A New Model For Aging At Home: Care Management -- Every Step Of The Way

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The vast majority of older Americans, 90 percent of them, want to age at home. Many have lived in their homes for decades, where they are surrounded by the familiar -- from photos on the wall to shops on the street -- and can visit or receive visits from family and neighbors. Today, there's no reason anyone should have to compromise on this wish for their later years. Thanks in large part to the growing popularity of Managed Long Term Care (MLTC) health care plans, we now have the ability to keep even the sickest elderly patients stable and comfortable at home.

MLTC plans do this by coordinating all the various elements of an older person's care in a responsive and collaborative fashion, taking into account his or her psychosocial as well as physical well-being. They make sure doctor's appointments are made and kept; arrange necessary home care services from visiting nurses, home health aides, social workers and behavioral health counselors, as well as speech, occupational and physical therapists. They also connect people to community resources such as transportation and support organizations focused on vision impairment and other special needs. They support family caregivers and educate each individual to better manage his or her own health as well.

The MLTC program offered by my company, VNSNY CHOICE Health Plans, provides members with an entire array of services that are overseen and revised as necessary by a nurse care coordinator/manager who is attentive to all the details, large and small, of each plan member's daily life. In addition to what we typically think of as home care, such as visits by a home health aide, the nurse care coordinator coordinates with interdisciplinary team members to ensure that medical treatment plans are being followed and behavioral health needs met. The care coordinator makes sure a support system is in place, prescriptions are being filled, and medications are being taken properly, and, on the most basic level, checks that there is enough food in the refrigerator.

Deepening Partnerships, Advancing Care
In this remarkably comprehensive and human way of thinking about care, we are always looking at where, in the day-to-day life of our members, we can improve their health and wellbeing. Recently, we stepped up efforts to collaborate with their physicians to identify potential gaps in care and ensure that the medical treatment of at-risk members is being coordinated effectively.

As a first step in this process, we are identifying members who have gaps in recorded health data for conditions such as asthma, diabetes or cancer. We then reach out to the physicians treating our members to review data and prescribed care protocols. "This keeps us all on the same page and makes sure no health needs are being overlooked," explains Dr. Lisa George, Medical Director for CHOICE.

We also touch base with physicians on other aspects of members' care, including any pharmacy issues, such as difficulty filling prescriptions and taking medication as prescribed, as well as health conditions that might have been addressed by the physician without being fully noted in the member's medical record. "For example, a doctor might treat an MLTC member for a bronchial infection without noting that the member's underlying emphysema was also addressed, or check on a patient's diabetes management without recording that the patient was also treated for a diabetic foot wound," Lisa says. "By assessing the member's disease burden more accurately, we'll be able to do a better job of improving their care and ensuring appropriate reimbursement for better results."

Home Is Where the Care Is
As healthcare reform across the country seeks to lower costs of care while increasing quality and access, New York State has adopted Managed Long Term Care as the best system to help the most vulnerable, at-risk elders age in place. Almost all of our members are eligible for nursing home care but would rather live at home. So, we bring the care to them, no matter the level of need or the medical complexity.

Through this approach, we're able to help MLTC plan members like Mr. G live at home -- despite the fact that he needed dialysis four days a week and, because of his size, had trouble navigating the flights of stairs in his apartment building. Through his care coordinator and other members of his interdisciplinary care team, we arranged transportation for him to and from treatment, assisted him with the stairs, and advocated for him to be moved into a first-floor apartment.

With other members, we'll make sure critical behavioral health issues are attended to. "I deal a lot with depression, schizophrenia, and other psychiatric conditions," says Grace Owen, a social worker who assists our MLTC members. Frequently, she'll administer depression screens over the phone then connect members to additional services as needed. "I also help members and their family caregivers navigate Medicare and Medicaid, make sure their prescription drug plan is in place, and arrange things like food stamps or housing," she says.

Providing support and resources for caregivers is another vital component of MLTC. For another one of our social workers, Sandra Thomas, a simple phone call about a 96-year-old member's Medic Alert bracelet led to an extensive counseling session with the member's daughter, who is in her 70s. "The mother wasn't sleeping well, and the daughter was exhausted trying to care for her in the night," says Sandra. She gave the daughter educational materials and a link to a support group. "The entire family is our member," she says.

Many of New York's most vulnerable elders are now enrolled in one of the state's new integrated managed care plans for individuals dually eligible for Medicare and Medicaid. Under these plans, they receive help in obtaining wheelchairs and other equipment, from simple shower grab bars to items as complex as a Hoyer lift. In our own MTLC plan for dual eligibles, we maintain a 24/7 member service customer care hotline for participants, and our social workers help support members with housing issues by linking them to community resources.

Most importantly, our MLTC interdisciplinary care teams are in continuous touch and are consistently focused around the goals of the participant. How do we know? We ask. We recently enrolled a 79-year-old member who was virtually bedbound from a combination of arthritis, congestive heart failure and diabetes. With the help of her interdisciplinary team, she established a set of daily goals, and her MLTC case manager checks in by phone periodically to reinforce these goals. Meanwhile, her home health aide comes in daily to make sure she eats a good breakfast, takes her medications, and gets up and moving.

One person at a time, one day at a time, and one integrated, collaborative system at a time, we are creating a city, state and nation where people can fulfill one of life's simplest but most profound wishes: to grow old, safely and comfortably, in their own home.

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