Senior Outreach Brochure

Transcription

I
S
O
nnovations
in
enior
utreach
Novel Partnerships
Between Healthcare
Providers And
Community Based
Organizations
Yielding Measurable
Care Advances
With CMS Stars
California Association
of Physician Groups
C
alifornia’s medical groups have succeeded demonstrably in serving
over 1.5 million seniors in prepaid, comprehensive care in Medicare Advantage.
Technologically sophisticated, coordinated care systems with public accountability definitely helped to set expectations and define specific models for our
nation’s healthcare reform. Reform promises to bring the successes of systematic care with a medical home foundation to millions of additional seniors in
California and across the country. Fulfilling the promise of the Triple Aim—better technical care, patient experience, and affordability—will take a lot of work
and some fresh approaches.
California’s successes stand out notably with the nation’s best statistics in core
measures such as senior hospital utilization. The Medicare Advantage patients
also benefited from significantly superior performance compared side-by-side
to fee-for-service “traditional” Medicare in the same communities. The pressure
is mounting, however, to do this consistently in all areas of the state...for a considerably larger number of patients.
CMS has introduced a bold and sensible measurement strategy for Medicare
Advantage Health Plans. The CMS “Stars” system ranks Plans in an array of measures of clinical performance, patient experience, and administrative responsiveness, compiled from the entire state. We Californians are certainly familiar
with P4P and public reporting, and we welcome this new measurement opportunity. In candor...we realized 10 years ago that we are challenged to “ace” population-based standards by waiting for patients to make and attend traditional
appointments. We don’t wait, especially for preventive and chronic care, but
we have learned that effective outreach is easier said than done, especially for
patients with complex conditions and access barriers. The Stars ratings place
high stakes—financial, competitive, and prideful—upon solving this problem
for seniors!
We know we need to reach outside our “delivery system” comfort zones of offices, clinics, and hospitals to serve our seniors...especially those we don’t often
see. We believe that novel partnerships with local community organizations
can help reach our “silent seniors,” improving their personal experience of care,
the comfort of their years, as well as our accountability metrics.
Jennifer Yurick, in a brief 10 week internship with the HCC program (see appendix), interviewed many dozens of people and researched opportunities we
believe are actionable with a short turnaround time, using the Inland Empire as
a crucible. This publication describes seven of these in detail, and we hope to
stimulate others to explore additional ones.
“The most daring thing to do with your life is to create
stable communities in which the terrible disease of
loneliness can be cured.”
-Kurt Vonnegut
Wells Shoemaker MD, Medical Director
California Association of Physician Groups
915 Wilshire Blvd #1620, Los Angeles, CA 90017
E-mail [email protected]
Tel 213-239-5041 LA Office
Jennifer Yurick, HCC Intern
Table Of Contents:
A Still Life Portrait Of The Senior Healthcare
Experience
5 A Still Life Portrait Of The Senior Healthcare Experience
#1 “Gary”
7 Health Access Barriers For Silent Seniors
8 What Do Medical Groups Want And What Are Their Limitations?
What Do Community Organizations Want And What Are Their
9 Limitations?
Why Should Medical Groups Partner With Community
10
Organizations?
During a ride along with Riverside Meals Wheels my driver, Colleen, and I
made a routine stop at a home located near the University of California, Riverside. The unassuming house, which is located in an affluent community of Riverside, looked like it could be a part of any town’s quaint community. Colleen and
I got out of the car and began taking the appropriate food out of the coolers in
the trunk. A moment later, another car pulled into the driveway behind us.
A large, elderly man stepped out of the passenger side of the vehicle accompanied by a portable oxygen tank which he slung over his shoulder. The car
pulled out of the driveway as the man approached me. He introduced himself
as Gary (names have been changed to protect privacy) and graciously thanked
us for the meal. It was clear that he had not bathed that day. As he was talking,
Gary furiously scratched his forearm. He complained of the relentless itching
and claimed that he had been without relief for about a week. Fortunately, Gary
was able to attend his doctor’s appointment.
11 Methods Of Community Outreach: An Annotated Toolkit
12 Senior Health Fairs
14 Pharmacy Drug Reconciliation Or The “Brown Bag” Exercise
15 Senior Home Safety Visits
16 Senior Advisory Board
Cool Seniors: Avoiding Heat Related Injuries In Hot California
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Communities
When my companion asked about his diagnosis, Gary replied, “He said it was
worms. I think that’s what he said. I don’t really know. I guess it has to be worms.
I’m not sure what to do about it.”
19 Ride Along With Meals On Wheels
#2 The Coolers: What’s Behind Door #1?
20
Senior Vitality Center: Inspired By Choice’s “Senior Wellness
Center”
21 Other Promising Opportunities
24 Conclusion
25 Appendices
He then turned to me and asked, “Do you know what this is?” while extending
his arm towards my face.
“I’m not a professional. I’m sorry, Gary. I really wish I could help you,” I said.
He grunted and continued his aggressive scratching. By the time I replied to
him, we had reached the front door. Gary’s wife stood in the doorway while two,
overweight dogs came barreling out. Along with the dogs, an unpleasant odor
wafted out through the doorway. From where I was standing, I could see piles
of personal belongings lining the hallway and living room. Although I could feel
the June afternoon sun beating down on me, I could also feel the heat from inside the house escaping into the summer air. Colleen reminded the couple that
they should turn on their air conditioner. Gary’s wife nodded and said she would
do that. I climbed into the car and waved to Gary as we were pulling away. He
did not wave back. He was too preoccupied with scratching his arm.
Photo by Katie Dureault
“This stop will be quick. They never answer the door,” said Colleen tactfully.
She was right. Perched on a patio chair near the front door was a blue cooler.
Inside was a pack of ice and a note which read: “Please keep milk cold.”
At first, I thought they were running an errand or their children had come to
take them out and they would not be home in time to receive their meal. However, the cooler sighting was not an isolated incident. Three out of the ten stops
for that route routinely put out coolers to receive their meal. I couldn’t help but
wonder why and what lies beyond the front doors of those homes.
Health Access Barriers For Silent Seniors
#3 What Garden?
Elsewhere in Gary’s neighborhood lies a modest church which is home to
Father’s Garden. Despite being located in a church, Father’s Garden is a secular
community garden where anyone is free to rent a plot for a $25 deposit and a
monthly fee of $5. I arrived at the church on a Tuesday afternoon to find that all
the doors were locked, and there was absolutely no one to be found. Puzzled,
I went home to search for the Father’s Garden website. It wasn’t surprising to
read that Sunday afternoons are the best time to make contact with the garden manager. The website indicated that automatic drip sprinklers are highly
encouraged as community members will have not have regular access to their
gardens.
Later that week, I ventured to the San Bernardino Community Garden with
the hope that that site would be better equipped and more accessible than
the garden in Riverside. What I discovered was that a slightly dilapidated tract
home now stands on the ground where the garden once thrived.
For the most part, seniors are taking great strides to become more engaged
in their healthcare experience. However, the vignettes above illustrate a hidden
senior population which I will refer to as the “silent seniors.” The silent seniors
remain out of the healthcare loop for several reasons. Here are the reasons that
I have encountered during my research in the Inland Empire, in order of influence:
• Difficulty accessing transportation
• Isolation from family and loved ones
• Behavioral issues including, but not limited to, depression and dementia
• Financial constraints
• Fear and uncertainty
• Lack of health literacy; not understanding their diagnosis or treatment
• Lack of education regarding science and health issues
• Climate, particularly in our Inland Empire summer times
• Limited access or unawareness of community organizations which support healthy lifestyles
• Personal and cultural pride issues regarding accepting “charity”
Most seniors experience a combination of these barriers. Isolation is a barrier that many medical groups cannot overcome with traditional outreach measures. Seniors without access to transportation or who have a physical disability
depend heavily on the help of family and friends. Without a strong psychosocial
network, these seniors can be involuntarily cut off from the outside world. Isolation from family and friends often leads to depression. Having a behavioral
disorder makes it difficult to maintain a healthy lifestyle, including attending
regular PCP visits. Isolated and depressed seniors are unlikely to maintain regular doctor appointments and keep up with the treatment for their chronic conditions. Ultimately, the health of a senior who is struggling with isolation deteriorates which can lead to avoidable complication or a hospital admission.
The impact of potentially avoidable illness, injury, and costs on medical groups
will be addressed later in this paper.
What Do Medical Groups Want And What Are
Their Limitations?
What Do Community Organizations Want And
What Are Their Limitations?
Healthcare providers are all motivated to deliver superior care, but their actual performance varies. Further complicating the situation is the implementation of CMS Stars rating which rewards health plans and, by extension, medical
groups which provide excellent care and potentially penalizes those that fail
to meet its standards. Aside from the ethical implications of reaching out more
effectively to every senior, the financial incentive provides yet another reason
for medical groups to improve access and encourage seniors to be proactive
about their health.
The term “community organization” encompasses a broad, diverse concept.
For the sake of this paper, I will define a community organization as the following:
Primary care physicians (PCP) are already burdened by a multitude of responsibilities, both clinical and administrative. This isn’t easy anywhere in California,
but it can be even more distressing for those who serve communities which
have a deficit of physicians, such as the Inland Empire. (The Inland Empire has
fewer than 50 PCP’s per 100,000 population, where San Francisco Bay Area has
close to 120.) On top of maintaining timely access to appointments for a steady
flow of patients, medical groups and their practitioners are now faced with engaging a population of seniors whom they don’t see regularly. Using standard
registry approaches, any health plan, medical group, or PCP will find that there
are several patients who have not to seen their physician within a year or longer,
which is a long time for patients with multiple medical conditions. Although
PCPs strive to serve their patients, this may be hard to accomplish under the
model of healthcare that is currently in place unless the patient comes in for
an appointment. Unfortunately, some patients do not come to the attention of
their PCP until they are admitted to a hospital.
It is clear that something needs to change in order to address the silent senior population. However, asking a PCP or medical group to accomplish this
task with “business as usual” strategies is a stretch. Traditional delivery systems
are already stretched too thin, and this is a task for which they were not designed. When I met with Brandon Koretz MD, faculty gerontologist at UCLA,
he expressed a genuine concern for “silent seniors.” Yet, his concerns cannot
be alleviated unless there are changes made to the delivery of care. Dr. Koretz has few effective resources by which he can contact patients who aren’t
maintaining regular visits. With CMS Stars in place, health plans and, in turn,
every medical group will feel that impact. Furthermore, CMS Stars provides a
publicly reported “report card” on every health plan. The plans, in turn, have
performance reports for each medical group. In addition to missing out on financial incentives, low-performing groups run the risk of being eliminated from
a health plan’s network. If this were to happen, a group could lose a significant
number of its patients overnight and its likelihood to survive in the competitive
medical world will be challenged.
A formally or informally organized group of individuals whose mission is to
serve or improve the lives of the people living within its community.
A community organization can be anything from a community senior center,
community garden, religious institution, cultural affinity group, or service organization.
Much like medical groups, community organizations want to improve the
quality of life for the population they serve. Two factors set these organizations
apart from medical groups:
1. They offer limited or no medical services.
2. Most, if not all, community organizations are non-profit, operating on
lean budgets or workforce.
During my research, I found that almost all community organizations yearn to
provide more services for its members but lack the resources, connections, and
budget to do so. Some community organizations are working on addressing
their members’ wishes which range from STD informational sessions to social
dances. In reality, however, many are struggling to maintain the programs that
are already in place.
In some cases, community organizations and medical groups have created
relationships that are mutually beneficial. Health plans are especially active in
forming these partnerships. One example of this partnership occurred in Moreno Valley in July, 2011. SCAN, a Southern California health plan which focuses
exclusively upon seniors, agreed to sponsor the Moreno Valley Senior Community Center’s July 4 BBQ in exchange for holding a health plan informational
session at the center. In this scenario, everyone was a winner; the community
center was able to hold their social gathering and SCAN shared educational materials and exposure to potential members.
The parameters placed on medical groups by CMS Stars are primarily concentrated on screenings and preventive measures. Not only do the parameters
relate directly to the quality of health and patient experience, they also relate to
cost effective measures which logically should reduce medical spending in the
long run. For example: The cost of a network wide fall prevention program is
relatively small compared to the cost of one hospitalization for a broken hip.
Regardless of whether or not the standards of CMS Stars are cost-effective,
they are mandatory and represent another task for medical groups to meet.
However, it is clear that few, if any, medical groups and no health plans meet
the five star rating for every measure at this moment.
Why Should Medical Groups Partner With
Community Organizations?
Methods Of Community Outreach:
An Annotated Toolkit
Despite the positive outcomes of this arrangement, the opportunity to increase CMS Stars and to enhance the health of the senior population could
have been expanded. Let’s imagine a hypothetical situation: Suppose that a
resourceful and imaginative health plan also sent registered nurses to a senior
center to administer flu vaccines at no charge. Several seniors (especially those
that have a low socioeconomic status) might jump at the opportunity. Accessing the vaccine was convenient, certainly. It took place in a social atmosphere
instead of the harried usual clinic setting. At the end of the day, 300 seniors
received the flu vaccine and appreciated the generosity of the health plan. Yet,
even in a hypothetical construct, the scenario is not perfect.
What follows in this section are seven, developed strategies for senior outreach. The strategies were created by listening to the needs of medical groups
and observing community based organizations. All of the strategies are intended to be:
When preventive screenings are performed in community centers, the data
may be sequestered unless the information is shared with the providers. Although flu vaccination is a measure of the CMS Star criteria, a health plan’s rating might be unaffected by this generous outreach due to the lack of communication. On top of this potential waste, few people want to have screenings
performed on them multiple times, especially when it involves a needle stick.
In order to improve CMS Star ratings without placing an extra burden on overworked PCPs, the lines of communication between community organizations
and medical groups must be open and efficient.
The necessary personnel and materials will be suggested for each strategy. A
brief explanation on how to conduct each strategy will also be included. In order for any strategy to be successful, it must be creatively customized to reflect
the unique resources and needs of the community.
• Actionable at a community level
• Implemented in a short amount of time (e.g. months, not years)
• Affordable
• Effective at boosting CMS Stars scores
The main focus of effective outreach is to address silent seniors. This is where
community organizations have a tremendous potential synergy to offer. As illustrated in vignettes #1 and #2, Riverside Meals on Wheels frequently makes
contact with seniors that are out of the healthcare loop. Many other organizations also have access to the seniors’ homes and environments. They can become the eyes and ears of the true status of a senior’s living condition but, at
the moment, they have no means to communicate their findings. If healthcare
is a comprehensive discipline, then a patient’s environment needs to be addressed in order to maintain a healthy lifestyle. Physicians do not customarily
ask about the condition of a patient’s home. Even if a PCP knew that a patient
was living in squalor, what could this concerned physician do to change it aside
from involving a social worker?
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1. Senior Health Fairs
Who needs to be involved?
• Medical Director of medical group
• Venue Events Coordinator
• Licensed medical professional (e.g. NP, PA, RN)
• Volunteers (e.g. health students from local college campuses)
What materials are needed?
• Medical equipment (dependent on the screenings)
• Large venue (e.g. community halls, schools, churches, Indian casinos)
• Internet access for secure access to medical group and EHR when available
Novel Partnership Idea: In the Inland Empire, Indian casinos, while not a traditional health-related location, could become excellent venues for a senior
health fair. Most casinos have their own shuttle service which can be utilized
for seniors to access the health fair. The event hall of a casino is large enough
to hold all of the booths for the health fair. Many seniors enjoy visiting a casino,
needless to say! In return, casinos are always thrilled to have greater attendance
and will most likely become active supporters of this event.
How will this affect CMS Stars rating?
This event has the potential of reaching at least 12 of the CMS metrics. The
amount of metrics met depends entirely on how many screenings are offered at
the health fair (see Appendix II).
Morongo Casino Resort & Spa in Riverside County
• Ability to schedule PCP appointments remotely (e.g. MyHealthDIRECT)
• Incentive for seniors to attend (e.g. live entertainment, door prizes, free
admission to buffet etc.)
Comments:
Health fairs are an ideal event for performing multiple services for a large
group of attendees in a short time frame. Several medical groups have conducted health fairs at senior community centers and have been successful in
attracting a large crowd. However, these health fairs were not without their
problems. Data collected from health screenings were not always shared with
the PCP. By holding the health fairs in senior centers or other public settings,
medical groups may run the awkwardness of having non-members attend the
event, encumbering the complexity of unreimbursable costs, confidentiality,
continuity of care, and liability.
In order for a senior health fair to work efficiently, there appear to be three
key success factors.
1. Electronic Connectivity There needs to be a way for data to be shared with
a PCP. This could easily be accomplished by utilizing an EHR or through
a secure access. There also needs to be a way for seniors to schedule appointments for screenings which require a clinical setting. By using a direct electronic connection to scheduling seniors at the Fair would be able
to secure appointments for services needing a more clinical setting at the
event in real time.
2. Location The event location needs to be somewhat exclusive. In other
words, holding the event at a creative location will reduce the chance of
non-member attendance and improve the sense of “special” treatment
for patients receiving care from the sponsoring organization. The health
fair could be advertised solely to medical group members.
3. Attraction The event needs to have incentives for attendance. Providing
a lively social milieu, live entertainment, free food, or door prizes will increase the appeal for seniors to attend.
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2. Pharmacy Drug Reconciliation Or The
“Brown Bag” Exercise
3. Senior Home Safety Visits
• Medical director of medical group
• Retail Pharmacist and support staff
• Home health professional (e.g. LVN, RN, NP, PA)
• Independent Contractor for structural repairs
• Large venue
• Internet access for utilizing EHR or secure access to medical group
• Ability to schedule PCP appointments remotely
• Medical equipment (dependent on which screenings are chosen)
• Incentive for pharmacist
• Home safety checklist
• Incentive for seniors
• Laptop computer with internet access for utilizing EHR or secure access to
medical group
Comments:
Medication reconciliation is known to be important, but difficult to accomplish on a large scale for individual doctors. We discovered some workarounds
that keep the frontline doctors in the loop, since these professionals are the
ones with ultimate responsibility for prescription and oversight.
Drug safety checks can be performed in conjunction with a senior health fair or
at a local pharmacy. Medication errors, oversight, and confusion can be a major
factor for hospital readmission. Many seniors, especially those with chronic conditions, can take 10 or more medications a day. Seniors who have been recently
discharged from the hospital or faced with a new diagnosis are often confused
about how to correctly take their medications. Many seniors have medications
which are outdated, redundant, or even dangerous. By offering a chance for
seniors to display their full array of meds (yes, almost always a Brown Bag full) to
a pharmacist, the rate of senior hospital readmission should decrease.
If the drug safety check is performed at a health fair, the medical group could
provide administrative personnel to aid the seniors with filling out an information form. Meanwhile a pharmacy technician can lay out and tabulate the drugs
to speed the pharmacist’s analysis. The pharmacist’s professional opinion can
ideally be transmitted to the PCP using the same channels as the other screening, or some other efficient manner which the group would designate.
If a medical group establishes a formal bond with a local pharmacy, drug
safety checks can be conducted as an on-going basis at the retail location. Patients can stop by the pharmacy at their leisure. Again, a convenient communications pathway to the PCP is essential. The pharmacists’ recommendations
can be shared on an EHR, or the form can be scanned and shared electronically
through a secure connection. (Nobody wants paper in this century!) Because it
is unethical to provide monetary incentives in certain circumstances, the pharmacy can offer incentives that will improve safety in other avenues for the senior such as replacing rubber feet on canes and walkers, providing free non-slip
pads for bathrooms, offering to tighten the screws on eyeglasses and walkers,
and other ideas which will likely flow early in the dialogue.
How will this affect CMS stars rating?
The medication reconciliation activity has the potential to meet 2 CMS stars
metrics. Potentially, other criteria such as measuring blood pressure and delivering preventive vaccines can easily be incorporated (see Appendix II).
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• Vehicle
Comments:
The Gold Standard for care is the person-to-person PCP visit. Health Fairs are
a first line fall-back, and the Home Visit is a third. Senior Home Visits are more labor intensive, but they should pay off by reaching people who otherwise would
remain “invisible” until some medical calamity. If a senior does not contact his or
her PCP for an annual physical nor does he or she attend the group-sponsored
health fair, the senior can be encouraged to allow a home visit. If the senior approves, a home health worker can be sent to the senior’s home to evaluate his
or her health and their living conditions. Some screenings can be completed in
the home and home health can communicate the results back to the PCP. Home
health can also encourage the senior to complete screenings which require a
clinical setting. If the senior obliges, home health can make that appointment
immediately using a laptop with access to PCP scheduling.
Home health workers can also be trained how to complete a home evaluation. For example, easy criteria to check might include:
• Set water heaters to 120ºF or lower,
• Install hand rails in the bathroom and
• Place non-slip mats in shower stalls,
• Verify that food is in the refrigerator,
• Check for fall risks such as loose rugs and tripping hazards
If there are any changes that need to be made (e.g. hand rail installation),
home health could contact an independent contractor. The cost of that intervention could be offered to seniors at a reasonable rate or covered partially by
the health plan, medical group, or community volunteer agency for low-income
seniors. (Note: Physical home improvements are generally NOT covered by Medicare and health insurance, but certainly make sense if a group can arrange these
through some other pathway.) The use of an independent contractor for those
modifications also lifts the liability from the medical group. If dietary needs are
not being met, home health can contact Meals on Wheels to aid the senior.
This event has the potential of meeting 12 CMS stars metrics (see appendix II,
page 26).
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4. Senior Advisory Board
• CEO of medical group
• Senior members
• Hospital administration
• PR and publications, with budget and staff to do it professionally
• Regular meetings
Key Success Factors:
• Top level administrators buy in with personal “face time”
• Charismatic senior leaders from community with organizational skills
• Frequent meetings to maintain energy and exposures
Comments:
Currently, Torrance Hospital Independent Physician Association Senior Advisory Board (THIPA SAB) serves as an empowering forum for both the medical
group and its members. A Senior Advisory Board (SAB) allows interaction between administrative professionals and the seniors they serve. Meetings should
be held monthly to discuss senior concerns regarding the medical group. By
listening and addressing senior concerns, the medical group will be aware of
issues before they manifest into exacerbated problems.
SAB is also an effective method of putting new projects into effect. For example, if a medical group wanted to launch the Senior Home Safety Visits (above),
they could have SAB members contact seniors via telephone to obtain consent
for the visit and reassure regarding the honorable intentions and credentials of
the visitors. SAB members can also perform a follow-up call to see that all the
needs have been met.
SAB can also be a birthplace for new ideas and projects. By creating an amicable environment, SAB members can suggest projects which address the needs
of their community. A senior SAB member and a member of the medical group
can provide valuable insight to group administrators essentially functioning as
a committed focus group.
The effect on CMS stars depends on how SAB is utilized. At the very least, SAB
can improve a senior’s perception on healthcare quality (see Appendix I). After
all, their primary goal is to prove feedback on how to improve quality. At its fullest potential, a SAB can help to provide novel methods of accomplishing several
preventive measures, possibly touching more than 12 technical metrics as well
as other patient satisfaction and perception metrics (see appendix II, page 26).
SAB encourages:
• Listening
• Feedback
• Outreach
• Credibility
THIPA’s Senior Advisory Board
SAB is an excellent forum to provide health education of topics which pertain
to the senior age group. THIPA SAB generates attractive, legible, and easy-tounderstand newsletters which address a variety of health education topics and
lists valuable resources. The monthly newsletters are sent out to members to
keep seniors engaged in maintaining their health.
THIPA SAB also conducts successful health education programs. For lots of
reasons, seniors may not be able to attend a function on a given day, even when
they really want to. THIPA’s SAB’s schedules their health education programs
frequently at different dates and times.
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5. Cool Seniors: Avoiding Heat Related Injuries
In Hot California Communities
• Medical Directors of medical groups
• Southern California Edison
• Director of Meals on Wheels
• Outreach phone calls
Comments:
Extreme temperatures in the Inland Empire pose a risk factor for heat stroke
which can lead to ER visits, hospital admissions, or worse. Low-income seniors
too often do not have air conditioning in their home and sometimes rely on
cooling centers. However, cooling centers can be difficult to access for the following reasons:
• Require transportation,
• Usually closed on weekends
• Often close early when temperatures are still high.
Southern California Edison (SCE) offers a public program which provides lowcost or no-cost access to portable, single room air conditioners. In addition to
this, SCE offers help with electric bills for those who are economically disadvantaged. Seniors often live on a month-to-month basis financially and are worried
about a huge spike in electric spending during the summer months. By getting
in touch with SCE, seniors will have the option to receive a reduced rate or average their spending across a 12 month period.
At the very least, this program will improve a senior’s perception of healthcare
quality and community support, which logically should impact their reports for
patient satisfaction. Air conditioning installation requires access to a senior’s
home which could provide an avenue for a follow-up senior home safety visit.
Once a home visit has been conducted, a medical group could potentially touch
up to 5 CMS metrics (see appendix II, page 27).
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6. Ride Along With Meals On Wheels
• Home Health Workers (e.g. LVN, RN, NP, PA)
• Independent contractor
• Medical equipment (dependent on screenings)
• Home safety checklist
• Laptop computer with internet access for utilizing EHR or secure access to
medical group
Comments:
A medical group can identify individuals who participate in the Meals on
Wheels program. These individuals usually have barriers that cause isolation
and make it difficult to visit their PCPs. Home health workers could periodically
ride along with Meals on Wheels volunteers to conduct home safety evaluations
as well as performing some screenings included in CMS stars metrics. By having
a secure access to a medical group, a home health worker can share the results
and other information immediately with PCPs. They will also be able to schedule appointments for screenings which cannot be conducted in the home. Programs such as My Health Direct can provide the technology for directly scheduling appointments from remote locations. This type of outreach is similar to the
previously mentioned Senior Home Safety Visits. Because isolated seniors have
already formed a relationship with Meals on Wheels, they will be more likely to
cooperate with a medical group that is associated with a trusted community
based organization.
Not only will this improve a senior’s outlook on the quality of healthcare, could
potentially also meet up to 12 CMS requirements. This program can also help to
secure appointments that will complete additional two or more requirements.
The amount of requirements met depends on what screenings a medical group
chooses to provide in the home (see appendix II, page 27).
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7. Senior Vitality Center: Inspired By Choice’s
“Senior Wellness Center”
• CEO of urgent care center or hospital
• Healthcare professionals (part-time physicians, PA, NP, RN)
• Medical equipment (dependent on screenings)
• Venue
• EHR or secure access to medical group
Comments:
Choice Medical Group in Apple Valley built a Senior “Vitality” Center—a freestanding, affiliated system to offer extended evaluation and counseling in full
coordination and support of PCPs. Annual physical exams as well as other
screenings and preventive measures included in CMS Stars can be performed
effectively in this setting. In addition to screenings, healthcare professionals can
also discuss diet, medication, physical activity, and mental health. This is an ideal environment to conduct health risk assessments and connect a senior to appropriate resources. Patient visits could be conducted by a part-time physician,
PA, NP, or RN. The key success factor for a vitality center is the prompt and complete sharing of information with the PCP. It is crucial to have a secure access for
PCPs to receive information concerning their patient. The local group can take
the leadership steps to frame this approach as complementary, respectful, and
supportive, NOT competing or undermining to the role of the member PCP’s.
Choice Medical Group has built a separate facility for their Wellness Center.
This may not be feasible for all medical groups. Instead of creating a new facility, medical groups could partner with urgent care centers or hospitals to create
a vitality center. Both venues are ideal for meeting all of the required screenings
because each has sufficient medical equipment, safety accommodations, and
experienced staff. Medical groups and urgent care center or hospitals can set
aside a block of time weekly for seniors to conduct their annual physical exam,
and thread in some of the attractive elements described in the Health Fair approach above.
How will this improve CMS stars rating?
A senior wellness center has the potential of improving more than 12 measures of CMS stars. Unlike some of the previously mentioned solutions, a vitality center has the capability of accomplishing breast cancer and osteoporosis
screening and relatively easy accommodation of testing requiring blood sampling (see appendix II, page 27).
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Other Promising Opportunities
Several methods with potential to improve CMS stars rating that were not examined in detail in this initial community research. These are options that may
merit additional exploration.
1. Partnerships With Health Plans
• Health plans are an obvious partner for improving CMS ratings, with a
clear first-line interest.
• They are a great source for sponsorship, educational materials, expert
guidance, and other resources.
• Health plan participation can be incorporated into any of the ideas previously mentioned. A health fair could conceivably be co-sponsored by several health plans to cover all of the patients in a medical group, certainly
appealing to the physicians’ sense of equity in care.
2. Community Gardens
• Fresh vegetables!
• Forum for Registered Dieticians to discuss healthy eating habits
• Forum for professional personnel to discuss physical activity as well as
performing screenings
• Co-sponsor Farmers’ Markets or provide transportation to these
• Note the novel community garden program at Kaiser-Permanente’s Santa
Clara facility, possibly to spread statewide
3. Home Health Visits To Assisted Living Facilities
• Seniors living independently but in controlled settings with multiple senior-focused features.
• While Skilled Nursing Facilities (SNFs) usually have a physician who oversees the facility, assisted living facilities often do not. This creates a potential gap in care for those residents.
• Home health workers (RN, NP, PA, possible PharmD’s) can conduct medication reconciliation and some screenings.
• Home health workers can conduct or train assisted living staff to conduct
home safety evaluations.
4. Utilization Of Health Students From Local Colleges
• Many health students are eager to gain hands-on experience. However, several schools are facing budget cuts which severely decrease the
amount of opportunities for their students.
• Health students can be incorporated into health fairs and some home
safety projects. Health students, especially nursing students, will be able
to perform some screenings (e.g. BP) as well as educational services. Students can also help with the facilitation of the events (e.g. checking to
make sure forms are filled out correctly).
21
• This is also a great way for medical groups to build affinity from students
who may, in fact, represent future workforce for that group.
5. Physical Activities Groups
• Most communities have groups of seniors involved in physical activities
(e.g. Riverside Walkers or Silver Sneakers).
• These groups are an excellent forum to provide education via an RN or RD
or other partners with community physical fitness interests.
6. Community Ambassador Program (CAP)
• This model has been successfully executed by the Fremont Department
on Aging and Family Services.
• Community ambassadors are trained and are responsible for facilitating
the acquisition of health services within their community.
• CAP can work to provide screenings and educational events.
• CAP may be tied to an ethnic or religious institution in order to address
the needs of their community in a culturally sensitive manner.
• Seniors are often in need of services that cannot be handled by medical
groups. CAP refers seniors to the services they need, with “social worker”
knowledge and contacts.
• Conversely, healthcare providers can refer seniors to CAP if they feel that
the senior is in need of some beyond the scope of traditional health services.
• The key to success will be the two-way linkage of these programs with
the groups’ mainstream medical information.
7. Mobile Mental Health Program
• This model has been successfully executed by the Fremont Department
on Aging and Family Services and is a part of CAP.
• These organizations can be tied into Community Ambassadors Program
or a similar concept.
• This is a great way to reach out to underserved populations with cultural norms unfamiliar to traditional medical delivery systems (e.g. Indian
tribes, small immigrant communities).
• Many ethnic and religious organizations exist in communities but, currently, do not have any ties to medical groups. (e.g. Chabad Jewish Center
of Riverside makes home visits to provide emotional support to seniors.
However, they do not have any resources to provide medical services or
equipment to seniors that need it.)
9. Informational DVD/VHS Starring Celebrities
• This is a quick way to deliver information to all seniors of a medical group.
The DVD/VHS can explain the importance for patients to obtain all the
necessary screenings.
• Make DVD/VHS entertaining and attractive.
• Some celebrities are happy to participate in community service.
• Could expand to other print or broadcast media.
10. Community Services Organizations (e.g. Kiwanis, Lions Club,
Rotary Club)
• Community service organizations have already positively impacted the
well-being of their community. However, they may lack the relationships
with medical groups to share information.
• Some of these organizations have a health mission and some perform
health screenings.
11. County Medical Societies
• This program could be tied to an ethnic or religious institution in order to
address the needs of their community in a culturally sensitive manner.
• County Medical Societies act on the best interest of physicians as well as
patients. Health outreach would represent a collaborative opportunity.
• Depression affects many seniors and few are willing or able to receive
help.
• This is an excellent source for sponsorship and health information exchange.
• Trained community ambassadors can visit seniors in their homes to counsel and provide emotional support.
• Create ties with behavioral health specialists (e.g. psychiatrists and psychologist) in order to train community ambassadors and prescribe therapeutic approaches and medication for those who need it.
22
8. Ethnic Affinity Organizations/ Religious Organizations
12. Public Health Departments
• They have a unique understanding of their community and can provide a
different perspective than medical groups.
• They have a genuine mission to improve community health.
• Public Health Departments can offer resources typically unfamiliar to
groups. These liaisons can be remarkably synergistic, as abundantly demonstrated in Santa Cruz and Humboldt Counties.
23
Conclusion
Appendix I: Participating Medical Groups
The solutions described in the annotated toolkit are meant to be flexible and
completely customizable to best serve a medical group’s population. It is unlikely that any medical group will be able to complete all of the solutions. However, every medical group should be able to do at least one.
Thank you for investing your valuable time in this project and for being ideal models for the delivery of quality care.
All of the solutions were researched and created during a 10 week period.
The work certainly does not address all of the possibilities to improve CMS stars.
There are several untapped resources in every community waiting to be utilized. This project should serve as inspiration for medical groups to take a closer
look at their community and develop clever outreach which will best suit everyone’s needs. If 7 developed strategies along with 12 potential strategies could
be developed in 10 weeks, imagine what could be accomplished in 3 months
with seasoned Quality Improvement staff and close community ties.
- Jennifer Yurick, October, 2011
Choice Medical Group
Blair Bryson, IPA Administrator
[email protected]
Tammi Castro CPC, Director of Managed Care
Associate Administrator
[email protected]
EPIC Management L.P. /
Beaver Medical Group
Charles Payton MD, MBA, CMO
[email protected]
Kayla Pelletier MBA, CHES, Patient Education
Director
[email protected]
Alicia Richards MBA, Director of Quality
Management
[email protected]
Facey Medical Foundation
Stephanie Bamford, Administrative Director of
Quality Management
[email protected]
Stuart Levine MD, Medical Director
[email protected]
Donald Rebhun MD, Medical Director
[email protected]
Healthcare Partners
Kaiser Permanente
Maria Ureña RN, MHA, PHN, Clinical Program Manager
[email protected]
Monarch Healthcare
Mike Weiss DO, FAAP, Quality Medical Director
[email protected]
NAMM
Vicki Medlen LVN, Executive Director for QI & Medical
Management
[email protected]
Riverside Medical Clinic
Debbie Church, Vice President of Managed Care and
Contracts
[email protected]
Riverside Physician Network
Howard Saner, CEO
[email protected]
Susan Arbour, Director of Senior Marketing
Senior Health Connections/
Torrance Hospital IPA Medical Group [email protected]
Sandra Bennett RN, MSN, Care Manager
[email protected]
Loretta Morrow, Member Services Manager
[email protected]
Jim Slay, Director of Senior Programs
[email protected]
24
Sharp Rees Stealy Medical Group
Jerry Penso MD, MBA, Medical Director for Quality
[email protected]
UCLA Multicampus Program in
Geriatric Medicine & Gerontology
Janet Frank DrPH, Assistant Director of Academic
Programs
[email protected]
Brandon Koretz MD, Associate Clinical Professor of
Medicine, Geriatrics Medical Director
[email protected]
David Reuben MD, Chief Division of Geriatrics
[email protected]
25
Appendix II: CMS Star Metrics Matched To
Senior Outreach Solutions
Measure
Measure
Prevention Measures
Breast Cancer Screening
Colorectal Cancer Screening
Glaucoma Screening
Osteoporosis Testing (Delete for 2012)
X
Annual Flu shot
X
Physical Activity in older Adults
X
Pneumonia Vaccine
Fall risk assessment in Older Adults
Annual PCP visit
Chronic Care Measures
X
X
X
Cholesterol Management in IVD - LDL screening
X
Medication Monitoring (Delete for 2012)
X
Cholesterol Management in IVD - LDL<100
Diabetes- A1c screening
Diabetes- A1c control A1c >9%
Diabetes- LDL screening
Diabetes- LDL<100
Diabetes- nephropathy
Diabetes- BP <140/90
Diabetes - eye exam
Osteoporosis Management (Active for 2012)
X
X
X
Hospital
All Cause Readmissions
26
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
CAHPS
X
X
Spirometry to confirm COPD (Delete for 2012)
Patient Experience
X
X
X
Improving bladder control
X
X
Hypertension BP<140/90
Rheumatoid Arthritis Management - DMARD
X
X
X
X
X
X
X
X
X
X
X
X
X
Prevention Measures
Breast Cancer Screening
X
Glaucoma Screening
X
Pneumonia Vaccine
Physical Activity in older Adults
X
X
Annual PCP visit
X
X
Fall risk assessment in Older Adults
Chronic Care Measures
X
X
X
X
X
X
X
X
X
X
X
X
Medication Monitoring (Delete for 2012)
X
X
Cholesterol Management in IVD - LDL<100
Diabetes- LDL screening
X
X
X
Cholesterol Management in IVD - LDL screening
X
X
X
Annual Flu shot
Diabetes- A1c screening
X
X
Osteoporosis Testing (Delete for 2012)
X
X
X
Colorectal Cancer Screening
X
X
Diabetes- A1c control A1c >9%
X
X
Diabetes- LDL<100
Diabetes- nephropathy
Diabetes- BP <140/90
Diabetes - eye exam
X
X
X
X
X
Osteoporosis Management (Active for 2012)
X
Hypertension BP<140/90
X
Rheumatoid Arthritis Management - DMARD
X
Spirometry to confirm COPD (Delete for 2012)
X
Improving bladder control
Patient Experience
CAHPS
X
All Cause Readmissions
X
Hospital
X
X
X
27
Appendix III: Participating Health Plans
Appendix IV: Organizations Supporting Senior
Outreach
Thank you for your dedication and effort in this project and for your constant effort to improve
healthcare quality.
Thank you for providing outstanding services to your senior community. I greatly appreciate the
time, patience, and passion you have shown.
Anthem Blue Cross
Tracy Wang, Inland Empire Contact
[email protected]
Blue Shield of California
Marc Richmond MD, Medical Director of Senior Plan
[email protected]
Health Net
Tao Le MD, Medical Director of Inland Empire Region
[email protected]
Elaine Robinson-Frank RN, MPH
[email protected]
Health Plan of San Mateo
Inland Empire Health Plan
Mary Giammona MD, Medical Director
[email protected]
Carolyn Thon MPA, Director of Member Services and
Outreach
[email protected]
Brad Gilbert MD, CEO
[email protected]
Ben Jauregui, Disability Program Manager
[email protected]
Gary Melton RN, Director of Healthcare Administration
[email protected]
LACare Health Plan
Jim Brown, COO
[email protected]
SCAN Health Plan
Jodi Cohn DrPH, Research Director
[email protected]
Lena Perelman, Director of Outreach
[email protected]
Izaro Elorduy MS, Community Relations Manager
– Inland Empire Region
[email protected]
United HealthCare
Jeffrey Mason MD, Medical Director
[email protected]
California Quality Collaborative & PBGH
Giovanna Giuliani MBA, MPH, Senior Manager
[email protected]
Diane Stewart MBA, Senior Director
[email protected]
Lance Lang MD, Clinical Director
[email protected]
http://www.moreno-valley.ca.us/resident_
services/park_rec/seniors.shtml
Chabad Jewish Community Center
of Riverside
Rabbi Shumel Fuss
[email protected]
Nola Tainter, Program Coordinator
[email protected]
Old Timers Foundation
8572 Sierra Ave, Fontana, CA, 92335
909-822-4493
http://www.oldtimers.org
Father’s Garden Community Garden
Bill Griffith
[email protected]
Fontana Senior Community Center
April Painter, Community Services Assistant III
[email protected]
Tiffany Starks, Community Services
Coordinator
[email protected]
Fremont Department on Aging and
Family Services
Karen Grimsich MSW, Administrator
[email protected]
James L. Brulte Senior Center
Donna Castrejon, Program Specialist –
Senior Programs
[email protected]
Beverley McDonough, Community Services
Coordinator
[email protected]
Janet Goeske Senior Center
Estella Granillo, Activities Coordinator
[email protected]
Joslyn Senior Center
21 Grant St, Redlands, CA, 92373
909-798-7550
http://www.ci.redlands.ca.us/recreation/
joslyn_center.htm
Moreno Valley Senior Center
25075 Fir Ave, Moreno Valley, CA, 92553
951-413-3280
28
MyHealthDIRECT
Tom Horton, Director of
Sales, Managed Care
[email protected]
Ontario Senior Center
225 East B St, Ontario, CA
909-395-2021
http://www.ci.ontario.ca.us/index.cfm/22/18934
Ralphs Pharmacy
Rebecca Cupp MBA, Vice President of
Pharmacy
[email protected]
Redlands Senior Center
111 W. Lugonia Ave, Redlands, CA, 92373
909-798-7579
http://www.ci.redlands.ca.us/recreation/
senior_center.htm
Riverside Meals on Wheels
Kathleen Parra, Executive Assistant
[email protected]
San Bernardino Department on Aging
and Adult Services
Colleen Krygier, Director
686 E. Mill St, San Bernardino, CA, 92415
909-891-3900
Southern California Edison
Patricia Minassian, Senior Strategist,
Brand Marketing & Communications
[email protected]
UCSF Center for the Health Professions
Angela Marks MSEd, Program Manager
[email protected]
5th Street Senior Center
600 W. 5th St, San Bernardino, CA, 92410
909-384-5430
29
About CAPG
The California Association of Physician Groups (CAPG) represents over 150
medical groups whose network physicians serve a total of about 18 million Californians in coordinated, pre-paid, comprehensive care, as well as PPO coverage
and governmental programs.
While there is a great diversity in size, geography, and patient population,
CAPG groups all share several crucial traits. They are physician governed, locally grounded, constantly measured, and formally accountable for the quality of
their work. They live within a real budget. They have reduced fruitless suffering
and cost by insisting upon evidence-based care, reaching patients who would
otherwise “fall through the cracks,” and developing novel approaches for individuals with complex needs. Through intelligent, centralized supports, CAPG
groups enable our doctors to live up to the aspirations of the Patient Centered
Medical Home, with emphasis upon preventive and chronic care.
The architects of federal healthcare reform borrowed heavily from CAPG’s approaches to technical quality, patient experience, and affordability, noting the
particular success with seniors in coordinated care systems. We are not content
with where we are, and this outreach project illustrates our desire to creatively
improve our services to the generation which raised us.
About Health Career Connection
For more information about CAPG’s members, wide-ranging programs, and publications,
we encourage you to visit www.CAPG.org.
Health Career Connection seeks to inspire promising students to pursue
health careers through a summer internship immersion in real-life healthcare
environments. Supported by the University of California and extending statewide, HCC aims to develop a future healthcare workforce representing California’s treasure of diversity.
HCC carefully screens and prepares candidates, typically nearing the completion of their undergraduate work, for writing, analytical, research, computer,
and interpersonal skills. HCC then matches candidates’ interests with organizations with demonstrated Initiative. A fractional list among over 50 past host organizations includes CAPG, Kaiser-Permanente, Alta Bates Medical Group, John
Muir Community Health Alliance, Molina Healthcare, and the Pacific Business
Group on Health.
The paid internship experience lasts 10 weeks, featuring a formal project
aligned with a specific organizational need. HCC interns consistently bring a
culturally attentive perspective to their work, and most have gone forward to
advanced degrees—MD, RN, MPH, MHA, MBA. It’s not unusual for an intern to
re-join the host organization as a future employee.
The HCC program cycles annually, with application processes during the
Spring. Information is available from www.healthcareers.org or Contact Temi
Ifafore, HCC National Program Director, at 1-866-579-4442 ext. 9.
30
31
California Association of Physician Groups
915 Wilshire Blvd., Suite 1620
Los Angeles, CA 90017
(213)-624-CAPG
www.capg.org
“Improving Healthcare For Californians”
32

Senior Outreach Brochure

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