The Los Angeles Jewish Home introduces…

CONNECTIONS TO CARE

A Rationale and Development of a

Post Acute & Chronic Care System for a New Age

PEAK LEADERSHIP SUMMIT-Innovative Models for the Future: Integrated Systems & Payment Models SymposiumMolly Forrest, CEO & President, LA Jewish Home

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Does this Sound Like Our World?

“It was the best of times, it was the worst of times, it was the age of wisdom, it was the age of foolishness, it was the epoch of belief, it was the epoch of incredulity, it was the season of

Light, it was the season of Darkness, it was the spring of hope, it was the winter of despair, we had everything before us, we had nothing before us, we were all going to Heaven, we were

all going direct the other way.”

Charles Dickens, Tale of Two Cities

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“20% to 30% of health spending is waste that yields no benefit to patients… much is done that does not help patients at all, and many physicians know it” - Don Berwick, New York Times, December 3, 2011

Yesterday:Fee for Service

Today: Manage the Episode(Traditional Sources)

Tomorrow: Manage Population Health

OUR FUTURE : Lower Cost, Better Outcomes & Improved Health

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Better patient

care and experience

Better population

health

TRIPLE AIM

Lower costs

5Fragmented System in ‘Silos’ of Care

Press the Individual into the Silo that seems to “fit”

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Lack of Transparency out-&-inside!

Limited/missing Research on Effective Care Services

7Misalignment of Financial Incentives

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In 1996, LA Jewish Home was A Fragmented System in ‘Silos’ of Care

1996-98 Data:700 residents/yearAverage age – 90; 90% femaleAverage length of stay – 7.9yearsHospital utilization – 10,000 days/year

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What are the goals?• Modernizing the Home• Data, data, data IdentificationAccumulationDevelopmentBenchmarkingExchanging with many! Partners, participants & payers• Integrating services with others• Sharing Costs of Care• Sharing Revenues from Care

The Big Picture – Who says an Elephant Can’t Dance?

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From …• Telling patients what to do

• Transfer of Information

• Compliance

To …• Listen, problem solve, collaborate

• Developing confidence and skills

• Building capability

Paradigm Shift in Individual Interactions

Outcomes …• Engagement in healthy behaviors• Better care experiences• Less likely to be hospitalized, readmitted, use emergency department or skilled nursing• Overall lower costs

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Change CommunicationCritical in Changing Relationships

Make it About

Quality of Care Delivery

Make it Easier to

Deliver the Care

Align Financial

Incentives

Communicate the

Rationale Loudly and

Clearly

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Introducing the Los Angeles Jewish Home’s

CONNECTIONS TO CARE

Mutually-Supporting ServicesProviding a Continuum of Senior Care

“In Your Home or Ours”

• Senior Housing and Residential Care 

• In-Home And Community-Based Senior Care Services 

• Jewish Home Non-for-Profit Parent Organization Programs  

ONE CALL DOES IT ALL

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The Los Angeles Jewish Home’s Connections to Care

Home- and Community-Based Services

•  HOSPICE • PALLIATIVE MANAGEMENT FOR PAIN AND CHRONIC CONDITIONS• GERIATRIC COMMUNITY CLINICS•  PRIMARY & SPECIAL MEDICAL CARE• MEMORY CARE SUPPORT GROUPS• PACE / Brandman Centers for Senior Care (A Program of All-inclusive Care for the Elderly)

•  PACE ‘Lite’—Self-Select PACE Services• CMS CARE TRANSITIONS•  BRIDGE PROGRAM•  HOME HEALTH AGENCY•  PERSONAL CARE SERVICES•  GERIATRIC CASE MANAGEMENT Medical Management • TRANSPORTATION•  CAREGIVER SUPPORT GROUPS

• INDEPENDENT SENIOR HOUSING

Fountainview at Eisenberg Village

Fountainview at Gonda Westside

Neighborhood Homes

• RESIDENTIAL CARE

• MEALS

• SKILLED NURSING

General Skilled Nursing

Memory Care

• SHORT TERM REHAB

• ACUTE GERIATRIC PSYCHIATRIC CARE

• INPATIENT HOSPICE

Housing & Residential Services

• PHILANTHROPY BUILDING SKILLS FOR TOMORROW’S SENIORS

• ANNENBERG SCHOOL OF NURSING Licensed Vocational Nurse (LVN) Personal Care Worker Home Health Aide Certified Nursing Assistant CNA) CSUN RN Program – Clinical Site Partnership

• EMPLOYMENT AGENCY

JHA Non-Profit Parent Organization Programs

855-227-3745

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“The difference is that of attitude… Ideas, like people, flourish when they are welcomed and embraced.”— Barbara J. Winter

• Leadership – commit prioritization of efforts & resources

• Culture – change from “solo silo” to new care delivery

• Communication – leaders , partners and local providers

• Implementation – beware ! A quest for data perfection limits operational performance; begin at the beginning

• Patient Engagement – develop mechanisms to reach out to patients and care-givers ; avoid the “opt outs”

• Data Analytics – capable of processing data • Leadership and follow-thru on actionable reports

$72 Million – Keeping the Promise

Goldenberg-Ziman Memory CareJoyce Eisenberg Keefer Medical CenterSkirball HospiceJewish Home Center for Palliative CareBrandman Centers for Senior Care (PACE)

CMS Innovation Awards

Care Transitions

Hirsch Family Campus

$215 Million – Keeping the VisionGonda WS Healthy Aging Campus

Polak Family Assisted & Memory Care

Towers Independent & Assisted Living

Goldstein Chapel

Jewish Home Care Services

Bride = connections to care”

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As a Non-Profit What Asset is Available?

Philanthropy & Community Support

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1996-98 Data:700 residents/year; 10,000 days Average age – 90; 90% female75% governmental assistanceAverage length of stay – 7.9yearsHospital utilization – 10,000 days/year

2013 Data:4300 total seniors served; 75% governmental assistance65% of these aided by short-stay or at homeAverage age in residence – 90; 90% femaleAverage length of stay – 7.0 yearsHospital utilization – 3300 days/yearReadmission to acute within 30 days of admit:

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Hospice/Palliative CareCare Management

Provides medical and palliative care management by specialized Physicians, Nurse, Care Managers,

and Social workers for chronically frail seniors

High Risk and Care ManagementIntensive 1:1 physician, social worker & case

management for the high risk, and/or post-discharge population. Patient is transferred to Level 2 when

stable. Physicians and Care Managers are highly trained and closely integrated into community resources

Complex Care and Disease ManagementProvides medical and palliative care management by specialized Physicians, Nurse Care Managers,

and Social workers for chronically frail seniors

Self Management, PCPProvides self-management for people

with chronic disease

Stratifying Patients / Not “Inpatient” &“Outpatient”

Level 4Care Management

Level 3High Risk

Level 2Complex Care & Disease

Management

Level 1Self-Management & Health

Education Programs

LOCA

TIO

N F

OR

CARE

DEL

IVER

Y IS

AN

YWHE

RE

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Geriatric Care Model: Patient Risk Stratification Tool

Patients ACO TME

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Proportions of High Cost ( Atrius Health ACO) Patients & attributable to them

Costs (YTD: Aug 2012)

% OTHERS % ALIVE H/VH Risk% DECEASED

20% of patients

60% of costs

Using Electronic Health records databases. The tool allows to identify members at risk of hospitalization, poor health outcomes, high costs

The model consists of five key factors:• Likelihood of Hospitalization• Hospital admissions or ED Visits• Behavioral Health diagnosis• CHF or COPD• >= 15 medications

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Areas of Focus Today ….--Considerations in the Preparation for California “Duals”

Data Analytics for Connections to CareCare TransitionsSNF ReadmissionsShort Term RehabilitationPACE & PACE “Lite”Home HealthHospicePalliative CareIndependent Physician Association IPAHCC Adjusted Risk Scores/Revenue Sharing

Skilled Nursing Memory Care Residential Care Independent Senior Housing Acute Geriatric

Psychiatric Short Term Rehab Memory Care Support Group Inpatient Hospice  PACE Brandman

Centers for Senior Care PACE ‘Lite’ Alternative Care Settings Senior Centers Community Centers

Community Clinics Primary & Special Medical Transportation CMS Care Transitions Bridge Program

Home Health Agency Personal Care Services Geriatric Case Management Medical Management

Hospice and Palliative Care Annenberg School of Nursing Licensed Vocational Nurse (LVN) Personal

Care Worker Home Health Aide Certified Nursing Assistant Philanthropy Employment Agency

Skilled Nursing Memory Care Residential Care Independent Senior Housing Acute Geriatric

Psychiatric Short Term Rehab Memory Care Support Group Inpatient Hospice  PACE Brandman

Centers for Senior Care PACE ‘Lite’ Alternative Care Settings Senior Centers Community Centers

Community Clinics Primary & Special Medical Transportation CMS Care Transitions Bridge Program

Home Health Agency Personal Care Services Geriatric Case Management Medical Management

Hospice and Palliative Care Skilled Nursing Memory Care Residential Care Independent Senior

Housing Acute Geriatric Psychiatric Short Term Rehab Memory Care Support Group Inpatient

Hospice  PACE Brandman Centers for Senior Care PACE ‘Lite’ Alternative Care Settings Senior

Centers Community Centers Community Clinics Primary & Special Medical Transportation CMS

Providing Seniors With All the Services They Need

Your Home or Ours--- ”One Call Does It All”

The Los Angeles Jewish Home’s New

CONNECTIONS TO CARE

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IndependentLiving

Assisted Living• Memory Care• Home Care

Skilled Nursing• Short Term Rehab• Chronic LTC• Memory Care

Acute Psychiatric• Community Mental Health• Medication Management

PACE or PACE-Lite• w/ MD• w/o MD

Clinic• MD/NP Services Palliative Care Hospice

Care TransitionsPersonal Care/

Companion “Bridge”

Home HealthAgency

IPADistance

Care-giving Caregiver Support TransportationEmployment

Agency

Tel-Assurance

• Menu & Meal prep• Home-delivered meals

Handyman Shopping

Houeskeeping/Laundry

HC Technology• Non-Invasive Surveillance• Invasive Surveillance• E-Access HC

Pharmacy• Prescription• Intravenous• Infusion

Durable MedicalEquipment (DME) Medical Home

1 3 54

6 7 8 109

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Connections to CareCustomer Relations

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23 24 25 26Other?

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Questions?