Understanding Risk Factors for Long Term Care

June 26, 2013 Washington, D.C.

Sheila L. Molony PhD, APRN, GNP-BC Director, Quality Improvement

About CCCI
Private, nonprofit organization founded in 1980 Identify choices and provide services to support people of all ages, abilities and incomes to live at home (>12,000 people/year) Public Division (123 towns)
Access Agency - CT Home Care Program (CHCP) Aging and Disability Resource Center (ADRC) Money Follows the Person (MFP) Chronic Disease Self Management Program (CDSMP) Community Care Transitions Program (CCTP)

Private Division (statewide)

Care Management Associates (CMA)
www.ctcommunitycare.org

Typical CCCI Client

Female, age 86 Lives alone or with a child Primary supporter: daughter, age 66 Multiple chronic conditions
1- 3 hospitalizations per year Takes 8.6 daily medications (including at
least 2 high risk meds)

Sees numerous healthcare providers

(PCP; specialists)

Eligible for Medicare & Medicaid

(dually- eligible)
www.ctcommunitycare.org

Need for Assistance in Activities of Daily Living

Require assistance with house-cleaning, laundry, shopping (>90%) Require assistance with bathing (> 80%) Require assistance with moving from bed to chair, walking and/or using toilet (> 1520%)

Cognitive impairment (> 18 20%) Uses a walker or wheelchair (> 50%) Lives in dwelling with architectural barriers to mobility (> 29%)

www.ctcommunitycare.org

Process of Care Management

Case-finding Assessment Person-centered care plan development Informed choice Implementation of plan of care Access and authorization Coordination Communication Monitoring quality cost

Care Plan Development

Available services and community resources to meet identified needs Payment sources Frequency and intensity of service Cost of plan of care Timing and scheduling Service negotiation

Contextual Factors
Reimbursement structure Linkages to healthcare system Organizational infrastructure