bphc enrichment series for grantees: serving an aging population (65+) in health centers
DESCRIPTION
BPHC Enrichment Series for Grantees: Serving an Aging Population (65+) in Health Centers. Thursday, May 24, 2012 2:00 PM – 3:30 PM EST. Serving an Aging Population: Learning Objectives. Identify key demographic trends of the 65+ population - PowerPoint PPT PresentationTRANSCRIPT
BPHC Enrichment Series for Grantees:
Serving an Aging Population (65+) in Health Centers
Thursday, May 24, 2012
2:00 PM – 3:30 PM EST
2
• Identify key demographic trends of the 65+ population
• Understand key issues for serving the 65+ population in health centers
• Name key services being provided to the 65+ population in health centers
• Describe successful grantee programs at improving health outcomes in the 65+ population
• Identify where to go for additional TA and resources on aging
Serving an Aging Population: Learning Objectives
3
Agenda in BriefWelcome
Dr. Matt Burke, HRSA
Profile of Older Americans
Bob Hornyak, Administration for Community Living
Caring for the Elderly in Community Health Centers
Marty Lynch, Executive Director/CEO, LifeLong Medical Care
Wellness Information for Senior Empowerment
Allison Dubois, Chief Operations Officer
Elizabeth L. Phillips, Director of Health Education Services
Hudson River HealthCare, Peekskill, NY
Serving an Aging Population (65+) in Health Centers
Dr. Lynda Jackson-Assad, Medical Director
Dr. Debra Bartley-Rice, Director, Adult Medicine Department
Dr. Robert Hutchins, Physician, Adult Medicine Department
Jackson-Hinds Comprehensive Health Center, Jackson, MS
Robert HornyakDirector, Office of Performance and Evaluation
Department of Health and Human ServicesAdministration for Community LivingCenter for Disability and Aging Policy
Profile of Older Americans
5
“For too long, too many Americans have faced the impossible choice between moving to an institution or living at home without the long-term services and supports they need. The goal of the new Administration for Community Living will be to help people with disabilities and older Americans live productive, satisfying lives.“
- Secretary Kathleen Sebelius
• New agency of U.S. Department of Health and Human Services announced by Secretary Kathleen Sebelius on April 16, 2012
• Single agency brings together the efforts of the Administration on Aging (AoA), Office on Disability (OD), and Administration on Developmental Disabilities (ADD)
• Charged with developing policies and improving supports and services for seniors and people with disabilities
Administration for Community Living (ACL)
6
Administration on Aging
Administration for Community Living (ACL)
7
The Older Population• 65+ = 40.4 million (13.1% of the population) in 2010, i.e., a 5.4 million
(15.3%) increase since 2000. • Persons reaching age 65 have an average life expectancy of an
additional 18.8 years (20.0 years for females, 17.3 years for males)• Older women outnumber older men at a ratio of 13:10 (i.e., 23.0
million older women to 17.5 million older men)• 85+ = 5.5 million (1.8% of the population) in 2010.
Future Growth of Older population• 65+ population is projected to increase to 55 million in 2020 (36% increase
within the decade). By 2030, 65+ will grow to 19.3% of the population
• The 85+ population is projected to increase to 6.6 million in 2020 (19% increase)
Profile of 65+ Older Americans (2011)
8
Marital Status• Older men were much more likely to be married than older
women• 72% of men vs. 42% of women
• 40% older women in 2010 were widows
Living Arrangements• About 29% (11.3 million) of non-institutionalized older persons live
alone (8.1 million women, 3.2 million men)• 47% of older women age 75+ live alone• About 485,000 grandparents aged 65 or more had the primary
responsibility for their grandchildren who lived with them
Profile of 65+ Older Americans (2011)
9
Income• Median income of older persons in 2010 = $25,704 for males,
$15,072 for females• Median money income (after adjusting for inflation) of all households
headed by older people fell 1.5% from 2009 to 2010• Households containing families headed by persons 65+ reported a
median income in 2010 of $45,763
Profile of 65+ Older Americans (2011)
10
Poverty• Almost 3.5 million elderly persons (9.0%) were below the poverty
level in 2010• This poverty rate is not statistically different from the poverty rate in
2009 (8.9%)• In 2011, the U.S. Census Bureau released a new Supplemental
Poverty Measure (SPM) which accounts for regional variations in livings costs, non-cash benefits received, and non-discretionary expenditures but does not replace the official poverty measure.
• The SPM shows a poverty level for older persons of 15.9%, an increase of over 75% over the official rate of 9.0% mainly due to medical out-of-pocket expenses.
Profile of 65+ Older Americans (2011)
11
Minority Population• Up from 5.7 million in 2000 (16.3% of the elderly population) to 8.1 million in
2010 (20% of the elderly)
Profile of 65+ Older Americans (2011)
12
Future Growth of Minority Population
• Projected to increase to 13.1 million in 2020 (24% of the elderly).
• Projected to increase by 160% between 2010-2030, comparing with 59% for Whites
Profile of 65+ Older Americans (2011)
13
AoA
20,000 Service Providers &500,000 Volunteers
56 State Units, 629 Area Agencies & 256 Tribal
Organizations
Provides Services and Supports to 1 in 5 Seniors
26MillionRides
26MillionRides
35 Million Hours of Personal
Care
35 Million Hours of Personal
Care
135,000 Caregivers
Trained
135,000 Caregivers
Trained
4 Million Hours of
Case Managemen
t
4 Million Hours of
Case Managemen
t
792,000 Caregivers Assisted
792,000 Caregivers Assisted
240 Millio
n Meals
6.4 Million Hours of Respite
Care
AoA Helps 11 Million Seniors (and Their Caregivers)Remain At Home Through Low-Cost Community Based-Services
14
• 3 million Older Americans Act (OAA) clients receive intense services such as home-delivered nutrition and homemaker services
• Near Poor is defined as below 150% of poverty
U.S. Population OAA Clients
60+ Population 57.8 million 11 million
Poverty 9.3% 30%
Near Poor 15-20% 73-85%
Who AoA Serves:The Poor and Near Poor
15
• In-Home Services include services such as homemaker, case management, and home-delivered nutrition.
• US Minority & Rural figures are for the 65+ population
U.S. Population 60+ OAA Clients(In Home Services)
Live Alone 27% 55%-69%
Diabetes 9.3% 26%-35%
Near Poor 15-20% 43%-53%
Minority 20% 25%
Rural 13% 37%
Who AoA Serves:The Frail and the Vulnerable
16
• Find an Area Agency on Aging in your area at: http://www.Eldercare.gov
Partner with Aging Network
17
• American Community Survey (ACS) Demographic Data (2004-2010) on AGIDhttp://www.agidnet.org/
• Minority Aginghttp://www.aoa.gov/AoARoot/Aging_Statistics/minority_aging/Index.aspx
• US Administration on Aging's “A Toolkit for Serving Diverse Communities”http://www.aoa.gov/AoARoot/AoA_Programs/Tools_Resources/DOCS/AoA_DiversityToolkit_Full.pdf
• Department of Health and Human Services, Office of Minority Healthhttp://minorityhealth.hhs.gov/
Aging Data Resource Links
18
Robert Hornyak
Director, Office of Performance and Evaluation
(202) 357-0150
http://www.hhs.gov/acl
Contact Information
Caring for the Elderly in Community Health
CentersMarty Lynch
Executive Director/CEOLifelong Medical Care
20
Population Aging Review• Baby Boomers: we are them
• Community Health Centers (CHC)45-64 age has grown 87%
• Doubling of the over-65 population to 70 million by 2030
• 85+ population from 2% to 5% by 2030
• Consumer preference: remain in the community if at all possible
• Afraid of nursing homes
21
Number of Persons 65+,1900 – 2030 (numbers in millions)
22
Take-Aways for CHCs
• Existing patients aging & communities aging
• High levels of poverty in elder population especially at health centers
• More disability as age increases• Disability very common in old-old
populations
23
Special Populations Aging Also
• Homeless population aging
• Average age of homeless in many areas is now in 50’s
• Homeless person at 55 has the health problems of a 70 year old
• CHC must be prepared to deal with difficult substance abuse, mental health, and housing issues as well as medical issues
• Disabled population who pioneered independent living is now aging
• HIV/AIDS population
24
Health Centers and Elderly
• UDS data says 7% elderly in health centers now… numbers up about 47% from 10 years ago
• Over one million elders served by CHCs• Age 45-64 has grown 87%• History of moms and kids in many CHCs• Some CHCs >15% elders
25
How are Disabled or Frail Elders Different from Younger Elders?
• Young elders, if healthy, are similar to your adult population except they have Medicare
• Every individual is different but, in general, by age 75 and over there are more:• Functional disabilities• Dementia related disability• Co-morbid chronic medical problems causing
disability
26
Functional Disabilities
• Patient needs assistance with normal Activities of Daily Living (ADL):• Bathing• Dressing• Toileting• Transfer• Continence• Feeding
27
Or Instrumental Activities of Daily Living (IADL)
• Use Phone
• Shop
• Food Preparation
• Housekeeping
• Laundry
• Transportation
• Taking Medications
• Handle Finances
28
Impact on Providing Medical/ Dental/Mental Health Care
• Daily living problems become as important, or more important, than traditional medical care
• Difficult to provide effective medical care without dealing with these problems
• Health Centers often not as familiar with arranging disability care
29
Core Services for Elders
• Physicians or mid-level providers who are interested in both chronic medical care and functional disability care
• Multiple medications management
• Multi-disciplinary team care with both hallway consults and team meetings
30
Core Services for Elders
• Case management/care coordination services available to assist disabled patients, their families, and work with medical provider
• Dental, Podiatry, Mental Health, Neuro-Psych Testing
31
Medical Care• Internists, Geriatricians, NP’s, PA’s• Training and interest• Longer visit times for complex histories and
problems• Chronic disease management/motivation• Functional and dementia issues interact with
medical problems – may overshadow medical issues• Depression, isolation, substance use
32
Case Management for Elders• Many definitions
• Nurse management to assist with medical management, transitions, durable medical equipment, prescriptions, education
• Social work case management to work on psycho social issues, functional disability, personal care arrangements, family, housing
33
Case Management for Elders
• Community health workers and peers can help with these functions
• Regular team meetings with other providers to discuss complex patients
34
Special Clinical Issues
• Dementia care and management including neuro-psych testing
• End-of-life care, palliative care: different cultures and beliefs
• Advance directives• Elder sensitive mental health services: warm
hand-off is key• Dignity driven decision making
35
Customer/Patient Experience
• RESPECT• Age and cultural competency interaction• No infantalization (forget “Dear” & “Honey”)• Staff trained in aging-related disabilities and
dementias• Changing expectation by age cohort• Phone Issues: Live operator vs. auto-attendant
for older ages
36
Adapting the Health Center
• Separate clinic times/spaces or not?• Layout to accommodate wheelchairs,
walkers, slow pace• Hand-rails & physical modifications• At least one power exam table• Accessible transportation• Daylight hours/security concerns
37
Special Services or Partnerships to Serve Elders
• Adult Day Health Care• Home Health Care• Assisted Living• Skilled Nursing Facilities• Senior Housing or Supportive Housing for Elders• Dementia Care• Respite Care• Senior Centers/Exercise/Nutrition Programs, Area Agencies on
Aging• Village Models
38
Business and Policy Issues
• Medicare FQHC rates are capped• 75% of CHCs have rates higher than cap• Data now being gathered to new base rate• New rate may still be lower than Medicaid
FQHC but better than commercial rates
39
Business and Policy Issues
• Elderly take more time and a team approach, like any complex population, more costly care, productivity will be lower than family practice
• Case management can be difficult to pay for – varies by state
• Health plans will compete for your patients
40
On the Positive Side
Huge untapped market for health centersElders require the health home approach
that CHCs are comfortable withPopulations are agingWe are familiar with other complex
populations like homeless and HIV/Aids
41
On the Positive Side
Medicare Advance Practice Medical Home Demo
Potential case management/disease management fees
Possible shared savings/bonuses with health plan contracts
42
Data Issues
• Many CHC cost and quality studies done for mom’s and kids population. Need same data on over 55 population
• Will need measures on functional disability, ADLs/IADLs and dementia
• UDS does not collect data on Duals… as we go into Duals pilots/demos we don’t know how many Duals health centers serve
• Paradigm shift in both service and data
43
Existing Specialized Health Plans/Demos Expanding
• Program of all-inclusive care for the elderly (PACE)
• Medicare Advantage special needs plans for dual eligibles, or nursing home residents, or special chronic disease populations
• State-based demonstration programs under home and community-based waivers or integrated managed care for dual eligibles
44
Health Reform Opportunities
• Many states working with CMS on Duals Plans to integrate medical care, long term services and supports and mental health
• Medicare Accountable Care Organizations present a bundled payment/share of savings, and integrated care opportunity
• Hospitals will be encouraged to work with community partners on transitions of care/avoiding readmissions
• Growing role for technology, in home monitoring, specialty tele-health, web portals for at least some elders
45
Recommendations
• Plan for expanding your elderly care. Some CHC elderly patients will have disabilities and special needs. Health Centers should also plan how they will meet those needs. Use PCMH as a tool to get there.
• Case Management or care coordination is critical for this subset of elders.
• Adult day health care and other long term services and supports can be an important part of a health center’s approach to primary care for elders with disabilities.
46
Recommendations (cont.)• Partnering with other health and aging social service
agencies is essential to assure access to resources not available at CHC.
• If CHC has significant Medicare/Medicaid eligible group, carefully examine benefits of contracting with or developing a Medicare Special Needs Plan (SNP) or a Duals pilot. Demand a share of any savings.
• CHCs with large number of disabled elders may wish to consider partnering with or developing a PACE program, although this is a major undertaking.
47
Contact Information
Marty Lynch
Executive Director / CEO
LifeLong Medical Care
www.lifelongmedical.org
(510) 981-4123
Allison DuboisChief Operations Officer
&Elizabeth Phillips
Director of Health Education ServicesHudson River Healthcare, Inc.
WISEWellness Information for Senior
Empowerment
49
• Overview of Hudson River Healthcare• Learn about various HRHCare
programs for Seniors• Discuss challenges• Discuss lessons learned
Learning Objectives
50
In the early 1970's a group of local residents and religious leaders addressed the lack of appropriate health services in their community. In particular, a group of four women, fondly referred to as our founding mothers, spearheaded the efforts and have remained committed to the organization since its inception.
Mission: To increase access to comprehensive primary and preventive health care and to improve the health status of our community, especially for the underserved and vulnerable.
Organizational History
51
Map of New York
52
• HRHCare currently provides services at 22 sites to 80,000 patients through 300,000 visits annually.
• Escalating numbers of under – and uninsured in HRHCare’s service area and increasing demand for services along with expanded medical capacity and service expansion have increased the patient population by 80% since 2006 (44,423 to 80,000)
Size and Scope
53
• Wellness Information for Senior Empowerment• Program serves seniors in 2 housing complexes,
but welcomes community members• Hosted by social worker• Group meets weekly, healthy meals are served• Information is shared about health issues• Addresses social isolation• Provides setting for group visits
WISE Program
54
• Seniors encompass a large age range, 65-85+, different cultures and both men and women• Difficult to find activities that interest this broad age
range, that are culturally and gender appropriate• Some seniors have difficulty with chewing or other
issues related to their teeth, making it more difficult to find appropriate food to serve
• Seniors may have physical limitations such as arthritis
Challenges
55
• Taking the time to understand the needs and wants of the group
• Finding activities that are appropriate across a broad age range and across cultures
• Bingo has been a popular activity that is universally enjoyed
• Choose foods that are easy to chew• Choose activities that require less fine motor skills
Overcoming Challenges
56
• Health Unites Generations• Group meets twice monthly, includes residents from
one senior housing facility and youth members• Addresses social isolation of residents• Discuss health topics, cultural events and social and
holiday celebrations• Provides meaningful cross generational interactions• Youth receive small stipend – helps to promote
positive youth development
HUGS Program
57
• Difficulty of youth and seniors interacting on a meaningful level
• Group stereotypes
Challenges
58
• Find common ground among group members
• Address group stereotypes and dispel
Overcoming Challenges
59
• Evidence based program• Training offered through Stanford University • Program teaches principles of Self
Management for people with any chronic disease or their caregivers
• Program at HRHCare called “Healthy Choices”
Chronic Disease Self Management Program
60
• The interdisciplinary staff includes:• Registered Dietitians • Registered Nurses• Certified Diabetes Educators • Clinical Assistants• Social Workers• Case Managers• Certified Health Educators• Patient Care & Outreach
Healthy Choices
61
• From May 2011 – Dec. 2011, staff delivered 7 workshops hosted in various locations (each workshop runs for 6 weeks each).
• We reached 80 workshop participants (majority being adults ages 55 +) of which 75% attended at least 4 sessions or more.
• Our 2012 – 2013 organizational goal is to deliver 2-3 workshops per year; with a regional approach to activate multiple counties.
Healthy Choices
62
• Initially in 2011 the health centers HIV Capacity grant provided funding for the CDSMP/PSPMP training and start up
• Collaboration with other social service agencies
Healthy Choices
63
• Peer Leader Activation and Retention• Time commitments required
• Developing Workshop schedules
• Recruiting Workshop host sites
Challenges
64
• Conduct ongoing marketing of programs • Build upon existing relationships, get
referrals from host sites• Have open houses to introduce potential
participants to workshop• Be flexible – work within existing groups
Overcoming Challenges
65
• Senior Prom
• Gerontology Services
Other Programs
66
67
68
Elizabeth L. Phillips MPH, MCHES
Director of Health Education Services
(914) 734-8612
Hrhcare.org
Allison Dubois
Chief Operations Officer
(914) 734 - 8503
Hrhcare.org
Contact Information
69
Presenters:Dr. Lynda Jackson-Assad
Medical Director
Dr. Debra Bartley-RiceDirector of Adult Medicine
Dr. Bob W. HutchinsAdult Medicine Physician
Jackson-Hinds Comprehensive Health Center
Serving an Aging Population (65+) in Health Centers
70
Dr. Jasmin Chapman
Chief Executive Officer
Main Clinic
71
Jackson-Hinds Comprehensive Health Center was established in 1970 and is one of the largest providers of primary health care services to the uninsured and under-served in Central Mississippi and one of the oldest Federally Qualified Health Centers (FQHC) in the nation.
About Jackson-Hinds
72
Jackson-Hinds ComprehensiveHealth Center Services at a Glance
73
• Jackson Hinds Comprehensive Health Center operates 15 clinics serving Hinds, Warren & Copiah counties which includes 5 free-standing school based clinics . Seventeen (17) additional schools are served via 2 Mobile Units.
• Dental services are provided via mobile unit in Jackson Public School District, Hazlehurst & Hinds County Schools
Where We Are
74
• Objective 1 – Understanding the challenges that are experienced by the geriatric patient when they receive healthcare.
• Objective 2 – Understanding the provider and other staff involvement in the healthcare of the geriatric patient.
• Objective 3 – Understanding the need to integrate ancillary and enabling services when caring for the geriatric patient.
Learning Objectives
75
Patients 65+ by Gender: Over 60% female
76
Diagnosis Patients 65+
Hypertension 1457
Diabetes 656
Heart Disease 209
Chronic Bronchitis/Emphysema 91
Depression 52
Top 5 Diagnoses of Patients 65+ Treated at JHCHC
77
Total Number of Patient Visits (65+)
78
1. Transportation
2. Visit• Scheduling • Registration
3. Medical History
4. Medical Examination
5. Reconciliation of Medication List
6. Pharmacy
7. Social Services
8. Home Evaluations
9. Durable Medical Equipment (DME) Suppliers
Challenges faced with the Geriatric Population 65+
79Transportation Van
Transportation to the Health Center needed. Patients must pay for private transportation.
Solution:•JHCHC has a van that is used to pick up appointed patients.
Challenge #1- Transportation
80
Clinic visits for Geriatric patients take much longer, especially when they are in a wheelchair or on walkers. Some elderly patients may need assistance with registration.
Solution:Preparation starts with scheduling Geriatric for morning appointments with extended visit time if deemed necessary by the provider. JHCHC has scheduling staff available to assist Geriatric patients with registration and completing forms.
Challenge #2- Visit
81
Family member or caregiver need to accompany patients on their visits, especially if the patient cannot give a good health history.
Solution:
At JHCHC, geriatric patients are encouraged to bring a family member/caregiver who is knowledgeable of their health issues when this is possible.
Challenge #3-Medical History
82
MA gets data needed and reviews health maintenance information and instructs patients and family members concerning health maintenance issues i.e. flu, pneumonia, smoking documentation and the need for age/ disease specific referrals inclusive of podiatry, optometry and dental.
Solution:
The MA assigned to a provider gets to know her/his patients. This familiarity promotes trust.
The provider may need assistance from a MA/Nurse during the examination to help patient get on and off exam tables.
Nurse needs to go over medications. Sometimes there is a need to
repeat instructions several times. Geriatric ADL is noted in the patient EHR and is addressed by the provider.
Challenge #4- Medical Examination
83
Reconciliation of Medication list can be challenging when dealing with geriatric patients.
Solution:
Patients are asked to bring all medications at each visit. Review medication list of actual medications at each
visit and discard medication that has been discontinued.
To ensure compliance and understanding of medications.
Provide a new copy of prescribed medications and Clinical Summary.
Challenge #5 Reconciliation of Medication List
84
Many of our elderly patients have problems obtaining their medication due to lack of resources, lack of transportation to the pharmacy and no third party coverage for medications.Solution:
JHCHC has an in-house pharmacy that participates with the 340B Program.
Eliminates transportation concerns and cost to obtain medications.
Readily available information on compliance, availability and prescription plan coverage.
Challenge #6 - Pharmacy
85
Prescription Assistance Program & Enabling Services
Solution:•JHCHC Social Workers perform eligibility assessments and assist patients that cannot afford their medications via the prescription assistance program and other ancillary prescription programs.•Social Workers sometimes make home visits if requested by the provider due to some type of extenuating circumstance.
Challenge #7 -Social Services
86
Home Evaluations: Living quarters of geriatric patients may sometimes pose health and safety risks. Home inspections are necessary. The living quarters of elderly patients sometimes have improper lighting, positioning of furniture and rugs that may contribute to injuries.
Solution:Home Evaluations: JHCHC has utilized Home Health agencies as well as our center’s Social Workers to help identify and find solutions to:
Home dangers Education on fall safety and fall risk Involvement of agencies that provide handicap or safety
equipment for the elderly i.e. bathtubs, shower stalls etc.
Challenge #8-Home Evaluations
87
Durable Medical Equipment (DME) Suppliers: Confusion, potential fraud. Many patients are bombarded with “cold call” solicitations from Diabetic and DME suppliers. This results in multiple forms being sent to the provider resulting in duplication and potential fraud.
Solution: Patients are asked to bring forms in to the provider to
ensure this is a legitimate company and the service was requested by the patient.
Use well known national or local vendors or request referrals from friends/family’s sales person with their vendor performance satisfaction.
Challenge #9 – DME Suppliers
88
Medications:•Medication panels change•Difficulty in reaching decision makers at the pharmaceutical plan administrators
Billing:
When patients have one of the five (5) advantage plans JHCHC verifies the correct advantage plan that covers the patient. These plans are as follows:
Advantra Freedom, Todays Option, Humana, Wellcare, Windsor
These plans differ in the time frames allowable for billing. Windsor has a limited billing time of 120 days (4 months). The other Medicare plans allow up to one year to bill.
Experience Dealing With Medicare
89
Alexander Waites ElderlyHousing Complex
90
JHCHC under its corporate umbrella operates an elderly and handicapped housing complex. A JHCHC employee acts as a facilitator for the residents.More than 70% of the tenants are 65 years or older.Approximately 80% of the tenants use JHCHC as their primary health care provider.
Alexander Waites Elderly Housing Complex
91
When necessary, primary care providers are kept abreast of resident’s medical issues by the Manager.
Residents are assisted in receiving enabling services such as transportation to physician offices as well as other activities in the community.
Activities such as educational presentations and bible study are done on site.
Inspection of the apartments for any hazards and HUD requirements are done regularly.
Alexander Waites Elderly Housing Complex
92
Transportation provided by the health center is very helpful. Cooperation with scheduling by clerks and providers is
necessary. Cooperation with family/caregivers of elderly patients is
key. Education of patients (bringing meds, any paperwork and
family/caregivers to each visit). Additional staff available to provider for care of the elderly.
Lessons Learned/Tips For Other Health Centers
93
On-site Social Services Department to assist in case management and enabling services will enhance geriatric patient management.
In-House pharmacy is beneficial due to its affiliation with the HRSA 340B Program.
Collaboration with Home Health Agencies is beneficial.
Lessons Learned/Tips For Other Health Centers
Contact InformationDr. Jasmin Chapman
Chief Executive OfficerJackson-Hinds Comprehensive Health Center
http://www.jackson-hinds.com
THANK YOU