Improving Care for Older Adults: Assessing the Need for a Managed Care Model in a Rural Area

Introduction: Older adults with complex medical needs are difficult to manage within various care settings, particularly in rural areas. The purpose of this project was to assess if Sweetwater County WY would benefit from an intervention aimed at improving care coordination in the form of a managed care model. Objective: A quality improvement initiative was undertaken through a multi-step process; a) a community needs assessment to gain a better understanding of barriers and existing supports (facilitators) related to caring for older adults with complex medical needs, b) the development of a list of county specific recommendations, c) the proposal of a managed care model for Sweetwater County based on findings obtained through the community needs assessment. Methods: Quantitative and qualitative data were collected through the analysis of semi structured survey responses from healthcare providers, and open-ended interviews with representatives from various healthcare organizations within the county. Results: Analysis of survey and interview data revealed that Sweetwater County needed improvement in several critical areas, 19 of 37 healthcare providers queried completed surveys. A total of 12 interviews were conducted. Survey responses included; 89% identified inadequate financial support as a barrier. 74% selected that transitions of care needed improvement, 84% identified home health services as a facilitator, and 58% chose that if available they would utilize palliative care services. Comments from the interviews were organized into the following categories; a) barriers to care, b) facilitators for care, and c) transitions of care. Barriers included comments related to the national health system structure, and financial reimbursement model. State Adult Protective Services were inadequate, poor local resources, collaboration, access, and rural health were barriers to care. Improvement was needed in regard to collaboration, retention, and access to case management. On a patient level safety, support and financial resources were barriers. Facilitators included comments that personal relationships improved communication and collaboration across agencies. The local hospital primary care network, and more providers willing to offer services to Medicare and Medicaid recipients were assets. Provider retention has improved from what it was in the past. On the patient level access to reliable transportation, local resources, financial support, and advance care planning improved the patient experience. Themes identified from comments about transitions of care included; communication, collaboration, resources and transportation. Discussion: The needs assessment identified the necessity for improvement of care coordination in Sweetwater County. It was concluded that a more focused assessment about the patient demographic and healthcare utilization would help to determine the most feasible and sustainable managed care model for the area. A model should be implemented along with county specific improvement initiatives to support the model. One model cannot be recommended over the other based on this assessment, however snapshots of three models were provided; Chronic Care Management Program, Guided Care, and Patient Centered Medical Home. Coordination of care is dependent on many factors, and requires a unique synergy between all agencies involved. While models provide a framework they need to be adapted to work for each individual community.

Running head: IMPROVING CARE FOR OLDER ADULTS: ASSESSING THE NEED Improving care for older adults: assessing the need for a managed care model in a rural area Patricia Green Project chair: Dr. Amanda Al-Khudairi Content Expert: Dr. Diane Kendall, APRN University of Utah In partial fulfillment of the requirements for the Doctor of Nursing Practice 1 IMPROVING CARE FOR OLDER ADULTS: ASSESSING THE NEED 2 Improving care for older adults: assessing the need for a managed care model in a rural area Abstract Introduction: Older adults with complex medical needs are difficult to manage within various care settings, particularly in rural areas. The purpose of this project was to assess if Sweetwater County WY would benefit from an intervention aimed at improving care coordination in the form of a managed care model. Objective: A quality improvement initiative was undertaken through a multi-step process; a) a community needs assessment to gain a better understanding of barriers and existing supports (facilitators) related to caring for older adults with complex medical needs, b) the development of a list of county specific recommendations, c) the proposal of a managed care model for Sweetwater County based on findings obtained through the community needs assessment. Methods: Quantitative and qualitative data were collected through the analysis of semi structured survey responses from healthcare providers, and open-ended interviews with representatives from various healthcare organizations within the county. Results: Analysis of survey and interview data revealed that Sweetwater County needed improvement in several critical areas, 19 of 37 healthcare providers queried completed surveys. A total of 12 interviews were conducted. Survey responses included; 89% identified inadequate financial support as a barrier. 74% selected that transitions of care needed improvement, 84% identified home health services as a facilitator, and 58% chose that if available they would utilize palliative care services. Comments from the interviews were organized into the following categories; a) barriers to care, b) facilitators for care, and c) transitions of care. Barriers included comments related to the national health system structure, and financial reimbursement model. State Adult Protective Services were inadequate, poor local resources, collaboration, access, and IMPROVING CARE FOR OLDER ADULTS: ASSESSING THE NEED 3 rural health were barriers to care. Improvement was needed in regard to collaboration, retention, and access to case management. On a patient level safety, support and financial resources were barriers. Facilitators included comments that personal relationships improved communication and collaboration across agencies. The local hospital primary care network, and more providers willing to offer services to Medicare and Medicaid recipients were assets. Provider retention has improved from what it was in the past. On the patient level access to reliable transportation, local resources, financial support, and advance care planning improved the patient experience. Themes identified from comments about transitions of care included; communication, collaboration, resources and transportation. Discussion: The needs assessment identified the necessity for improvement of care coordination in Sweetwater County. It was concluded that a more focused assessment about the patient demographic and healthcare utilization would help to determine the most feasible and sustainable managed care model for the area. A model should be implemented along with county specific improvement initiatives to support the model. One model cannot be recommended over the other based on this assessment, however snapshots of three models were provided; Chronic Care Management Program, Guided Care, and Patient Centered Medical Home. Coordination of care is dependent on many factors, and requires a unique synergy between all agencies involved. While models provide a framework they need to be adapted to work for each individual community. Key words: coordinated care, managed care model, facilitators, and barriers IMPROVING CARE FOR OLDER ADULTS: ASSESSING THE NEED 4 Introduction Older adults with complex medical needs are challenging to manage in primary care. Complex medical needs include more than one chronic condition impacted by inadequate physical capabilities, and poor emotional, mental, and/or social support. These individuals have difficulty managing their own health care needs and often lack support or assistance. They require intense time in the primary care setting, and multiple factors impact their ability to comply with prescribed medical regimens. Complex patients who live in rural areas and medically underserved areas are particularly vulnerable to adverse health outcomes due to a lack of specialty services, inadequate healthcare resources, and the need to travel to comply with healthcare regimens. Problem Description Rock Springs, Wyoming, and the surrounding Sweetwater County is rural/frontier based on population density. Patients who require specialty care generally have to travel over 170 miles to the nearest large city, Salt Lake City, Utah. Patients have the option to see specialists willing to travel to the area to offer services, but that care is generally delayed due to limited clinic hours offered, and long wait lists. Additionally, Sweetwater County struggles with the recruitment and retention of healthcare providers for every type of health care setting, including primary care. It is not uncommon for healthcare providers to move into the area, establish a patient base, and leave the area shortly after. Although family practice primary care providers often see geriatric patients, Sweetwater County has no established clinic for geriatric patients, and relatively few providers have specific training to care for older adults with complex needs. The county also struggles to maintain the consistency of healthcare resources, and programs. There are ongoing efforts by the local hospital to reduce unnecessary hospital IMPROVING CARE FOR OLDER ADULTS: ASSESSING THE NEED 5 admissions and address transitions of care in the area. For example, the local hospital hosts a monthly event, called Sweetwater Care Transitions Coalition meetings to promote goal sharing and encourage cooperation among community healthcare agencies. Attendance and community input fluctuates monthly. Recently, a transitional care nurse position was implemented to follow patients after hospital discharge. This program has been well received, but it will take additional time to be successful. There is an ongoing need for thorough assessment and evaluation of community resources in the county to improve care for older adults with complex medical needs. Available Knowledge Current data from the literature demonstrates that the primary care medical model is insufficient to care for older adult patients with complex needs. Mollica and Gillespie (2003) reported that a gap exists between supportive services and the traditional medical model of care. Trehearne, Fishman, and Elizabeth (2014) reported that despite the fact that the older adult population is rising in the United States, fewer healthcare professionals are receiving training in geriatric medicine. They point out that patients with multiple conditions are more time intensive and current reimbursement models have large financial discrepancies between Medicare and private insurers. The Journal of the American Geriatric Society (JAGS) published similar information discussing the need for improvement in the health care system related to quality, safety, coordination, and a renewed focus on quality of life for older adult patients. In the United States the current healthcare structure involves multiple specialists, complex patient instructions, and requires patients and families to navigate the healthcare system (JAGS, 2016). Lack of managed care for these individuals' results in lower patient satisfaction, poor health-related outcomes, IMPROVING CARE FOR OLDER ADULTS: ASSESSING THE NEED 6 preventable hospitalizations, and premature death. There is a need for implementation of comprehensive managed care strategies in the primary care setting. Rationale Improvements in healthcare delivery models require multiple system-level interventions. It is also important to recognize that systems are interconnected, and an intervention in one area of a system impacts additional areas. The Chronic Care Model (1998) was chosen as a framework for this project because it is based on multisystem level interventions. The Chronic Care Model (CCM) (1998) is based on the concept that improvement in healthcare requires a multidimensional approach that incorporates interventions on the patient, provider, and system levels (Fiandt, 2006). The CCM consists of 6 elements: organizational support, clinical information systems, delivery system design, decision support, self-management support, and community resources (Fiandt, 2006). The CCM model serves as a strategic framework for improving healthcare services; it is well established, highly utilized, validated, and it serves as a core component to a variety of quality improvement initiatives. Individual patients with complex healthcare needs such as multiple chronic illnesses, and inadequate support often have higher rates of healthcare utilization. Additionally, new penalties exist for hospital readmissions. As a result, several interventions have been developed to improve care of these individuals while reducing costs associated with their care. Among these approaches a variety of managed care models have emerged. There are multiple names for managed care models including complex care, coordinated care, and chronic care management programs. There are numerous managed care models available. The most well-known is the Patient Centered Medical Home. IMPROVING CARE FOR OLDER ADULTS: ASSESSING THE NEED 7 Specific Aims The purpose of this project was to formally assess the need for a coordinated care model in Sweetwater County Wyoming, to examine existing models of care, and to propose the most feasible managed care model for the county. The primary aim of the project was to evaluate healthcare resources in Sweetwater County, Wyoming through a needs assessment (Appendix A) to highlight common barriers and facilitators for providing care for older adults with complex needs (Appendix B and Appendix C) This assessment focused on local needs, current services, systems design, and available supportive resources. The assessment was meant to highlight key observations to develop area specific recommendations (Appendix D) to support the implementation of an evidenced-based managed care model. The secondary aim of this project was to develop area specific recommendations based on data gathered from the community assessment. In this portion of the project, three existing evidence-based models were compared with regard to feasibility, applicability, and sustainability in the county (Appendix E). Benefits and limitations for each model were included. It was important that the needs assessment drive the recommendations for improvement in Sweetwater County. The third aim was to share the data, community assessment, and specific recommendations with relevant stakeholders. Area specific recommendations were customized to the specific needs of the county with regard to practical application of future interventions. The final report summarized the key findings, observations, and recommendations specific to the county based on relevant literature when applicable. IMPROVING CARE FOR OLDER ADULTS: ASSESSING THE NEED 8 Methods Context The final report was highly specific to the area and needs of Sweetwater County Wyoming. The organization and layout of the community-based needs assessment and the comparison between existing managed care models is replicable. This project illustrated a process of conducting a community needs assessment for the Medicare population in order to assist in the development of feasible county specific recommendations to improve chronic care management in Sweetwater County. Intervention(s) A quality improvement initiative was implemented to assess the quality of existing local resources for older adults to customize recommendations for the area. By use of inquiry and investigation, quantitative and qualitative data was gathered in the form of healthcare provider surveys, semi structured interviews with representatives from various healthcare organizations, and attendance at Sweetwater Care Transitions Coalition Meetings. The interviews were timed, and written notes were taken throughout the process, and then typed up for analysis. The most common themes from the assessment data were identified and organized into categories. Several individuals participated in the community needs assessment including multiple providers in the area, physician specialists, and primary care providers through semi- structured surveys. Several representatives from various healthcare organizations participated in the interview process. Additional data were gathered from secondary sources including; Sweetwater Care Transition Coalition Meetings, United States census data, and previous studies conducted in the area. IMPROVING CARE FOR OLDER ADULTS: ASSESSING THE NEED 9 Descriptive analysis and content analysis were utilized to interpret assessment data from semi-structured surveys and open-ended interviews. Responses from semi structured survey questions were organized into bar graphs using Microsoft Excel. The additional provider comments from the surveys were listed because they provided valuable input related to healthcare provider perceptions (Appendix B). A content analysis was utilized to group common themes from the interview data (Appendix C). Once themes were identified a list of key observations was developed followed by a list of community specific recommendations (Appendix D). A snapshot of three managed care models was also provided based on level of integration and expenditure of resources (Appendix E). Comparison of the models included the features, strengths, and limitations for each model. The final written community assessment was presented to community stakeholders (Memorial Hospital of Sweetwater County) for review. Study of the Intervention(s) Semi structured survey questions were developed based on subject matter reviewed from Sweetwater care transitions coalition community meetings, and known barriers and facilitators identified from the literature. Memorial Hospital of Sweetwater County (MHSC) provided the most recent version of a healthcare provider contact information list, and a list of Sweetwater County resources. Providers were selected from the list based on services offered to Medicare recipients. The providers included physician specialists, emergency room physicians, primary care providers, hospitalists, and surgeons. Providers from the pain clinic, dentists and eye doctors were excluded from the assessment. Although their input would have been valuable, survey questions focused on multiple chronic medical conditions. The surveys were delivered in person to medical offices, and left with frontline office staff. The unit director for the emergency IMPROVING CARE FOR OLDER ADULTS: ASSESSING THE NEED 10 department, medical/surgical unit, and intensive care unit placed survey packets for emergency room physicians and hospitalist in the doctor's communication box. Each survey packet included a cover letter to explain the purpose of the survey and instructions for completing the survey. A link to the electronic version of the survey was included to allow multiple modes of completion. Each packet included a self-addressed envelope with paid postage for return. The survey was brief, with check boxes, but included areas for open-ended responses, such as explanations and additional comments. Questions were developed to gather pertinent data related to barriers to care, community resources commonly used (facilitators to care), areas for improvement, interest in billing for chronic care services, and additional resources participants would like to see in the area. Survey data was provided in Appendix B. A semi structured open-ended interview tool was developed after a review of the literature, and incorporated questions similar to those in the provider survey. The tool was adapted for each interview, as some questions were not applicable to every agency. A brief review of the healthcare organization was conducted via online websites prior to the interview to supply pertinent information regarding services and contact information. Information obtained from the website was verified in the interview process as applicable. Twelve open-ended questions were designed to gather specific information regarding the program of interest including content about the structure of the organization, services offered, information about utilizing the service, future goals for the program, any known barriers, facilitators, assessment of transitions of care, involvement from health care providers, and follow up services. Interview data was provided in Appendix C. IMPROVING CARE FOR OLDER ADULTS: ASSESSING THE NEED 11 The following community organizations were contacted by phone; three home healthcare agencies, two ambulance companies, two skilled nursing facilities, Hospice of Sweetwater County, two assisted living centers, two senior housing facilities, Volunteer Information Referral Services (Respite), two senior centers, and discharge planning at Memorial Hospital of Sweetwater County. Four monthly Sweetwater Care Transitions Coalition Meetings were attended throughout this project. The meetings were hosted by Memorial Hospital of Sweetwater County (MHSC) collaborating with representatives from Mountain- Pacific Quality Health Services (MPQHS), and Quality Improvement Organizations Centers for Medicare and Medicaid Services (QIOCMS) for the state of Wyoming. The purpose of the meetings was to engage members of the community, patients, providers, and organizations in an effort to improve the continuum of care in the community. Demographic data were reviewed routinely related to hospital admissions compared to state and national levels. Readmission rates were also reviewed along with the stay type for admissions. The most common stay type for readmission was heart failure (MHSC, in patient 30 day readmissions for Medicare fee for service patients, MPQHS). Analysis Most managed care models have been developed in an effort to decrease rates of hospital readmissions, and preventable hospitalizations. Within the literature, measures for the evaluation of managed care models included analysis of International Classification of Diseases (ICD) codes, and Center for Medicare and Medicaid Services (CMS) demographic data tracking healthcare utilization. The majority of established managed care models and similar interventions are effective at decreasing hospital readmissions slightly, but results are mixed. As managed care models have moved past implementation stages emphasis has started to shift illustrating the IMPROVING CARE FOR OLDER ADULTS: ASSESSING THE NEED 12 importance of spending time determining more standard approaches for measuring the effectiveness of interventions. The surveys were designed for providers following patients with chronic conditions. The majority of respondents were primary care providers. Emergency room physicians and hospitalists did not participate in the survey. The questions on the interview tool guided the dialogue during the interview process. Not all questions applied to each organization and the tool was adapted as needed. Handwritten notes were taken throughout the interview process, typed and then organized into themes/categories following the interview. The analytic approach utilized was adapted from a publication written by Percy (n.d.) that summarized an adapted approach from McCraken (1988). This analysis was not conducted with use of a software program because the data were fairly simple to group manually. The comments from the collected interview data were compiled into three main categories; a) barriers to care, b) facilitators to care, c) and transitions of care. The first round grouping themes resulted in several pages listing the comments regarding the barriers to care, which were organized into additional categories based on national-local-provider-and patient level barriers; an additional state-level category also emerged. The comments were grouped according to commonalities, for example comments related to communication and collaboration. The facilitators to care were compiled in a similar manner resulting in patterns for patient, provider, and local-level facilitators. The third category included specifics related to transitions of care. The themes from this area all occurred on a local level. For the content analysis; although a scientifically validated tool for conducting the interview would have been useful, data were limited for creating one as a gap in the literature exists. In addition, it was important that the data were specific to the local area, and included an IMPROVING CARE FOR OLDER ADULTS: ASSESSING THE NEED 13 area-specific evaluation of resources. The principal investigator interviewed representatives from healthcare organizations, and conducted the content analysis to extrapolate themes from the data. Although having a second reviewer to identify themes from the data would have decreased bias, and improved validity, the resources for doing so were lacking. Assessing outcomes based on this intervention is outside the scope of this project. Ethical Considerations This study is a quality improvement initiative. The University of Utah Institutional Review Board determined that this study is exempt from human subjects review. Results Thirty-seven total surveys were delivered to providers. Eighteen hard copies of the survey were returned, and one electronic version was completed. The majority of responses were from primary care providers, two internal medicine physicians, five primary care physicians, two nurse practitioners, five physician assistants, and five specialty services including; one urologist, one pulmonologist, one general surgeon, one ear nose throat specialist, and one registered nurse director of dialysis. Descriptive results were compiled in Microsoft Excel and formatted into bar graphs with additional comments listed in (Appendix B). Table 1 summarized this information. Table.1 Survey Question/ Answer (Number of selected responses) What potential barriers do you see caring for patients with multiple chronic illnesses in your setting?/Inadequate financial support (17/19) 89% What community resources do you frequently recommend/utilize refer? /Home health services (16/19) 84% What aspects of caring for older adults with chronic illnesses would you like to see improve?/ Transitions of care (14/19) 74% IMPROVING CARE FOR OLDER ADULTS: ASSESSING THE NEED 14 Do you currently bill for chronic care services? Are you interested in providing the services for doing so?/ Unsure at this time (9/19) 47% If you had the following resources would you utilize them? Palliative care services/ (11/19) 57% Examples of additional comments: • • • • • • • • Cost Lack of financial support for patients Frustration with medication review Frustration with paperwork Needed improvement in patient education and support Need for better care coordination More reimbursement More community resources and support. Representatives from several healthcare organizations participated in the interview process (see table 2). Of those contacted, 12 interviews were granted, 7 were conducted in person and 5 were telephone interviews. Each interview was timed, recorded, and then typed up for analysis. Common themes were identified and included in the final community assessment (Appendix C) Table.2 Healthcare organization Representative Interviewed Sweetwater Medics Ambulance Ambulance Director Managing Member Castle Rock Ambulance Ambulance Director Mansface Terrace Housing Business Manager Memorial Hospital of Sweetwater County Discharge Planner Young At Heart Senior Center Executive Director Rocky Mountain Home Health Care Administrator Social Worker Volunteer Information Referral system (VIRS) Registered Nurse IMPROVING CARE FOR OLDER ADULTS: ASSESSING THE NEED Mission at Castle Rock Director of Nursing Sage View Care Center Executive Director Hospice of Sweetwater County Director 15 Main barriers to care Comments about a negative perception or obstacles noticed when delivering care were included in the category barriers to care. This was organized into national-level, state- level, local- level, provider-level, and patient- level based on which level barriers commonly occurred. Many comments could be applied to multiple levels of barriers. The national level included comments related to Medicare, and regulation. Local level barriers included comments about barriers that occur within the county. Provider level barriers included comments pertinent to delivery of care by providers. Patient level barriers included comments pertaining to barriers that exist on a patient level including support, planning, and personal resources. A state level category emerged from the data related to adult protective services. See tables (3-7) Table 3. Examples of comments related to national-level barriers Themes identified system, financial "gaps in coverage" "a serious gap in geriatric mental health services" "the creation of disease based care creates entrepreneurial health care" "the health care system is based on volume not quality and inspires competition between providers instead of collaboration to build the health of populations" "Regulatory requirements create relentless paperwork" "There is limited reimbursement for care coordination" "Prescription medications are costly" "limited coverage for dental health" IMPROVING CARE FOR OLDER ADULTS: ASSESSING THE NEED "Dementia is largely private pay" Table.4 Examples of comments related to state-level barriers Themes identified: Adult Protective Services "Adult Protective Services is lacking" "Adult Protective services make it difficult for advocacy on the patient's behalf" "nothing is ever done about concerns reported to APS" Table. 5 Examples of comments related to local-level barriers Themes Identified; resources, collaboration, access, rural health "lack of specialty service, especially mental health" "no geriatric mental health services" "no inpatient hospice facility, no palliative care" "allocation of county funding, leaves some having to raise money, cut services, wait lists" "gaps for telehealth" "dependence on out of state resources" "out of state transfers common," "need to travel" "impacts finances and support" "no heads up for services needing to facilitate care" "Coordination of care between agencies lacking" 16 IMPROVING CARE FOR OLDER ADULTS: ASSESSING THE NEED Table. 6 Examples of comments related to provider-level barriers; Themes Identified; collaboration, retention, access to case management "Competition with other providers" "Retention in area" "Attracting providers" "Lack of specialists" "Availability on call, outside regular hours" "Lack of access to case management" "Provider to provider report lacking" "Out of state providers" "Practicing fear based medicine, defensive medicine, inappropriate referral" Table. 7 Examples of comments related to patient-level barriers; Themes Identified; safety, support, financial "ability to afford treatments and additional services" "caregiver burden" "caregiver often ill themselves" "HIPPA prevents neighbors from advocating" "lack of accurate historian" "neglect" "abuse" "hording" "poor family dynamics" "unsafe living conditions" "self-care deficit" 17 IMPROVING CARE FOR OLDER ADULTS: ASSESSING THE NEED 18 Main facilitators Facilitators were organized into local, provider, and patient level. Local level themes included; collaboration and personal relationships, provider-level; community investment, primary care practice umbrella, offering care for Medicare and Medicaid, and retention. Patientlevel facilitators included; transport services, local resources, financial ability, family support, and advanced care planning. Interestingly the main facilitators identified from the comments were the opposite of barriers to care showing that local collaboration when it exists is an asset to the community. In addition, personal relationships strengthened community bonds. The community is connected and individuals are dependent on one other. On the provider level: physician retention has improved, with more physicians offering services for Medicare and Medicaid recipients. The primary care office addition to the hospital (PCP umbrella) has been an asset and has improved collaboration and communication on community levels. Furthermore, many providers see patients outside the hospital in more rural areas of the county, and see more nursing home patients than in the past. The medical directors for both skilled nursing facilities are employed by the local hospital. Retention and investment in the community have improved somewhat as many physicians have renewed contracts to provide services in the area. On the patient level, family support, social support, utilization of local services, financial ability, advanced care planning, and access to transportation facilitate better care of individuals. These factors impact the ability of patients to comply, and undoubtedly facilitate transitions of care between organizations and professionals. Transitions of care IMPROVING CARE FOR OLDER ADULTS: ASSESSING THE NEED 19 Communication, collaboration, resources, and transportation were the themes that emerged from the analysis of comments related to transitions of care. There were several references to collaboration and communication from the hospital to additional healthcare organizations mostly related to paperwork and the lack of familiarity with regulatory processes for other healthcare organizations. This included lack of timely comprehensive medical records and lack of medical documentation required for initiating or continuing services among healthcare agencies. One example of this was a lack of medication reconciliation and re-initiation of pre hospital treatments at discharge. Skilled nursing facilities often prescribe nutrition supplements, and specific wound treatments that are discontinued in the hospital and not reinstated at discharge. Several representatives made comments related to a lack of comprehensive medical records from the hospital when a patient is discharged to their organization. Although records were transferred in a timely manner often, important paperwork was missing, including physician discharge summaries, and important lab and diagnostic data required for initiating or continuing services with the collaborating healthcare organization. There were also issues with the length of time required to discharge a patient to a facility, especially when an out of state pharmacy was involved for ordering medications or when local pharmacy hours were limited. Every interview representative expressed appreciation for the discharge planners (case managers), and transitional care nurse from the local hospital. Representatives from all organizations made references to ways adequate collaboration between partnerships with organizations improved transitions of care. Representatives expressed appreciation for public health, home health, hospice, case management, and respite services. They reported that when IMPROVING CARE FOR OLDER ADULTS: ASSESSING THE NEED 20 individuals were familiar with and competent at their job description it was an asset to the community. Changes to staff and services were reported as a barrier to care. Discussion Summary A major strength of this analysis was the in depth discussions of issues surrounding multiple health needs of patients. There were both broad and specific observations noted in the data collected, broad comments about the healthcare system and lack of reimbursement, to specific comments about intra-facility communication and collaboration. Key barriers included a lack of financial support for older adults, and lack of mental health services for the Medicare population. Many essential services are still lacking in the community including palliative care, and an inpatient hospice facility. The data from this assessment demonstrated that rural communities are connected to and reliant on one another for support. This data highlighted the importance of taking the time to assess staff burnout within organizations, and assess job satisfaction of the people involved on all levels of patient care. There is a definite need for improvement of transitions of care, and coordination of care for Medicare beneficiaries. Interpretation Comments about barriers of care outweighed comments about facilitators. When barriers exist they are difficult to eliminate. Barriers that occur on the national level impact all other levels of care. Gaps in mental health services also impact every level of care. Improvements need to be made on the national level to make a meaningful difference on a patient level. This finding is well validated by the existing literature regarding fragmented healthcare and disparities in health care. IMPROVING CARE FOR OLDER ADULTS: ASSESSING THE NEED 21 There were many comments about provider retention, lack of local specialists, and providers leaving the area after establishing a patient base. The lack of mental health specialists in the area was also discussed. There would be benefit to examining this issue in more depth to better comprehend factors that impact this. There were several comments related to patient resources. Financial support, advanced care planning, social support, and access to reliable transportation improve the patient experience. Lack of support and planning negatively impacts patient care. Limitations Emergency providers and hospitalists did not complete surveys. Assessing transitions of care from their perspective would have been valuable to assess intra-agency communication, collaboration, paper work, and regulations. In retrospect it would have been better to approach hospital administrators and examine the best way to group providers to introduce the project in person and request that they complete the survey. However, the schedules of hospital physicians and administrators posed a challenge. The design of the survey tool was valuable overall but it became clear that one of the questions was poorly worded and needed additional explanation. The question inquired about billing for chronic care, and assessed interest in providing services to do so in the future. Several providers checked the box that they were unsure. It would have been best to provide background information on what billing for chronic care means. Overall, the survey responses were valuable. The terminology managed care can be confusing as multiple words and phrases are used throughout the literature. The cover letter seemed to provide the necessary definitions, and for the most part it appeared the providers understood the purpose of the survey. IMPROVING CARE FOR OLDER ADULTS: ASSESSING THE NEED 22 This project was somewhat limited in regard to participation. Not all agencies participated in the interview process. It was difficult to make time to call back and follow up after a message was left within the time frame of this project. Two home health agencies and two assisted living centers did not participate in the interview process and their perspective would have been highly valuable. Patient support including; family, social, and financial factors were facilitators when in place and barriers when supports were lacking. The strengths of personal support structures were important factors determining the quality of care of individuals. This finding was well validated in the literature. It would be important to further assess if quality improvement measures and existing community allocation of public funds address this issue. The patient perspective was not included in this assessment and would have offered valuable information. It would have been interesting to examine patient perceptions of healthcare organizations, barriers to utilization, and facilitators of care. It was left out of this assessment because of time and access. It would have been difficult to gather an appropriate sample of the public for assessment. Examining input from nursing professionals would have been highly valuable, especially as nurses are integrated into every aspect of care on all levels of patient care. The reason nursing input was excluded from this assessment was to simplify the data. It would have been difficult to analyze that amount of data within the time constraints of this project. Although quality data were still collected, having the intimate knowledge of direct care staff cannot be underestimated. Conclusions This assessment validated the need for improvement of care coordination in Sweetwater County. The main conclusions were; that a more focused assessment would help to determine the IMPROVING CARE FOR OLDER ADULTS: ASSESSING THE NEED 23 most appropriate managed care model for the area, and more data would also provide additional insight into feasibility and sustainability. A model should be implemented along with area specific improvement initiatives to support the model. One model cannot be recommended over the other based on this assessment, however 3 models were examined, and compared. They were based on level of integration within the community low level with a Chronic Care Management Program, mid-level with Guided Care, and high level with the Patient Centered Medical Home. Coordination of care is dependent on many factors, and requires a unique synergy between all agencies involved. While models provide a framework they need to be adapted to work for each individual community. Acknowledgements I would like to acknowledge my husband Steven Kourbelas Thank you for continued support, and all of your assistance with editing, formatting, and graphics. I would like to acknowledge my project chair, Amanda Al-Khudairi for being patient and taking so much time to assist with the project. To my content expert Dr. Diane Kendall, APRN Thank you for the time you spent helping me with my project, and providing me the opportunity for observation of care coordination. Thank you to all of the people in the community for participating in my project. A special thank you to Memorial Hospital of Sweetwater County for being so welcoming and sharing such important information with me. IMPROVING CARE FOR OLDER ADULTS: ASSESSING THE NEED 24 References Agency for Healthcare Research and Quality. (2012). Coordinating care for adults with complex care needs in the patient-centered medical home: challenges and solutions. White Paper Retrieved from www.ahrq.gov Agency for Healthcare Research and Quality, U.S Department of Health and Human Services. (2012). Coordinating care for adults with complex care needs in the patient centered medical home: challenges and solutions. Retrieved from https://pcmh.ahrq.giv/page/coordinating-care-adults-complex-care-needs Ament, B. H., Wolfs, C. A., Kempen, G. I., Ambergen, T., Verhey, F. R., & Vugt, M. E. (2015). 8. British Medical Journal Center Research Notes, 8(217). http://dx.doi.org/10.1186/s13104-015 American Nurses Association. (2012). The value of nursing care coordination. Retrieved from http://www.nursingworld.org/carecoordinationwhitepaper Barrett, E., Salem, L., Wilson, S., O'Neil, C., Davis, K., & Bagnulo, S. (2015, July 20). Chronic kidney disease in an Aboriginal population; A nurse practitioner led approach to management. The Australian Journal of Rural Health, 23, 318-321. http://dx.doi.org/10.1111/ajr.12230 Berry D. (personal communication Feb 2018) Bleijenberg, N., Ten Dam, V. H., Drubbel, I., Numans, M. E., Wit, N. J., & Schuurmans, M. J. (2016). Treatment fidelity of an evidence-based nurse-led intervention in a proactive primary care program for older people. Worldviews on Evidence Based Nursing, 13(1), 75-84. http://dx.doi.org/10.1111/wvn.12151 Boult, C. (Personal communication, May, 2017) IMPROVING CARE FOR OLDER ADULTS: ASSESSING THE NEED 25 Boult, C., Giddens, J., Frey, K., Reider, L., & Novak, T. (2009). Guided care a new nursephysician partnership in chronic care. New York: Springer Publishing Company. Boult, C., Karm, L., & Groves, C. (2008). Improving chronic care: the guided care model. The Permanente Journal, 12. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3042340/ Boult, C., Reider, L., Leff, B., Frick, K. D., Boyd, C. M., Wolff, J. L., ... Scharfstein, D. O. (2011). The effect of guided care teams on the use of health services: Results from a cluster randomized controlled trial. Archives of Internal Medicine, 171, 460-466. Retrieved from www.archinternmed.com Boult, C., Leff, B., Boyd, C. M., Wolff, J. L., Marsteller, J. A., Frick, K. D., ... Scharfstein, D. O. (2013, January 10). A matched-pair cluster-randomized trial guided care for high-risk older adults. Journal of General Internal Medicine, 5, 612-621. http://dx.doi.org/10.1007/s11606-012-2287-y Commission for Case Manager Certification. (2011). Care coordination: Case managers connect the dots in new delivery models: Issue brief. Retrieved May 24, 2017, from https://ccmcertification.org/sites/default/files/downloads/2011/4.%20Care%20coordinatio n%2C%20case%20managers%20connect%20the%20dots%20%20volume%201%2C%20issue%202.pdf Coordinating care for adults with complex care needs in the patient-centered medical home: Challenges and solutions. (2012). Retrieved from www.ahrq.gov Counsell, S. R., Callahan, C. M., Clark, D. O., Tu, W., Buttar, A. B., Stump, T. E., & Ricketts, G. D. (2007, December 12). Geriatric care management for low income seniors a IMPROVING CARE FOR OLDER ADULTS: ASSESSING THE NEED 26 randomized controlled trial. American Medical Association. Reprinted JAMA, 298, 26232633. Retrieved from www.jama.com Davis, K., Buttorff, C., Leff, B., Samus, Q. M., Szanton, S., Wolff, J. L., & Bandeali, F. (2015). Innovative care models for high cost Medicare beneficiaries: delivery system and payment reform to accelerate adoption. The American Journal of Managed Care, 21, 349-356. Retrieved from www.ajmc.com Davis, M. M., & Schmitt, L. J. (n.d). The standards of practice for case management a foundation for care coordination across the entire care continuum. Case Management Society of America. Retrieved from www.csma.org Fernago A. (personal communication Jan 2018) Fiandt, K. (2006). The chronic care model: description and application for practice. Retrieved from http:www.medscape.com/viewarticle/549040 Franke, K (2018) December 13. 2017, January 10, 2018, March 14, 2018, April 11,2018. Sweetwater Care Transitions Coalition Meetings Gardner M. (personal communication (March 2018) Gatti R. (personal communication Jan 2018) Grant, R. W., Ashburner, J. M., Hong, C. C., Chang, Y., Barry, M. J., & Atlas, S. J. (2011). Defining patient complexity from the primary care physician's perspective. American College of Physicians, 155, 797-804. Retrieved from www.annals.org Healthcare and Human Services Resource Guide Memorial Hospital of Sweetwater County (n.d) Health care Resource Guide Hays, S. L., & McCarthy, D. (2016, Dec 7). Care management plus: strengthening primary care for patients with multiple chronic conditions. The Commonwealth Fund. Retrieved from IMPROVING CARE FOR OLDER ADULTS: ASSESSING THE NEED 27 http://www.commonwealthfund.org/publications/case-studies/2016/dec/caremanagement-plus Hudon, C., Chauinard, M. C., Diadiou, F., Lambert, M., & Bouliane, D. (2015, November/December). Case management in primary care for frequent users of healthcare services with chronic diseases: a qualitative study of patient and family experience. Annals of Family Medicine 13, 523-528. http://dx.doi.org/10.1370/afm.1867 Institute of Medicine. (2001). Crossing the quality chasm: A new health system for the 21st Century. Retrieved from www.nap.edu/catalog/10027 Jenkens. R. (personal communication (December 2018) Johns Hopkins University. (2013). Guided Care: comprehensive primary care for complex patients. Retrieved from http:guidedcare.org/program-history-results.asp Kendall D. (personal communication Nov 2017) King N. (personal communication Jan 2018) Kodner, D. L. (2015). Managing high-risk patients; the mass general care management program. International Journal of Integrated Care. Retrieved from http://www.Ijic.org Lamb, G. (2014). Care coordination: the game changer how nursing is revolutionizing quality care. American Nurses Association: Author. Lee, V. S., Kensaku, K., Hess, R., Park, C., Young, J., Hunter, C., ... Pendleton, R. C. (2016). Implementation of a value-driven outcomes program to identify high variability in clinical costs and outcomes and association with reduced cost and improved quality. Journal of American Medical Association 316, 1061-1072. http://dx.doi.org/10.1001/jama.2016.12226 IMPROVING CARE FOR OLDER ADULTS: ASSESSING THE NEED 28 Loeb, D. F., Bayliss, E. A., Candrian, C., DeGruy, F. V., & Binswanger, I. A. (2016). Primary care providers' experiences caring for complex patients in primary care: a qualitative study British Medical Center Family Practice, 17(34), 1-9. http://dx.doi.org/10.1186/s12875-016-0433-z Loeb, D. F., Binswanger, I. A., Candrian, C., & Bayliss, E. A. (2015, September/ October). Primary care physician insights into a typology of the complex patient in primary care. Annals Of Family Medicine, 13, 451-455. http://dx.doi.org/10.1370/afm.1840 Lopez, R. P., Mitchell, S. L., & Givens, J. L. (2017). Preventing burdensome transitions of nursing home residents with advanced dementia: its more than advance directives. Journal of Palliative Medicine. http://dx.doi.org/10.1089/jpm.2017.0050 Mandros, N. (personal communication, December 2018) Marse, S. (personal communication, Jan 2018) Mathematica Policy Research. (2011). Fourth report to congress on the evaluation of Medicare coordinated care demonstration. Retrieved from www.mathematica Mitchell, G. K., Senior, H. E., Bibo, M. P., Makoni, B., Young, S. N., Rosenberg, J. P., & Yates, P. (2016). Evaluation of a pilot nurse practitioner led, GP supported rural palliative care provision. British Medical Center Palliative Care, 15. http://dx.doi.org/10.1186/s12904016-0163-y Mollica, R. L., & Gilespie, J. (2003). Care coordination for people with chronic conditions. Retrieved from www.partnershipforsolutions.org Oh, K. M., & Warnes, A. M. (n.d). A nurse-led rapid response service for frail older people: an assessment. British Journal of Community Nursing, 15. Retrieved from www.magonlinelibrary.com IMPROVING CARE FOR OLDER ADULTS: ASSESSING THE NEED 29 Percy, K. W. (n.d). Analysis of semi-structured interview data. Department of Family, Consumer and Human Development. Retrieved from https://www.scribd.com/document/249952429/Piercy-Analysis-of-Semi-structuredInterview-Data Pham, H. H., O Malley, A. S., Bach, P. B., Saiontz-Martinez, C., & Schrag, D. (2009). Primary care physicians' links to other physicians through Medicare patients: The scope of care coordination. Annals of Internal Medicine, 150(4). Retrieved from www.annals.org Rich, E. C., Lipson, D., Libersky, J., Peikes, D. N., & Parchman, M. L. (2012). Organizing care for complex patients in the patient centered medical home. Annals of Family Medicine, 10, 60-62. http://dx.doi.org/10.1370/afm/1351 Rose, S. M., Hatzenbuehler, S., Gilbert, E., Bouchard, M. P., & McGill, D. (2016). A population health approach to clinical social work with complex patients in primary care. National Association of Social Workers. http://dx.doi.org/10.1093/hsw/hlw013 Rust. R (personal communication (March 2018) Samus, Q. M., Johnston, D., Black, B. S., Hess, E., Lyman, C., Vavilikolanu, A., ... Lyketsos, C. G. (2014). A multidimensional home based care coordination intervention for elders with memory disorders: The Maximizing independence at home (MIND) pilot randomized trial. American Association for Geriatric Psychiatry, 22(4). http://dx.doi.org/10.1016/j.jagp.2013.12.175 Segelman, M., Cai, X., Reenen, C. V., & Temkin-Greener, H. (2017). Transitioning from community based to institutional long term care: comparing 1915 waiver and PACE enrollees. The Gerontologist, 57(2), 300-308. http://dx.doi.org/10.1093/geront/gnv106 IMPROVING CARE FOR OLDER ADULTS: ASSESSING THE NEED 30 Shuler, P. A., Huebscher, R., & Hallock, J. (2001). Providing holistic health care for the elderly: utilization of the Shuler nurse practitioner practice model. Journal of the American Academy of Nurse Practitioners: 13(7), 298-302. Retrieved from https://www.ncbi.nlm.nih.gov/pubmed/11930602 Suijker, J. J., Buurman, B. M., Riet, G. T., Rijn, M. V., De Haan, R. J., De Rooij, S. E., & Moll van Charante, E. P. (2012). Comprehensive geriatric assessment multifactorial interventions and nurse-led care coordination to prevent functional decline in communitydwelling older persons; protocol of a cluster randomized trial. British Medical Journal Health Services Research, 12(85). Retrieved from http://www.biomedcentral.com/14726963/12/85 Taylor J. (personal communication Jan 2018) The American Geriatrics Society Expert Panel on Person-Centered Care. (2016). Person-centered care: a definition and essential elements. Journal of the American Geriatrics Society. http://dx.doi.org/10.111/jgs.13866 Trehearne, B., Fishman, P., & LIN, E. H. (2014). Role of the nurse in chronic illness management: making the medical home model more effective. Medscape: Nursing Economics 32, 178-184. Retrieved from http://www.medscape.com/viewarticle/831596 United States Census Bureau (2017). U.S. Census Bureau (2011). Aging Geographic characteristics, American Community Survey 5-year estimates. Retrieved from http://factfinder2.census.gov/faces/tableservices/jsf/pages/productview.xhtml?pid=ACS_ 11_5YR_DP04. Wagner, E. H. (1998). Chronic disease management: What will it take to improve care for chronic illness? Effective Clinical Practice, 1, 2-4. http://dx.doi.org/Retrieved from IMPROVING CARE FOR OLDER ADULTS: ASSESSING THE NEED 31 Ward, M. C., Miller, B. F., Marconi, V. C., Kaslow, N. J., & Farber, E. W. (2015). The role of behavioral health in optimizing care for complex patients in the primary care setting. Society of General Internal Medicine. 31(3), 265-267. Watts, S. A., Gee, J., O'Day, M. E., Schaub, K., Lawrence, R., Aron, D., & Kirsh, S. (2009). Nurse practitioner-led multidisciplinary teams to improve chronic illness care: the unique strengths of nurse practitioners applied to shared medical appointments/ group visits. American Academy of Nurse Practioners.167-172. http://dx.doi.org/10.1111/17457599.2008.00379.x IMPROVING CARE FOR OLDER ADULTS: ASSESSING THE NEED APPENDIX A: COMMUNITY NEEDS ASSESSMENT Community Needs Assessment Assessment of Community Resources for Medicare Beneficiaries in Sweetwater County, Wyoming Spring 2018 32 IMPROVING CARE FOR OLDER ADULTS: ASSESSING THE NEED 33 Executive Summary This is the final summary for a Doctorate of Nursing Practice (DNP) project aimed at improving care for older adults with complex needs. The purpose of this project was to assess the need for a managed care model in Sweetwater County, WY to identify the most appropriate managed care model for the area, and to propose a model for implementation. This project entailed assessing existing support structures (facilitators) for caring for older adults with complex needs, and gaps that exist (barriers) through a semi structured survey process, and interviews with representatives from healthcare organizations within the County. Based on assessment findings, a list of recommendations was developed to address local needs for the county. A snapshot of three evidenced-based managed care models was provided for consideration. • It is recommended that Memorial Hospital of Sweetwater County (MHSC) embark on an improvement initiative to better care for older adults through the implementation of a managed care model after a more focused assessment of the patient demographic takes place to differentiate the most appropriate model in regard to feasibility and sustainability. MHSC should also work with healthcare organizations in the community for the continued evaluation of the managed care intervention. Periodic review of the literature should also be conducted to identify best practices as they become available. • Healthcare organizations in the county should work to improve intra-agency collaboration and communication through policy and education. Background Sweetwater County faces many challenges related to caring for older adults with complex needs. Although several specialist physicians provide care in the area, and several travel to the area to offer services many patients are still required to travel for care and follow up. Additionally, Sweetwater County struggles with the recruitment and retention of providers for every type of setting including primary care. It is not uncommon for healthcare providers to move into the area, establish a patient base, and then leave the area shortly after. Sweetwater County also struggles to maintain the consistency of healthcare resources and programs. There are ongoing efforts by the local hospital to reduce unnecessary hospital IMPROVING CARE FOR OLDER ADULTS: ASSESSING THE NEED 34 admissions and address transitions of care in the area. For example, the local hospital hosts a Sweetwater Care Transitions Coalition meeting to engage community professionals and encourage cooperation among community agencies. A transitional care nurse position was implemented to follow patients post hospital discharge. This program has been well received, but it will take time to be successful. There is an ongoing need for thorough assessment and evaluation of community resources in the county to improve care for older adults with complex medical needs. Managed Care Models Individual patients with complex healthcare needs, chronic illnesses, and inadequate support structures often have high rates of healthcare utilization. New penalties exist for hospital readmissions. As a result, several approaches have been developed to improve care of these individuals while reducing costs associated with their care. Among these approaches managed care models, referred to as complex care, coordinated care, and chronic care management programs have been developed. There are numerous managed care models, the most well known of which is the Patient Centered Medical Home. As these models have moved past implementation phases it is now possible to derive best practices from the available literature, and adapt interventions to address needs unique to an area. The first step in improving coordination of care for older adults with complex needs in a rural setting is assessing the issues unique to the area. Although, evidenced based models for managed care provide assistance through frameworks, the adaption of managed care models requires planning, commitment and teamwork. According to the Agency for Healthcare Research and Quality (AHRQ) (2016) for longterm success and impact, practices must; a) improve outcomes for patients with major chronic illnesses, b) reduce costs through fewer emergency room visits and hospitalizations (especially re-admissions and admissions for ambulatory-sensitive conditions, and c) improve both patient and provider experiences (AHRQ, 2016). IMPROVING CARE FOR OLDER ADULTS: ASSESSING THE NEED 35 Project and Aims A quality improvement initiative was undertaken to address care needs for older adults in Sweetwater County through a multi-step process; a) a community needs assessment to gain a better understanding of barriers and existing supports (facilitators) related to caring for older adults with complex medical needs, b) the development of a list of county specific recommendations, c) the proposal of a managed care model for Sweetwater County based on findings obtained through the community needs assessment d) to share the data with relevant stakeholders for review and consideration. Summary of Services for Medicare Beneficiaries. Sweetwater County is the largest county in the southwestern corner of the State of Wyoming. It spans 10.427 square miles. The county includes the towns of Wamsutter, Rock Springs, Green River, Eden, and Farson. According to the United States Census Bureau the population of Sweetwater County Wyoming in July 2017 was 45,534 people. In 2016 10.5% of the population was aged 65 or older (US Census Bureau, 2018). Rock Springs is considered the hub of health care for the county. The majority of healthcare services are accessed in Rock Springs, and neighboring Green River. Memorial Hospital of Sweetwater County (MHSC) MHSC is a nonprofit, 99-bed, regional acute care facility offering 24 hours in patient services and limited outpatient services. The hospital has a medical office, regional cancer center, and separate family practice and occupational medicine office building. Services include; intensive care, emergency, medical/ surgical, surgery, same day surgery, dialysis unit, full service lab, sleep disorder lab, rehabilitation unit, medical imaging center, cardiac and pulmonary rehabilitation services, discharge planning, transitional care, dialysis, 24 hours laboratory services, medical imaging, physical, occupational, and speech therapy, social services, surgical services, surgical services select chemotherapy, and radiation services. Physician services include; pediatrics, OB/GYN, general surgery, orthopedics, otolaryngology, nephrology, urology, medical oncology, hematology, radiation oncology, pulmonology, family practice and occupational medicine. MHSC has a partnership with the University of Utah to improve access to specialty care. MHSC also has a partnership with Wamsutter health clinic to expand primary IMPROVING CARE FOR OLDER ADULTS: ASSESSING THE NEED 36 care services to distant areas within the county. Limited primary, urgent and occupational health care is offered in Wamsutter (MHSC Resource Guide, 2017). Castle Rock Medical Center (Green River) Castle Rock part of a hospital district governed by an elected Board of Trustees offers ambulance services, laboratory services, radiology services, occupational health, pediatrics, and family medicine (MHSC Resource Guide, 2017). Primary Care Providers Primary care providers include Donaldson Medical Center, Hunter Family Medical Clinic, and family practice clinics including those run by Lori Heitz, APRN, Melinda Poyer, D.O, and Jean Stachon M.D (MHSC Resource Guide, 2017). Sweetwater Medics Sweetwater Medics is a full-spectrum ambulance service, specializing in emergency response, local and long distance medical transportation, event standbys and flight team/patient transportation for air ambulance (MHSC Resource Guide, 2017). Big Sandy Medical Clinic Big Sandy medical clinic is a telehealth clinic staffed 2 days per week by emergency medical technicians who teleconference with select providers throughout the region. A chiropractor is on site 1 day per week, and an M.D/D.O. 1 day per month. Physical therapy services are offered on a limited basis. The clinic is funded by community donations and occasional federal grants. (MHSC Resource Guide, 2017). Eden Valley Ambulance Eden Valley Ambulance is a volunteer ambulance in Sweetwater County funded by a tax mil levy. It operates as an addition to the fire district. The area spans 1440 square miles of mostly farmland and desert. It includes oil and natural gas leases. Patients must be transported to hospitals in Rock Springs (40 miles away) or Lander (80) miles away. The minimal staff and volunteer service is able to provide coverage 24 hours a day, however on rare occasion support from neighboring ambulance services is required (Gardner, M, 2018). IMPROVING CARE FOR OLDER ADULTS: ASSESSING THE NEED 37 Air ambulances/ Life Flight AAA advanced air ambulance, Air Med- University of Utah, Angel Flight West, Intermountain Life flight, Wyoming Life flight. Provides emergent life flight services (MHSC Resource Guide, 2017). Mountain Pacific Quality Health This organization focuses on quality improvement initiatives and partners with providers, practitioners, patients and other quality health advocates to share knowledge tools and best practices to improve the patient experience. This organization partners with MHSC and hosts Sweetwater Care Transitions Coalition Meetings (Franke, K, 2018). Sage View Care Center - EmpRes Healthcare Management This center offers skilled nursing services offered for post-acute care, long-term care, rehabilitation therapy, memory support, respite stays, hospice services, and supplementary care options (MHSC Resource Guide, 2017). Hospice of Sweetwater County This service provides hospice, and bereavement services for terminally ill patients and their families including high-quality individualized care to patients at the end of life. Support and services are extended from admission through bereavement. Hospice has integrated specialized programs for end-stage heart disease and end stage lung disease for qualifying patients. Patients have the option to continue to participate in pulmonary and cardiac rehabilitation services at Memorial Hospital of Sweetwater County (MHSC Resource Guide, 2017). Best Home Health and Hospice This service provides in-home, skilled nursing services as well as physical therapy, occupational therapy, speech therapy, home delivered meals, transportation services, a waiver program, social work, and on-call services (MHSC Resource Guide, 2017). Cowboy Cares IMPROVING CARE FOR OLDER ADULTS: ASSESSING THE NEED 38 This service is a home health and community resource agency that offers skilled nursing, certified nurse assistant services, physical, occupational and speech therapy, social work, and a resource specialist (MHSC Resource Guide, 2017). Rocky Mountain Home Health Services This service provides skilled nursing services, home health aids, and therapy services. Rocky Mountain Home Health services recently integrated a program specific to chronic obstructive pulmonary disease and congestive heart failure management (MHSC Resource Guide, 2017). Deer Trail Assisted Living This service provides assisted living, memory care, dining services, limited nursing services, assistance with activities of daily living, and activity services (MHSC Resource Guide, 2017). Young At Heart Senior Center This service provides skilled nursing services in home to a limited extent, home health aid, therapy services, meal services, social activities, immunizations, and health maintenance through a variety of programs (MHSC Resource Guide, 2017). Mission At Castle Rock Skilled Nursing Facility This facility provides 24 hour licensed nursing services for temporary and extended care, dental care, therapy services, and social and podiatry services (MHSC Resource Guide, 2017). Mission at Castle Rock- Villa- Assisted Living Center This service includes assisted living with dining services, housekeeping, laundry and activities (MHSC Resource Guide, 2017). Golden Hour Senior Center This center offers services including recreation, congregate meals, home delivered meals, adult home care, information and referral, legal aid, transportation, assistance in completing Medicare forms, outreach, visiting and notary services (MHSC Resource Guide, 2017). VIRS (Volunteer Information Referral System) IMPROVING CARE FOR OLDER ADULTS: ASSESSING THE NEED VIRS offers in home personal care for disabled or ill individuals and assists with the clients' daily activities. VIRS provides relief time for caregivers and collaborates with other service agencies to fulfill individual needs (MHSC Resource Guide, 2017). 39 IMPROVING CARE FOR OLDER ADULTS: ASSESSING THE NEED 40 Methodology Quantitative and qualitative data were collected through inquiry and investigation, attendance at Sweetwater Care Transitions Coalition Meetings, semi structured survey responses, and open- ended interviews. Descriptive results were displayed after surveys were compiled in Microsoft Excel and formatted into bar graphs (Appendix B) Open-ended interview data were organized into common themes utilizing an adapted version of content analysis without the use of a software-coding program (Appendix C). Process A semi structured survey tool was developed, and a packet was created that included a cover letter with a link to the electronic version, a hard copy of the survey, and a self addressed envelop with paid postage. The packet was hand delivered to providers' offices and left with front office staff. Survey packets were left in the doctors' communication box for emergency room providers, and inpatient hospital providers. A 12-question interview tool was designed to gather information about healthcare services and barriers to and facilitators of care in the area. Healthcare organizations were requested by phone to participate in the interview process either over the phone or in person. Interviews were timed and handwritten notes were taken throughout the interview process. The tool was adapted as needed for each agency, as not all questions were relevant for every organization. Following the interview, the notes from the interview were typed up and comments were compiled to identify themes or patterns. Comments from the interviews were organized into three groups; a) barriers, b) facilitators, and c) transitions of care. Barriers included comments related to factors that prevent quality care for older adults with complex medical needs. Facilitators included comments about factors that improve care. Transitions of care included comments specific to patients transitioning between organizations. Comments were then grouped according to national, state, local, provider and patient levels. Comments about the healthcare system, specific to Medicare were included in national barriers. Comments about Adult Protective Services were included in state- level barriers. Comments that were related to the local issues were included in the area for local level. The IMPROVING CARE FOR OLDER ADULTS: ASSESSING THE NEED 41 provider level included comments related to relationships with providers or access to providers. For the category of facilitators: local, provider, and patient-level comments were identified. Comments about transitions of care all occurred on the local level. Results: Data from Surveys: Nineteen total healthcare providers completed a five-question healthcare provider survey. Thirty- seven total survey packets were delivered with eighteen hard copies and one electronic version returned. The majority of responses were from primary care providers, two internal medicine physicians, five primary care physicians, two nurse practitioners, five physician assistants, and five specialty providers including, one urologist, one pulmonologist, one general surgeon, one ear nose throat specialist, one registered nurse director of dialysis. Question #1: What potential barriers do you see caring for patients with multiple chronic illnesses in your setting? (Check all that apply) • 17/19 healthcare providers selected inadequate financial support as a potential barrier to caring for older adults with multiple medical conditions • 13/19 identified lack of patient engagement and self management skills • 13/19 selected inadequate social support and communication between healthcare professionals involved in the patient's care. Question #2: What community resources do you frequently recommend/ utilize/ refer? • 16/19 providers selected home health services as the most common community resources utilized • 13/19 selected physical therapy services • 13/19 selected assisted living centers, • 13/19 selected skilled nursing facilities Question #3: What aspects of caring for older adults with chronic illness would you like to see improve? • 14/19 providers identified transitions of care as the aspect of caring for older adults with chronic illness they would like to see improve. IMPROVING CARE FOR OLDER ADULTS: ASSESSING THE NEED 42 Question #4: Do you currently bill for chronic care services? Are you interested in providing the services required to do so? • 9/19 providers selected that they were unsure if they billed for chronic care services or interested in providing the services required to do so Question #5: If you had the following resources would you utilize them? Why or Why not • 11/19 providers reported that they would utilize palliative care services, and education sessions for patients and families if available. Several providers filled out the section for additional comments. Comments from the survey are included in Appendix B. Data from Interviews Twelve interviews were conducted, 7 in person and 5 via telephone. The following healthcare professionals participated in the interview process; • • • • • • • • • • Sweetwater Medics LLC- ambulance director, and managing member Castle Rock Ambulance- ambulance director Memorial Hospital of Sweetwater County- discharge planner Mansface Terrace Senior Living- business manager Young at heart Senior Center- director Rocky Mountain Home Health Care: administrator and social worker Volunteer Information Referral System (VIRS)- registered nurse Mission at Castle Rock- Skilled Nursing Services: director of nursing Sage View Care Center: executive director Hospice of Sweetwater County: Director The analytic approach utilized was adapted from Percy (n.d) for performing a content analysis for semi structured interview data. This analysis was not conducted with use of a software program, as the data was fairly simple to group manually. IMPROVING CARE FOR OLDER ADULTS: ASSESSING THE NEED 43 Results Interview data Barriers to Care Many comments about barriers to care were related to transitions of care, including issues related to communication, collaboration, resources, and transportation. Several representatives made comments related to a lack of comprehensive medical paperwork after hospitalization and emergency room visits. They reported that records are typically transferred in a timely manner after agency request, but important paper work is often missing including physician discharge summaries, and diagnostic and laboratory medical records required for continuing services. Representatives from skilled nursing facilities reported that on occasion when patients are sent to the emergency room with a specific complaint, other issues were addressed instead of the chief compliant. They also reported that patients are discharged to skilled nursing facilities without medication reconciliation and comparison of pre hospital medications and treatments. In addition, nutrition supplements are often prescribed in nursing homes, and then discontinued in hospital and not reinstated in that transition of care, which is also the case with prescribed wound treatments. Representatives also reported issues with the length of time it takes to discharge patients from the hospital medications are often delayed when an out of state pharmacy is involved for ordering medications, and the pharmacy in the area has limited hours. The reported barriers that occurred on the national level were related to the national healthcare system, and financial reimbursement. National level barriers impact every other level of care, state, local, provider and patient level. Examples of comments included gaps in coverage, the cost of prescription medications, gaps in mental health services for older adults, paperwork, lack of reimbursement for care coordination and follow up, Medicare's regulatory process to order durable medical equipment, national regulatory requirements for skilled nursing facilities and difficulty with transitions of care based on Medicare and Medicaid regulations. Ambulance personnel commented about the lack of educational training related to providing care for individuals with chronic illness as opposed to acute conditions, although most of the call volume is related to chronic health issues. There were additional comments about a lack of dental health coverage, and that care for dementia patients is largely private pay. The healthcare system and financial reimbursement model encourages competition among providers instead of focusing IMPROVING CARE FOR OLDER ADULTS: ASSESSING THE NEED 44 on teamwork to address the health of populations. These problems are evident in the majority of the literature related to care coordination and care management. These barriers are difficult to overcome, and state and local resources are burdened with bridging those gaps in care. On a local level, comments were divided into four main themes; resources, collaboration, access, and rural health. Intra-agency collaboration and communication were the most common themes. The majority of comments were related to transitions of care. Additional comments were related to the fluctuation in resources, one example of which is that the allocation of county funding leaves some services forced to raise money or seek alternative means or revenue. This creates gaps in supportive services, and waitlists. Sweetwater County lacks physician specialists in the area, which seemed to be improving with the ongoing efforts of Memorial Hospital of Sweetwater County to expand services. Services lacking in the area included: inpatient hospice services, and inpatient palliative care. Cost, geographic distance from care, and healthcare resources are particularly burdensome for distant areas within the county such as Eden valley, Farsen area, and Wamsutter. On a provider level, retention of providers in the area is an ongoing issue. There is a lack of clear understanding about what attracts providers to the area, and about why providers do not choose to stay in the area. In addition, there were comments regarding collaboration with healthcare agencies. Examples include, lack of access to healthcare providers to communicate information about patients, lack of on call coverage for clinics. Lack of access impacts areas unequally. Distant frontier areas of the county such as Farson, Eden Valley, and Wamsutter lack consistent primary care services. On a patient level the most common theme that impacted care was social support for the patient. Financial barriers exist in regard to affording medications, and following up with additional therapies. Transportation was a huge barrier, especially when the patients are unable to transport themselves or are required to travel with equipment such as oxygen equipment, wheelchairs, or other assistive devices. Safety was a factor that was especially evident from organizations most familiar with the issues. It is not uncommon for healthcare providers such as home health and ambulance personnel to encounter safety concerns in the home, such as unsanitary conditions, hoarding behaviors, domestic abuse, and drug and alcohol abuse. IMPROVING CARE FOR OLDER ADULTS: ASSESSING THE NEED 45 There were several comments about a state level barrier, that Adult Protective Services was lacking, there is not always resolution and proper follow up when cases are reported to the State. This concern was mentioned by several agencies, and comments were made in the physician surveys as well. Facilitators On a local level, representatives made several comments about personal relationships with agencies, in that people go above and beyond their job descriptions to assist in patient care. Case management (discharge planners) at the hospital were mentioned by every representative for being accessible and very helpful when providing care for individuals. Familiarity of job descriptions was cited as an asset to the community. Representatives also expressed appreciation for agencies that had a high rate of staff retention. On the provider level, representatives reported that physician retention has improved, as has the number of physicians offering services for Medicare and Medicaid beneficiaries. Several representatives commented that the primary care office addition to the hospital has been an asset to the community. They reported that providers from the hospital have been very helpful in staffing clinics outside Rock Springs to provide services to people in more distant areas of the county. Representatives from the nursing homes reported high satisfaction rates with the providers who make rounds in their facilities. The medical directors from both skilled nursing services are employed by the local hospital. On the patient level, several representatives reported that family support, social support, advanced care planning, and access to reliable transportation helped to facilitate care. Patients who had reliable and dependable family members to help coordinate healthcare services, communicate with healthcare professionals, and assist with transportation were at an advantage. These factors impact patients' ability to comply with prescribed regimens and follow up, and undoubtedly facilitate transitions of care between organizations and professionals. IMPROVING CARE FOR OLDER ADULTS: ASSESSING THE NEED 46 Interpretation The comments about facilitators to care were often the opposite of barriers, showing that local collaboration is an asset to the community. Personal relationships in the community strengthened communication and collaboration within organizations. In rural areas personal relationships with providers and healthcare representatives is common. The community is reliant on one another for support. Barriers of care heavily outweighed facilitators. When barriers exist they are difficult to eliminate, in addition nationwide barriers to care impact all levels of care, which illustrates that improvements are needed on the national level to make a meaningful difference on the patient level. This finding is well validated in the literature and research regarding fragmented healthcare, and disparities in healthcare. Gaps in mental health services also permeate through every level of care. On a state level, improvements need to be made to protect older adults. Comments on a patient level were mostly related to support structures. It was clear that financial ability, advanced care planning, social support, and access to reliable transportation are facilitators to care. The lack of support and planning are barriers. Based on this analysis, community organizations would benefit from continued efforts to retain providers, and integrate them into the county. Developing policies to improve intra-agency communication and collaboration would also be beneficial. Further assessment could provide insight into the perspective of providers who did not participate in the survey including emergency department providers, and providers who work within the hospital. It is important to understand their perspective in regard to transitions of care, and paper work. Understanding the specifics of the workflow, and assessing these providers understanding of regulations related to other healthcare organizations would be helpful in determining if additional support and training are needed. For example, it is noted in the literature that emergency room providers, and inpatient physicians have an increased workload when patients and families have not considered advanced care planning. An assessment of whether these issues have an impact on patient care would be beneficial. Additionally, the hospital lacks inpatient palliative care services, and specific program interventions for delirium IMPROVING CARE FOR OLDER ADULTS: ASSESSING THE NEED 47 for older adults. It would be beneficial to determine if the hospital would benefit from the development of these programs. A goal of this assessment was to determine which one of the established evidencedbased managed care models would be the most appropriate for the area. Unfortunately, this assessment is limited, and one managed care model cannot be recommended over another. Although the information gathered in this assessment demonstrates a need for continued improvement, and can serve as pre intervention assessment data, a better understanding of the patient demographic, healthcare utilization and financial resources is required to determine the level of intervention needed. The key distinction is determining if care coordination versus case management is needed. The best way to do so is to take the time as an organization to understand the needs of the patients, and the resources available to determine which model will benefit the most patients or the most at-risk patients. All healthcare organizations, provider practices, and patients benefit from purposeful aims to improve care coordination. Larger healthcare systems that offer a variety of services have more of a need to manage care for patients. They also tend to have more resources for doing so. In Sweetwater County, a managed care model would be the most appropriate for Memorial Hospital of Sweetwater County, as it offers the most services to residents of the county. They would also benefit monetarily more so than other organizations as there is potential to decrease pricey re hospitalization penalties. Therefore, the recommendation based on the findings of this report is that a managed care model should be implemented at MHSC. Strengths of this analysis Health care representatives provided valuable input about barriers to and facilitators of care in the community. Personally interviewing representatives from organizations offered an open dialogue for them to speak candidly about experiences providing care in Sweetwater County. The physician surveys also offered valuable insight into the experiences of providers caring for older adults with complex needs. Additional comments were very insightful and therefore were simply listed rather than organized according to themes. All data were gathered with respect to the individual representative's time and schedule. IMPROVING CARE FOR OLDER ADULTS: ASSESSING THE NEED 48 This assessment helped demonstrate how connected the community is and how reliant upon one another for support. It highlights the importance of taking the time to assess burnout and job satisfaction of the people involved in all levels of patient care. The need for continued improvement of transitions of care, and coordination of care for Medicare beneficiaries did emerge, and was validated by this assessment. The assessment also offers valuable data for ways agencies can collaborate to improve care for individuals. Room for Improvement The question in the survey tool related to billing for chronic services was poorly worded. It was clear that this question needed additional explanation as most providers selected "unsure" as their response. This project was limited as not all agencies participated in the interview process. Input from two home health agencies, Best Home Health and Hospice and Cowboy Cares would have been very valuable. In addition, input from Deer Trail Assisted Living would have also been highly valuable for this assessment. In regard to methodology validated survey tools and interview tools would have been valuable. A gap exists in the literature pertaining to such tools. Additionally, this assessment is highly individualized to the area, and therefore more standard tools may not have been as beneficial. In regard to the content analysis there is potential for bias as the principal investigator also identified themes from the data. However, since this project is a needs assessment it was not necessary to go to such lengths to improve internal validity. The purpose of this assessment was to capture a dialogue among professionals to glean insight into the issues unique to the area. Emergency room providers and inpatient providers at the local hospital did not complete surveys. Their perspective would have also been highly valuable for this assessment. Assessing transitions of care from their perspective would offer insight into the workflow during hospitalization and the barriers and facilitators that they perceive. It is important to acknowledge additional ways to improve workflow, and support patients in the hospital. The patient's support system family, social and financial resources are the most common factors related to quality of life. They are also important factors for facilitating patient care. It is IMPROVING CARE FOR OLDER ADULTS: ASSESSING THE NEED 49 important to assess if existing quality improvement measures, and community allocation of public funds address this issue. Another important limitation to this assessment is the lack of patient input. The patient perspective would provide better understanding of the patient experience including their perceptions of healthcare organizations, barriers to utilization, and facilitators. This perspective was left out of the assessment due to the issue of access. It would have been difficult to gather an appropriate sample of the public for this portion of the assessment. This assessment lacks nursing input. Examining this perspective of care would have been valuable, especially as nurses are integrated into every aspect of care on all levels. The reason it was excluded from this assessment was to simplify the data. It would have been difficult to analyze that level of data within the time constraints of this project. The intimate knowledge of direct care staff cannot be underestimated. Key Findings • There is a need for improved intra-agency collaboration related to transitions of care, specifically, collaboration, communication, resources and transportation. • Further assessment is needed to identify the most appropriate managed care model for the area. Snapshots of three managed care models were offered for comparison and consideration. They are included in the appendix section of this document. • In addition, a summary of recommendations for the area was composed to assist in the development of improvement initiatives aimed at better managing care for patients with complex needs. Conclusions 1. The assessment data validated the need for improvement of care coordination in Sweetwater County and provided pre intervention information to assist with planning, development and evaluation for a managed care intervention 2. More assessment is needed to determine the feasibility and sustainability of a managed care model in the area. For example, significant issues exist related to care transitions and intra-agency communication and collaboration. Focused assessment of this issue would highlight key needs. Additionally, further evaluation of the patient population would IMPROVING CARE FOR OLDER ADULTS: ASSESSING THE NEED 50 show which model is more appropriate in regard to the level of intervention required. For example, determining the need for case management over care coordination based on risk stratification and patient records would identify and validate an intervention in more detail than this assessment. 3. A model should be implemented with area specific improvement initiatives to support the model. 4. Three models with various levels of integration and expenditure of resources are proposed. Snap shots of each model are reviewed in the appendix section. The next step would be determining if patients would benefit from case management, care coordination, or both. This step would help distinguish the level of intervention required. For this project 3 models are proposed. One is Chronic Care Management Program, the second is Guided Care, and the third is the Patient Centered Medical Home. • The Chronic Care Management Program, is most appropriate for mostly independent patients at risk for hospitalization. It is a telephone-based intervention focused on reducing health care costs, building a community network of support, encouraging wellness visits, discussing advanced planning, and helping to set patients up with community resources • The guided care model bridges between telephone based interventions, and patient centered medical home. There is room for variation in the delivery of the model. This model employs a nurse partner who goes into the patient's home and individualizes care plans with the patient. • For the patient centered medical home more intense intervention is required. This model is best for frail older adults who lack transportation and resources. IMPROVING CARE FOR OLDER ADULTS: ASSESSING THE NEED 51 APPENDIX B: Survey Data Date: Dear Health Care Professional, My name is ___________, and I live in___________. I am a DNP Student with the University of Utah in the Adult Gerontology primary care program. As a portion of my scholarly project, I am evaluating available community resources for older adults with complex medical needs (i.e.one or more factors impacting health such as multiple chronic illnesses, multiple providers involved in care, inadequate financial, psychological and/or social support). I would greatly appreciate your perspective caring for these patients. Attached is a survey tool to complete and place in the self-addressed envelope. I realize that you are busy and I designed this to tool to be very brief to accommodate your schedule. If you are interested in sharing more information, feel free to write additional comments throughout the form. If you have questions regarding the tool please feel free to contact me. The information is provided below. Respectfully, Name and Title Xxxxxx Rock Springs WY 82901 Email: xxxxx Email: xxxxx Phone and text: xxxx PLEASE NOTE: IF YOU PREFER TO FILL THE SURVEY OUT ELECTRONICALLY: The Survey can be completed electronically by entering the following address into any web browser; insert electronic link IMPROVING CARE FOR OLDER ADULTS: ASSESSING THE NEED 52 IMPROVING CARE FOR OLDER ADULTS: ASSESSING THE NEED 53 IMPROVING CARE FOR OLDER ADULTS: ASSESSING THE NEED Question 1 Results: Question 2 Results: 54 IMPROVING CARE FOR OLDER ADULTS: ASSESSING THE NEED Question 3 Results: Question 4 Results: Question 5 Results: 55 IMPROVING CARE FOR OLDER ADULTS: ASSESSING THE NEED 56 Additional Comments: • • • • • • • • • • • • • • • • • • • • "Limited choice of medication as cost is a factor" "Barriers to follow up- lack of support, transportation, when basics aren't being followed through with properly impacts adding more such as physical therapy, counseling. " "Lack of communication with hospitalist and report, prefer report by phone, Computer EMR is challenging, paperwork," "Lack of reimbursement a lot of work, not appreciated by Medicare, a lot of time included" " it is my sincere belief that if people could be taught about aging in a way to prepare them many chronic illnesses would almost take care of themselves" Dialysis: many of our patients are currently over 75+, 85+ being started on dialysis, these patients have multiple comorbidities and their quality of life, and their families' quality of life are severely reduced because of this. More education, support and alternate means of care are necessary to decrease the number of elderly patients we see being misled by the implementation of hemodialysis. Love to offer education and in service to offer insight on recent pathways of CKD, and ESRD and how it affects our elderly population My biggest frustration is med reconciliation with older adults I would utilize these services but time and expense to the patient would be a factor 1st: they are broke, need financial help to get proper care / meds, 2nd social support from family and relatives, transportation needs for appointments, poor coordination of care. this should do to begin with…thank you. One of the limitations to providing rounded care is the lack of family support, I have several geriatric patients with dementia who miss appointments, don't take their meds as prescribed despite home health effort and family is unwilling to get involved to help out, have had to call APS with cases getting closed with no resolution to the problem. Chronic care resources and education would benefit patients to help understand the importance of compliance and to understand medications and importance of lifestyle changes and regular follow up care/ testing Care management in primary care would help facilitate the care of the patient Home visit follow ups with provider is too time intensive Chronic care nurse resources would help ensure care and needs are being met Education sessions for patients and family would help coordinate care and educate family regarding patient's needs Cover sheets patient information sheet Information for patient that could help them facilitate care with other providers Goals with care meetings with patients: yes, to help motivate and encourage patient Advanced care planning and support: would help patient care and compliance Palliative care would help meet patient needs Patients a lot of time do not have very good resources or communities are resource poor especially with chronic care and psychiatric needs. I think improvement in this area would help all providers to better serve their patients. IMPROVING CARE FOR OLDER ADULTS: ASSESSING THE NEED 57 APPENDIX C: Interview Data Interview Guide Name of interviewee… position… date… time… length of interview (all that apply) Introduce self and project. 1) Please tell me about the services that your organization provides… Description of services, what information is pertinent for providers or people referring clients for services? 2) What is the process for referral or admission to your organization? 3) What facilitators are there for providing care? 4) What are common barriers? Financial? Cultural? Political? 5) What Community support and resources do you utilize? 6) What is the typical involvement from healthcare professionals, visits, communication? 7) What are issues that happen with complications/ referrals with specialists? 8) How is Staff/ Teamwork? 9) Is there access to case management? 10) Follow up calls/ In person Visits? 11) Discuss transfers to/from the hospital (e.g. new admissions, sending to ER). What is the process? Who is involved? 12) What approaches has the facility implemented to decrease challenges/improve transitions? 13) What factors influence the client returning to your organization after additional services are needed (such as a hospitalization, or discontinuation of services for a period of time) IMPROVING CARE FOR OLDER ADULTS: ASSESSING THE NEED 58 IMPROVING CARE FOR OLDER ADULTS: ASSESSING THE NEED 59 APPENDIX D: AREA SPECIFIC RECOMMENDATIONS Summary of Recommendations Identify outcomes to measure the effectiveness of a managed care intervention. As a community, define the main goals for intervention and develop measures for success; • • • • • To improve care coordination for all patients To decrease adverse drug events To improve patient compliance To develop streamlined system designs to improve patient care and decrease rates of preventable hospitalizations and readmissions To increase revenue (cost of implementation needs to be considered) Rationale: standardized outcomes are needed. Most interventions are implemented to prevent unnecessary hospitalizations and reduce re hospitalizations. Nearly all interventions are effective to some degree because any intervention aimed at improving care coordination is better than no intervention. However, there is need to identify outcomes to measure effectiveness of managed care interventions. Further assessment would help to determine the most feasible model in the area. Rationale: More intense interventions such as the patient medical home offers more services, and requires more expenditures than telephone based models. If the majority of patients referred for managed care have more complex needs, a more comprehensive managed model may be more appropriate. Determine the need for care coordination vs case management. Review relevant literature periodically for updates and shared data. Rationale: Best practices related to managed care are starting to be available in the literature. There are also a variety of helpful tools such as risk stratification tools, disease specific interventions, and high healthcare utilization algorithms. Determine if patients would benefit from in-home visits. Nurse? Provider? Both? Rationale: Determine what portion of patients have limited capacity to comply with in person office visits, such as limited mobility, limited transportation, limited support or cognitive impairment. Determine how many patients depend on others for transportation. This is a costly intervention and must make a significant difference in preventable hospitalizations and decrease readmissions to be feasible and justify the expenditure of resources. Investigate issues around physician retention. Develop an intervention to reliably assess patient satisfaction in the area, the reason for initial attraction in the area, and the reason for leaving when applicable. Rationale: Such an intervention would be valuable for future physician retention efforts. IMPROVING CARE FOR OLDER ADULTS: ASSESSING THE NEED 60 Investigate interagency issues with communication and collaboration among providers who did not participate in the survey process to identify if additional improvement measures such as inpatient palliative care would be beneficial. Rationale: This perspective is important for a clear understanding of issues pertaining to transitions of care. Determine contributing factors of issues related to transitions of care, specifically comprehensive medical records • • Assess provider perceptions of the problem Assess workflow to determine efficiency (example getting bogged down with crisis management) • Determine if comprehensive medical data from primary care are shared with providers in the hospital. Strive to improve advanced care planning and discussion throughout the community. Rationale: Hosting events and offering routine information outside of a crises situation is valuable for the public. Examples: The Hospice Foundation of America promotes a being mortal project aimed at increasing discussion about end of life. There are numerous interventions contained within the literature aimed at improving discussion about end-of-life care, including video interventions, and those specific to patients with dementia. Develop community level interventions aimed at improving health outcomes for the county population. Educate community members about available resources to improve familiarity and enhance self-care. Rationale: Streamlining regional improvement measures is highly beneficial for increasing awareness and improving outcomes for certain populations. Offering regional level interventions impacts a greater number of patients. IMPROVING CARE FOR OLDER ADULTS: ASSESSING THE NEED APPENDIX E: Snapshots of Managed Care Models OVERVIEW OF PATIENT CENTERED MEDICAL HOME 61 IMPROVING CARE FOR OLDER ADULTS: ASSESSING THE NEED OVERVIEW OF CHRONIC CARE MANAGEMENT PROGRAM 62 IMPROVING CARE FOR OLDER ADULTS: ASSESSING THE NEED OVERVIEW OF GUIDED CARE 63