CONNECTING THE DOTS Essential Linkages Between Healthcare and LTC

CONNECTING THE DOTS
Building an Integrated Healthcare Community
Essential Linkages Between Healthcare and
LTC
Peh Kim Choo
Director, Hua Mei Centre for Successful Ageing
Tsao Foundation
9/10 Dec 2014, Bangkok
FOCUS:
• Profile of a frail elder
• The current healthcare
experience
• Essential linkages to
building an integrated and
productive care system
© 2014. Tsao Foundation. Not to be reproduced or disseminated without permission.
LONG TERM CARE: DEFINITION
LTC refers to myriad services designed
to provide assistance over prolonged
periods to compensate for loss of
function due to chronic illness or physical
or mental disability
Feder J, Komisar HL, Niefeld
M.Long- Long term care in the
United States: an overview. Health
Affairs 2000
© 2014. Tsao Foundation. Not to be reproduced or disseminated without permission.
A SAMPLE LIST OF COMMUNITY LTC SERVICES
services (provided in recipients’ own homes)
Personal care assistant service
Personal attendant service
Homemaker agency and personal care agency services
Home hospice services
Home delivered meals
Home reconfiguration or renovation
Medical services
Transportation
Cash payments or allowances managed by the consumer or a consumer representative to pay
for above services
•Services provided in congregate living settings that are expected to be the recipient’s home, such as
assisted living, adult foster homes, small group homes, and residential care facilities
•
Cooking, housekeeping, mobility assistance, which are all services provided by personal care
assistants and personal attendants or home health aides under HCBS (could be consolidated
as restaurant service as well as in-home services in the resident’s unit)
•
Personal care (could include medication administration, medication) management
•
Activity program
•
General oversight and safety supervision
•
Wellness assistance and health monitoring
•
Palliative care
•Services provided outside the recipient’s home (regardless of whether it is a private home or a group
residential setting)
•
Adult day care
•
Day health care
•
Senior center programming
•In-home
•
•
•
•
•
•
•
•
•
© 2014. Tsao Foundation. Not to be reproduced or disseminated without permission.
WHO IS THE FRAIL ELDER?
An elder who is :
• likely age 75 or above
• may be alone or living with family
• likely to be cash strapped for services
• fairly independent (though may not be safe) in
ADL but likely to need help in IADL
• likely to be in low mood
• suffers from an average of 5.4 medical conditions
including dementia and psychiatric problems
• likely to have an average of 5-7 medications
• family stress could be common
© 2014. Tsao Foundation. Not to be reproduced or disseminated without permission.
WHAT THEN ARE THE NEEDS AND ITS IMPLICATIONS
Issues
Multiple chronic medical
conditions
Implications
•
•
•
Need an overall medical/health care and education plan
Need coordination and management with medical
providers, essentially the health system to build stability
Need different medical and allied health services such as
PT, OT, speech therapy
Complex medication
regime, often poly
pharmacy
Medication noncompliance
Need education and/or constant monitoring or complete
medication management
Compromised function
leading to functional
dependency
•
•
•
Need support in managing ADL and IADL
Need means to access services
Need build psycho-social support network
Complex social circumstances
and needs particularly, perhaps
around financing, care and
accessibility to healthcare and
other necessary services
•
The elder’s physical and psychological adjustment to their
condition
The family’s adjustment to care needs of the elder
The community’s adjustment to the number and needs
of elders
•
•
•
•
•
© 2014. Tsao Foundation. Not to be reproduced or disseminated without permission.
WHAT HAPPENS WHEN THESE ISSUES ARE NOT
TAKEN CARE OF IN THE WAY IT NEEDS TO BE?
Self
• I am useless
and a burden
• We are not
Family sure we can
cope
• Frequent hospitalization
• Resource over-utilization
Community
• ‘Falling through the
cracks’
© 2014. Tsao Foundation. Not to be reproduced or disseminated without permission.
Accessibility
Affordability
© 2014. Tsao Foundation. Not to be reproduced or disseminated without permission.
Quality –
well being
of elder and
families
The Issues:
-Do we communicate, transit,
integrate, flow seamlessly
between one segment to
another and amongst the
segments?
-Accountability – who is
responsible for the care?
-Do we all have the same goal?
-How do we deal with the
changing needs of the elder
and his family across time?
Hospitals
Community
Services
© 2014. Tsao Foundation. Not to be reproduced or disseminated without permission.
Home
HEALTH LINKAGES 1: CARE
MANAGEMENT (CARE
COORDINATION)
Care Coordination Ring
Care Coordination
Measures Atlas
Advancing Excellence
in Health Care •
Agency for
Healthcare Research
and Quality
Improving Primary
Care Quality
Indicators
Updated June 2014
© 2014. Tsao Foundation. Not to be reproduced or disseminated without permission.
AGENCY FOR HEALTHCARE RESEARCH AND QUALITY, USA :
Defining Care Management:
“the deliberate organization of patient care
activities between two or more
participants (including the patient)
involved in a patient’s care to facilitate the
appropriate delivery of health care
services. Organizing care involves the
marshalling of personnel and other
resources needed to carry out all required
patient care activities, and is often
managed by the exchange of information
among participants responsible for
different aspects of care.”
© 2014. Tsao Foundation. Not to be reproduced or disseminated without permission.
CARE MANAGEMENT IS:
“The fundamental focus of case management is to integrate,
coordinate and advocate for individuals, families, and groups
requiring extensive services.”
Bower, 1992
Care Management is a process that efficiently and effectively
aligns client needs/issues with resources to meet personal/family,
clinical and cost outcomes.
Right services…right time…right place…right cost…
…right outcome
(The Center for Case Management)
© Tsao Foundation. No unauthorised reproduction.
Main Focus of Care Management
• ASSESSMENT and
PLANNING
• COORDINATION and
BROKERAGE
• MONITORING
• EVALUATION
AN EXAMPLE OF CARE MANAGEMENT IN ACTION
Mr. Ng, 61 years, Chinese divorcee when first admitted to
Hua Mei Care Management
Suffers from Stroke and Ischaemic Heart Disease
Lives in one room rental on his CPF saving of $5,000 for
3 years until money ran out
Rely on flat mate to buy food for him until their
relationship became strained
Cannot walk but can bottom shuffle and barely coping
Admitted to hospital for illness, after which hospital
MSW advised Nursing Home Placement because he was
dependent on others for his Activity of Daily Living
© 2014. Tsao Foundation. Not to be reproduced or disseminated without permission.
©Tsao Foundation. No unauthorized reproduction
©Tsao Foundation. No unauthorized reproduction
©Tsao Foundation. No unauthorized reproduction
©Tsao Foundation. No unauthorized reproduction
©Tsao Foundation. No unauthorized reproduction
©Tsao Foundation. No unauthorized reproduction
©Tsao Foundation. No unauthorized reproduction
©Tsao Foundation. No unauthorized reproduction
©Tsao Foundation. No unauthorized reproduction
© 2014. Tsao Foundation. Not to be reproduced or disseminated without permission.
Care Coordination Ring
Care Coordination
Measures Atlas
Advancing Excellence
in Health Care •
Agency for
Healthcare Research
and Quality
Improving Primary
Care Quality
Indicators
Updated June 2014
© 2014. Tsao Foundation. Not to be reproduced or disseminated without permission.
HEALTH LINKAGES 2: THE
PERSON-CENTRED
MEDICAL HOME (COMPREHENSIVE
PRIMARY CARE)
PRIMARY HEALTH CARE
“Primary care is the level of a health services system that provides
entry into the system for all new needs and problems, provides
person-focused (not disease-oriented) care over time, provides care
for all but very uncommon or unusual conditions, and coordinates or
integrates care, regardless of where the care is delivered and who
provides it. It is the means by which the two main goals of a health
services system, optimization and equity of health status, are
approached.”
-Johns Hopkins Bloomberg School of Public Health
Primary care is first-contact, continuous, comprehensive, and
coordinated care provided to populations undifferentiated by gender,
disease, or organ system.
- Starfield, B “Is Primary Care Essential?”The Lancet Volume 344(8930)
22 October 1994 pp 1129-1133
© Tsao Foundation. No unauthorised reproduction.
PERSON-CENTRED MEDICAL HOME
• A medical home not simply as a place but as a model of
the organization of primary care that delivers the core
functions of primary health care
• 5 Key components of PCMH
•
•
•
•
•
Patient-centered
Comprehensive care
Coordinated care
Superb access to care
A systems-based approach to quality and safety
– Agency for Healthcare Research and Quality: PCMH
Resource Center
http://pcmh.ahrq.gov/portal/server.pt/community/pcmh__h
ome/1483/what_is_pcmh_
© Tsao Foundation. No unauthorised reproduction.
PRIMARY CARE IS:
‘One approach to decreasing fragmentation, improving
coordination, and placing greater emphasis on the needs
of patients is the patient-centered medical home (PCMH).
Its components include patient-centered care with an
orientation toward the whole person, comprehensive
care, care coordinated across all the elements of the
health system, superb access to care, and a systems-based
approach to quality and safety.1
Ultimately, these components are intended to improve
patient outcomes—including better patient
experience with care, improved quality of care (leading to
better health), and reduced costs.2 ‘
1http://www.pcmh.ahrq.gov/portal/server.pt/community/pcmh__home/1483/what_is_pcm
h_ for AHRQ’s definition of the PCMH.
2 See Berwick et al. (2008) for a discussion of this “triple aim” of better patient
experience, improved population health, and reduced per
capita costs.
© Tsao Foundation. No unauthorised reproduction.
THE PCMH CARE:
Dan Duffy, M.D., School of Community Medicine, Tulsa, OK
© Tsao Foundation. No unauthorised reproduction.
THE HUA MEI CARE MANAGEMENT SYSTEM OF
COMSA@WHAMPOA
AN EXAMPLE OF PCMH
Referral
from
Service
Agencies
Integrated
Work Process
Case Finding
in the
Community
Risk
Screening
Low Risk
High Risk
The Person Centred
Medical Home –
Primary Care with Care
Management
Care Management
Trained ParaCare
Managers
© 2014. Tsao Foundation. Not to be reproduced or disseminated without permission.
Service Coalition
Network
ISSUES TO CONSIDER FOR
IMPLEMENTATION:
• Financing Framework
• Training and Development of
Manpower
• Communication Platform
• Siting within the Health Care System
© 2014. Tsao Foundation. Not to be reproduced or disseminated without permission.
THANK YOU