Assisted Living Organizational Chart - PowerPoint

							       A New Medical Home:
An Interdisciplinary Team Approach
    in an Assisted Living Facility

Department of Family and Preventive Medicine
   University of Utah School of Medicine
            Salt Lake City, Utah
                        Faculty
   Susan Saffel-Shrier, MS, RD, Cert. Gerontologist
   Karen Gunning, Pharm D, BCPS, FCCP
   Wilhelm Lehmann, MD, MPH
   Jennifer Bell, MD
   Nadia Miniclier, MS, PA-C
              Objectives
 Describe an assisted living medical home
  as a geriatric educational model – Year 1
 Synthesize clinical education strengths &
  weakness
 Recognize learner attitudinal factors
 Analyze the viability of this model
 Demonstrate major components of a
  geriatric assessment
                 Why Assisted Living?
   Current RRC geriatric continuity requirement
       Long term care facility
         • Physical structure vs continuum of services
       Evolution of NH industry
   Broader clinical education opportunities
       Population heterogeneity
       Transitional care
       Community based services
       Comprehensive assessments

Submission: A Innovative Proposal for a RRC
  Variance from Nursing Home Care to Assisted
  Living Experience
The goal of this innovative proposal
  is to provide the family medicine
   resident with a comprehensive
understanding of the long term care
    needs and continuum of care
   options that are available to the
 older adult through a continuity of
 care educational experience in an
        assisted living facility.
  Geriatric Continuum of Long Term Care
   Home and Community Based Care                Nursing Facilities
         95% of population                      5% of population

       Home            Residential Facilities
                                                  Acute Care
       Family            Assisted Living I        Rehabilitation
      Friends            Assisted Living II       Eden Experience
Area Agency on Aging      Group Homes             Special Care Units
   Personal Care              Hospice             Hospice
    Home Health         Adult Foster Homes
   Adult Day Care         Dementia Units
      Hospice            Congregate-HUD



                             Hospital
Sarah Ann Daft
  1827-1904
      Sarah Daft Demographics
   Male – 2
   Female-20
   Age
      x 82 yrs

      Range: 51-97 yrs

   Medical Power of Attorney-3
   Supplemental insurance-9
   Home health care- 5
Sarah Daft Home Clinic Organizational Chart

 University of Utah Faculty
                                            Sarah Daft Home
 Director: Susan Saffel-Shrier
                                        Sarah Daft Board of Directors
 MD Attendings: Will Lehmann
                                         Director: Marsha Gibson
                Jenny Bell
                                              SDH Families
 PA Attending: Nadia Miniclier
                                         Health Care Consultants
  Pharmacy: Karen Gunning

                                           Service Coordinators



 Pharmacy Students        PA Students       FM Residents
Clinic Session
                               SDH Flowchart
                                Consultations
  Geriatric                    Team Members
Topic Review                 Service Coordinators

                   Routine
                                 FM Resident
 Review Clinic      Care
                                                    Patient     Present
Schedule/ Assign
                                                     Visit         To
    Patients
                    Acute         PA Student                   Attending
                    Care         FM Resident
   SDH Care                                                      EMR
  Coordinators                                                  Charting
                                Consultations
                               Team Members
                             Service Coordinators
                                                               Orders to
                                                                Service
                                                              Coordinators

                                                                 End
                                                                Session
            Evaluation Process
 Pre-Mid-Post       test
     Knowledge
       • Validated T/F
       • GRS multiple choice
     Attitudes
       • Validated Likert scale
 Clinical   competency direct observations
 360’s
 Learner     focus groups
1. Baseline Knowledge (T/F-% correct)
 Question      All Residents   R-2    R-3    Geri Rotation   PA’s
Demographics       77%         100%   71%        85%         70%
Demographics       86%         100%   82%        85%         59%
Demographics      100%         100%   100%      100%         100%
Demographics       45%         50%    41%        46%         63%
Demographics       50%         50%    53%        38%         33%
Demographics       82%         67%    88%        85%         93%
Normal aging       86%         83%    88%        85%         90%
Normal aging       64%         50%    71%        54%         73%
Normal aging       95%         100%   94%        92%         97%
      Baseline Knowledge (T/F-% correct)
    Question        All Residents   R-2    R-3    Geri Rotation   PA’s
Abuse                  100%         100%   100%      100%         100%
End of life            100%         100%   100%      100%         100%
End of life            100%         100%   100%      100%         97%
Insurance               90%         100%   88%        85%         77%
Medications             86%         100%   82%        92%         93%
Medications             85%         100%   80%        92%         80%
Dentition              100%         100%   100%      100%         93%
Prevention/dental       95%         100%   94%       100%         90%

Prevention/flu         100%         100%   100%      100%         100%
        Baseline Knowledge (T/F - % correct)
    Question    All Residents   R-2    R-3    Geri Rotation   PA’s

Function            90%         100%   81%        83%         50%

Psycho-social      100%         100% 100%        100%         100%

Dementia            77%         83%    71%        69%         52%

Falls              100%         100% 100%        100%         97%

Osteoporosis        95%         83%    100%       92%         93%

Incontinence        82%         67%    82%        77%         73%

Incontinence        91%         83%    94%        85%         80%

Depression          91%         100%   88%        85%         97%
        Knowledge (multiple choice)
   Baseline Test (% Correct Answer)    Mid-Test
   Question     All Control Cohort 1   Cohort 1
                                R-2      R-3
Incontinence   32%    0%      33%        50%
#4,13           9%   14%       0%        38%
Nutrition      78%   86%      55%        63%
#10,14          4%    0%       0%        38%
Falls          27%   71%      22%        13%
#6,7           61%   43%      44%        88%
Osteoporosis   52%   57%      44%        38%
#1,15          17%    0%      66%        75%
        Knowledge (multiple choice)
   Baseline Test (% correct answer)    Mid-Test
   Question     All Control Cohort 1   Cohort 1
                                R-2      R-3
Dementia      61%    71%      66%        63%
9,16          39%    57%      33%        38%
Delirium      59%    71%      44%        63%
11,12         74%    71%      66%        25%
Depression    96%    86%      89%        88%
5,8           61%    71%      22%        50%
End of Life   57%    43%      55%        63%
2,3           91%   100%      89%        75%
     Assessment Competencies
1.   Patient-provider relationship
2.   Outside support care
3.   Medications
4.   Adaptive devices
5.   ADL/IADL
6.   Mobility-strength-balance
7.   Pain
8.   Hearing
9.   Care planning-advanced directives
          Assessment Competencies
1.        Geriatric syndromes
     1.    Malnutrition
     2.    Osteoporosis/falls/fracture
     3.    Depression
     4.    Incontinence
           1. Bowel/bladder
     5.    Dementia
Baseline Geriatric Assessment Competencies
    Observational Competency- Likert Scale : ≤ 5 on 1-10
Competency                 All residents    R-3      PAs
Hearing                        67%          50%      33%

Pain                           64%          33%      36%

Mobility                       54%          50%      54%
Provider/pt relationship       58%          17%      42%

Mental status screen           53%           0%      47%
Medications                    50%          50%      50%

Incontinence-bladder           44%           0%      56%

ADL/IADL                       45%         17%/33%   67%
Geriatric Assessment Baseline Competency
      Competency Likert: ≤ 5 on 1 to 10 Scale
Competency              All Residents    R-3    PAs
Advanced directives         45%         17%    55%
Depression                  45%         0%     56%
Memory                      44%         17%    56%
Falls-osteoporosis          43%         33%    57%
Nutrition                   37%         33%    63%
Outside support             37%         50%    63%
Adaptive devices            24%         17%    76%
Medications, Transitions
 and Assisted Living
Karen Gunning, Pharm.D. BCPS, FCCP
Associate Professor of Pharmacotherapy
   & Family and Preventive Medicine
       Geriatric Continuum of Care
     Home and Community Based                Nursing Facilities
         95% of population                   5% of population

     Home           Residential Facilities
                                               Acute Care
      Family          Assisted Living I        Rehabilitation
     Friends          Assisted Living II       Eden Experience
Area Agency-Aging      Group Homes             Special Care Units
  Personal Care            Hospice             Hospice
   Home Health       Adult Foster Homes
  Adult Day Care       Dementia Units
     Hospice          Congregate-HUD



                          Hospital
      Medications in the Assisted Living
                   Center
 Considerations:
    Unlike SNF – no mandatory pharmacist review in
     most states
    No limitations on psychotropic medications, no

     JACHO, no state regulations
    >50% of patients are over 85 years, over 25% with

     cognitive impairment, and the majority receive
     assistance with medication administration
 Medication management is one of the top 3 quality of
  care concerns for Assisted Living Centers
                                 JAGS 2008;56: 1199 – 1205
                                 GAO publication 1999:HEHS 97-93
Medications in the Assisted Living
             Center
   Considerations:
       Medication administration by unlicensed personnel
       MARs may be handwritten by personnel, changes
        may be slow to occur, errors occur in transcription
       Up to 28.2% error rate in med administration
        observed in one study
         • Majority of errors due to “wrong time”, but
           significant errors can occur with high risk drugs
         • Think: Warfarin, Insulin, pain medications, PRN’s,
           OTCs

                                       JAGS 2008;56: 1199 – 1205
                                       Annals Pharmacotherapy;2006:894
     Transitions: A focus point
 20% of the elderly population transition
 from one medical home to another during
 any given two year period
    20% of patients transferred from acute and
     long term care facilities experience adverse
     drug reactions due to medication changes.
    This occurs in the presence of licensed health
     professionals –
      • Consider the potential for serious adverse drug
        reactions when transitions occur from a facility to
        assisted living…

                                         Medical Care 2002;40(3):227
                                         Arch Intern Med 2004;164:545
    Transitions & the Multidisciplinary
    Team Medical Home: an example
   Let’s follow a patient:
   Assisted living  sent to ED for duplex ultrasound – positive
    for VTE. Admitted for treatment, during hospitalization
    determined to have broken ankle and hyponatremia.
   Sent out of hospital for rehab of foot and VTE management
    – in NH for 2 months – diagnosed with another DVT, many
    seizure meds changed, multiple falls.
   Out of NH, meds completely changed – 12 bubble packs of
    4 different doses of Dilantin. Dilantin toxicity, low albumin,
    elevated INR.
   Assisted living to ER – ER considering sending back to
    same SNF…..team intervention brings patient back to
    assisted living
         Transitions For MV:

 Home  to assisted living
 Assisted living to NH
 Assisted living to Hospital
 Hospital to assisted living
 NH to assisted living
              MV Lessons
 Phenytoin  toxicity & phenytoin
  pharmacokinetics
 Pharmacokinetic changes due to low
  albumin
 Warfarin drug interactions
 Hyponatremia
 VTE
 Fall prevention
  Baseline Evaluation: Medication Management
Competency 2: Medications
0---------------------3-------------------------5---------------------7------------------------------------------10
No Med         Med list                                     Med list reviewed              Med list evaluated
               reviewed                                     OTC inquired                   OTC/supplements

    Score at baseline (5 or less on scale):
           50% (PA’s, R2, R3)
    T/F: Age associated Changes in the metabolism of
     medications generally result in increased effect or
     duration of action
           86% overall 100% R2 82%R3 92%Geri Rotation 93% PA’s
     The Sarah Daft Equation
Seeing real geriatric syndromes and
 principles in real patients

+ group teaching/education
+ advocating and developing
 relationships with patients
= lessons learned and remembered
Physician Assistant
     Students
Clinic Session
                               SDH Flowchart
                                Consultations
  Geriatric                    Team Members
Topic Review                 Service Coordinators

                   Routine
                                 FM Resident
 Review Clinic      Care
                                                    Patient     Present
Schedule/ Assign
                                                     Visit         To
    Patients
                    Acute         PA Student                   Attending
                    Care         FM Resident
   SDH Care                                                      EMR
  Coordinators                                                  Charting
                                Consultations
                               Team Members
                             Service Coordinators
                                                               Orders to
                                                                Service
                                                              Coordinators

                                                                 End
                                                                Session
Initial Objectives for PA
         Students
   Long Term Care experience
       Unique setting in assisted living facility

   Longitudinal Care Experience
       With residents of the Sarah Daft Home
       With FM Residents as the „attending‟

   Interdisciplinary Care Model
       Pharmacy students, FM Residents

   Care Team Approach
        Challenges with Initial
             Objectives
        Scheduling Issues - for both PA
 Clinical
  and FM Resident

     Leads to decreased consistency in pairing of
      both learners with each other

     Leads to decreased ability for consistency
      with specific assigned patients - as the FM
      residents RRC focus on patient pairing over
      time
        Changes to PA Focus
 Long   Term Care Experience - no change

 Longitudinal   Care
     the PA students might or might not be with the
      same patients over the 12 months at SDH
     The PA students might or might not have the
      same attending FM resident
      Strengths / Weaknesses in
            New Structure
       Strengths                Weaknesses
 Focus on patient        • Loss of longitudinal
  care with broader         relationship with
  variety of patients       patients
 Interactions with       • Loss of longer
  multiple FM               relationship/ team
  „attending‟ residents     approach with FM
  - different styles,       resident
  ideas, mentorship       • Loss of „ownership‟
 More flexibility          over patient‟s well
                            being longitudinally
           Learner Feedback
PA Students
   “The experience with the patients was

    worthwhile and educational”

     “It's the only time when I had a real
      opportunity to have a holistic approach to
      geriatrics. In clinics, we're too busy and only
      do bit and pieces as appropriate. Sarah Daft
      allowed me to have a global real life
      experience to cement ideas a bit. I found the
      checklist particularly helpful, the one we
      reviewed with Nadia after we did a one-hour
      full visit cold and unprepared. It pointed out
      things I had forgotten”
         Learner Feedback
PA Students
   Student voiced frustration with the EMR, and
    the every other month use making it
    cumbersome to chart
   Students enjoyed working with the FM
    residents, although felt that sometimes the
    residents weren‟t knowledgeable about the
    PA scope of practice
   “It was helpful but the infrequency of visits
    made it difficult to improve”
          Learner Feedback
Family Medicine Residents
 “where can I work with more PA students? We
  work with them in the in-patient setting and here,
  I‟d like more opportunities”
 One FM resident has now worked with 2 PA
  students over the past 2 years - and stated he
  really enjoyed having the longitudinal
  relationship with them. He stated he‟d be
  opposed to changing the PA student schedules
 Another FM resident noted that she was
  apprehensive initially how this would work out
  with the PA learner, but noted it‟s been a really
  good experience
    Future Direction with PA Students
 Continue as part of team
 Set expectations of experience with both PA and
  FM Residents as far as „attending‟ relationship
  prior to starting
 Consider monthly blocks for PA students as the
  longitudinal approach with patients and FM
  residents rarely comes to fruition
           This will help with EMR skill
           This will help with Clinical Year scheduling
           This will provide the FM Resident opportunity to
            „attend‟ a broader range of learners
           This would potentially open up the # of slots for
            this rotation for PA students
OUR LEARNERS’ ATTITUDES
 Geriatric patients tend to be perceived by
  physicians as "resistant to treatment, rigid
  in outlook, demanding, and
  uninteresting”.(Reuben et al,2005)
 “Withadvancing residency status,
 …residents become increasingly less
 interested in care for the elderly.” (Helton
 2008)
    Dec. 2007 Focus Group Themes
 Recognition of aging population and necessity of
  including geriatrics in practice
 Anxiety regarding time constraints and complexity of
  holistic care for older adults in the clinic setting
 Enjoyment of relaxed atmosphere for 360 degree
  communication and deliberation when at a nursing home
 Desire to see spectrum of levels of care and improve
  communication with facilities and community resources
 Request for in depth orientation to facilities and
  paperwork
 Enthusiasm for continuity of care, including end of life
    Nov. 2008 Focus Group Themes
   Scheduling and complexity of care is still
    daunting
   No changes are planned yet for future geriatric
    practice
   Continuity with patients is working well and
    learners seem to be getting to know the pts
   “Medical Home” not being at a medical facility is
    awkward
   PA resident dyad is much appreciated.
The UCLA 14 Item Geriatric Attitudes Scale:
1. Most old people are pleasant to be with
2. The federal government should reallocate money
   from Medicare to research on AIDS or pediatric
   disease.
3. If I have the choice, I would rather see younger
   patients than elderly ones.
4. It is society’s responsibility to provide care for its
   elderly persons.
5. Medical care for older people uses up too much
   human and material resources.
6. As people grow older, they become less organized
   and more confused.
7. Elderly patients tend to be more appreciative of the
   medical care I provide than are younger patients.
8. Taking medical history from elderly patients
  is frequently an ordeal.
9. I tend to pay more attention and have more
  sympathy towards my elderly patients than
  my younger patients.
10. Old people in general do not contribute
  much to society.
11. Treatment of chronically ill old patients is
  hopeless.
12. Old persons don’t contribute their fair
  share towards paying for their health care.
13. In general, older people act too slow for
  modern society.
14. It is interesting listening to old people’s
  accounts of their past experiences.
90
80
70
60
                               residents
50
                               p.a.s
40
                               st marks residents
30                             geriatric experience
20
10
 0
     positive   low positive
Dollars and Sense
Wilhelm Lehmann, MD, MPH
                    COSTS
 Three half-day sessions per month of
 clinical team
     Family Medicine faculty attending
     Physician Assistant faculty attending
     Gerontology/Nutritionist
     PharmD
              Productivity
 Fiscal Year 2007-2008 Billing Data for St
  Joseph’s Villa Nursing Home and Sarah
  Daft Home
 Fiscal Year covers five months at each
  location (2 month lapse between activity at
  each site)
                Productivity
 St   Joseph’s Villa Nursing Home
      15 sessions
      Charges $7355/Payments $3465


 Sarah    Daft Home
      16 sessions
      Charges $7383/Payments $3522
                 Productivity
 Average    Payments/Session

     St Joseph’s Villa = $231.02

     Sarah Daft Home = $220.13


   note – final 5 months at SJV vs. first 5
 Of
 months at SDH
          Financial Viability
CPT                          Average
                             Payment
Code      RVU’s    Charges   Received
99334     1.52     $77       $52
(99212)   (1.03)


99335     2.36     $100      $67
(99213)   (1.67)


99336     3.34     $140      $95.62
(99214)   (2.53)


99337     4.80     $225      $120.00
(99215)   (3.43)
             Personal Example

Month        Provider     Attending    Sara Daft     In-Patient
            RVU's (OP)      RVU's       RVU's          RVU's      Monthly Total


   Apr-08          0.00        73.75         11.23                       84.98


  May-08           1.42        53.19         11.96                       66.57


   Jun-08          0.00        81.91         11.38                       93.29
            Financial Viability
 Summary     & Recommendations
    Average sessions at St Joseph’s Villa and
     Sarah Daft Home are comparable
    Average sessions at both locations fall below
     both average clinical and attending sessions
     at home clinics
    Residency program should subsidize this
     clinical activity or re-classify as educational
     FTE
Reflections on our Journey
             Transition from ECF
              to Assisted Living
 St   Joseph’s Villa Nursing Home
      Medicare and ECF Regulations
      Medical Director Ownership
 Sarah    Daft Home
      Non-medical facility
      New team structure, educational goals, and
       evaluation piece
      Unanticipated Challenges
 Greater than expected change from
  medical facility to non-medical facility
     No Charts
     Loss of Skilled Services & “Triage”
 Geriatricsis not the hot area of interest for
  most residents
 Scheduling challenges
 “Medical Director” issues continue
         Positive Outcomes
 Loss of “Learned Helplessness” by
  students and faculty
 Resident ownership of patients and of
  experience are key to both good clinical
  care and enjoyment of service
 Level of Appreciation by Facility, Staff, and
  Learners
              Going Forward
 Consider    expansion of sites to meet
  critical size of population required for
  RRC, as well as to improve productivity
 Target areas of breakdown in “seamless”
  healthcare delivery
     Include Home Health in medical home team
     Tap into referral coordination and other
      services of home clinics