interventions aimed at improving adherence whether the nurse is prepouring the medication or the pharmacy is bubble-packing medication. FY 2018: At least 95% of clients for whom the nurse monitors pharmacy bubble packs, pre-pours medication, or pre-fills insulin syringes will demonstrate full or partial adherence. Page 8
PERFORMANCE PLAN Measure 3.1c 70% 50% 30% 10% 0% 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 25% 75% 8 Clients 10 Clients 9% 10% 18% 73% 11 Clients Target > 70% 15 Clients Fewer visits Same number of visits More visits Eleven clients (44% of new clients) had unplanned emergency room (ER) visits in the three months prior to admission. 73% (8) of these clients had fewer unplanned visits in each of the first four quarters of being served, while one client (9%) had more visits than noted prior to admission. 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. What is the story behind the data? Exceeded goal: 73% percent of new clients had fewer ER visits One client in had more visits once services were initiated versus no clients in the previous two years. Small sample size; few clients reported ER visits prior to admission to program. Client factors such as falls, unstable physical or mental health conditions, and client preferences contribute to unplanned emergency room use. FY 2018: Discontinue this measure. Program will continue to emphasize client education about alternatives to ER use Explore a measure for FY 2018 or FY 2019 that shows how clients who are classified as nursing home level remain in community, versus moving to a more restrictive, less integrated setting (i.e., long term care residence) Page 9