Aug 202013
 

MediCaring is a comprehensive approach to providing medical care, long-term care, and social support services for older adults who are living with worsening disabilities and fragile health associated with aging. MediCaring4LIFE is a proposed test of MediCaring’s potential to improve lives and reduce costs of the period of frailty; it’s a proposal to the Center for Medicare and Medicaid Innovation.

The following YouTube video is a presentation on the Medicaring4Life proposal sponsored by the Center for Eldercare and Advanced Illness. A text summary of key points in the presentation appears below the embedded video. You may also view this presentation directly on YouTube (http://www.youtube.com/watch?v=LaeHLhqDfUw).

MediCaring, and MediCaring4LIFE (Local Improvements for Frail Elders)

Presented by Joanne Lynn ([email protected]) and Anne Montgomery ([email protected]), Center for Elder Care and Advanced Illness, Altarum Institute

What: MediCaring is a comprehensive approach to providing medical care, long-term care, and social support services for older adults who are living with worsening disabilities and fragile health associated with aging. MediCaring requires individualized care plans that reflect the elderly person’s strengths, needs, and likely future, and a local service delivery system that is monitored and managed to assure that what is most needed is readily available. MediCaring4LIFE is a proposed test of MediCaring’s potential to improve lives and reduce costs of the period of frailty; it’s a proposal to the Center for Medicare and Medicaid Innovation.

Who: People over 65 who are living with disabilities, or people over 85 who simply want coherent care focused upon their priorities, most often including living at home, staying comfortable, and preserving independence. The MediCaring4LIFE proposal to the Innovation Center would build MediCaring programs in four communities and serve 14,861 elderly people over three years.

Where: MediCaring can be implemented in any community where there is local leadership and commitment. The MediCaring4LIFE proposal will support reforms in four communities: Akron, Ohio; northeastern Queens, N.Y.; Milwaukie, Ore.; and Williamsburg, Va. One of the projects is led by a social services provider, and the others are led by health care providers. All involve Medicare, clinical leaders, community-based organizations, state Medicaid offices, local managed care entities (including the new managed long-term care companies), and community leaders. By the end of the three-year grant period, each community will have established local coalitions and a leadership structure capable of monitoring and managing health and social services for older adults in the area into the future, and able to start taking on responsibility for shared savings as part of the strategy for sustaining and continuing the gains.

Altarum Institute’s Center for Elder Care and Advanced Illness will coordinate the MediCaring4LIFE initiative, providing organization and project management, coaching and collaboration (with the Institute for Healthcare Improvement), quality measurement and monitoring (with the National Committee for Quality Assurance), clinical and ethical standards development (American Geriatrics Society), financial monitoring and modeling (Dobson|DaVanzo), legal analysis (EpsteinBeckerGreen), support for information technology (Growth House, Inc.), support for community building (Community Catalyst), and support for enabling involvement by frail elders and their families in transformation and governance (Consumer Voice).

How: The MediCaring4LIFE initiative will implement a set of evidence-based improvement activities that assure comprehensive assessment and individualized planning, ready availability of critical services at home (including medical, nursing, home modifications, transportation, caregiver support, and nutrition), and reliable services organized by an individually negotiated care plan that guides care across all settings.

Financing of services will be through existing programs where appropriate—primarily Medicare and Medicaid (accompanied by adjustments of certain rules to permit more flexibility)—as well as coverage for currently non-covered services with the supplemental award funding. In the third year, the project’s financial experience and evidence will anchor specification of a shared savings model for the targeted population (frail elderly people in a particular geographic area), using a modified Accountable Care Organization model as the financing design for serving the needs of elders living in the four communities.

The MediCaring approach aims to save at least 20% from medical costs and 5% from long-term care costs in the first three years. By providing much more coherent care planning that is accessible to all service providers, and which reflects strong input from elders and family members, the choices afforded to frail elderly people with serious disabilities and coming to the end of life will expand to allow those who wish to do so to forego aggressive and burdensome medical treatments that have little chance of meaningful gains. Many may instead choose services that allow them to live as well as possible in the time remaining—buoyed with good symptom relief, strategies that limit the effects of disabilities, support for caregivers, and fewer disruptions. To achieve this, the supportive services must be reliable and prompt, so that elderly persons and their families feel confident that they can stay at home rather than resorting to the hospital at the first sign of trouble. This also means that the care system must provide around-the-clock back-up by phone and have the capability to have the appropriate service or expert go to the home promptly. Both routine and urgent medical care and social supports must be available in the elderly person’s residence (e.g., home, nursing home, assisted living facility).

Frailty is a very high-cost part of our lives; the per-person per month costs regularly top $5,000 for an average of three years before death. Yet the home-based primary care program for veterans has cut hospitalization by more than half, and nursing home use by more than 80%. If MediCaring4LIFE reduces hospital use by just 25% and reduces net long-term care costs by 5%, the investment of about $1,000 per person per year will yield returns of more than twice the investment. Average costs per person per month will come down by about 20%—and these are conservative estimates. (We have recorded a webinar to provide an overview of the spreadsheet calculations behind these estimates on YouTube (http://www.youtube.com/watch?v=LaeHLhqDfUw).

The potential for improving life experience while saving money is feasible—but it requires breaking down conventional boundaries between medical care and social supports; informing affected people honestly about what they face and explaining their options; helping elderly persons and their families develop care plans that are centered around their goals and preferences; and developing a community-focused system that can help manage the local delivery system to organize care so that the services that are most readily available are those that are most needed.

Why: Until recently, frail elderly people have been largely unrecognized in our health care system. That will change with the aging of the largest single generational cohort in American history—the baby boomers. Millions of Americans will live into a fragile old age during the first half of the 21st century, with most needing personal care assistance for three years or more. The average lifetime costs of long-term services in old age exceed $5,000 per month, making this the most expensive part of the lifespan. For the economy to thrive while so many of us are living with worsening disabilities, the per capita costs of health care during the final phase of life must come down. For people to live well throughout their lives, the last part of life must offer opportunities for meaningfulness and must be lived with comfort and confidence. MediCaring aims to make dramatic improvements in reliability, trustworthiness, individualization, and efficiency of health and long-term care by deliberate design, ongoing monitoring and improvement, local management, and honest and well-supported care plans for each individual.

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