Strengthening Senior Health Care Delivery
John Muir/Mt. Diablo Community Health Fund
Building Bridges to Better Health
After funding a 6-month planning process in 2011, the Community Health Fund has provided a one-year, $350,000 grant to La Clínica de La Raza to launch its Strengthening Senior Health Care Delivery initiative. The goal is to improve the health and well-being of over 2,000 low-income, predominantly uninsured patients ages 50 and older. The initiative establishes care coordination across medical, optical, dental and behavioral health clinicians, and establishes a variety of innovations to help seniors address multiple health-related concerns more effectively and efficiently. The initiative also is in line with health system payment reforms aimed at improving reimbursement to promote efficiently delivered, higher quality health outcomes for broad populations. In addition, the CHF has contracted with the consulting firm Harder + Company to work with La Clínica to plan and conduct a professional evaluation throughout this first implementation year.
The Health Issue
In numerous settings, team-based care that addresses “the whole person” has improved health outcomes for many patients. It is particularly promising for seniors, who often suffer from multiple health concerns that cross clinical boundaries, including everything from dental caries, gum disease and hearing and vision loss to cognitive decline, depression, cancer and heart and lung disease. Treating seniors – particularly low-income seniors – is further complicated by the fact that they often struggle to get back and forth to provider visits and effectively navigate an increasingly complicated health care system.
Innovative team-based care can help older adults receive much of their care in fewer visits and ensures a more coordinated approach to helping seniors manage multiple health-related conditions. In addition, by focusing on improved outcomes, La Clínica is positioned well to sustain this effort, because changes coming in the reimbursement system will demand a focus on more efficient care and measurable clinical outcomes, rather than on volume of services alone.
Creating truly integrated holistic care for seniors is a significant challenge that demands a multi-faceted solution:
- La Clínica will improve coordination and communication among medical, dental, vision, and behavioral health providers to deliver integrated care for older adults.
- In October 2012, in conjunction with the University of California San Francisco Geriatric Education Center, La Clínica delivered the first in a series of quarterly trainings for all staff members in its Contra Costa clinics. The program includes didactic sessions along with sensitivity exercises that will help clinical and office staff members understand the challenges seniors face every day.
- La Clínica will implement a panel management system in which Panel Management Assistants (PMAs) will systemically review clinical data to identify older patients’ health risks and clinical needs. The assistants will use an established tracking tool which collects data and uses clinically valid algorithms to prompt the PMA when patients need clinical services, such as vaccines, fall risk assessments, mammograms, behavioral health screening or periodic follow-up exams. The system will also track whether patients made it to referral appointments – and notify the PMAs so they can follow up where necessary.
- La Clínica will deploy nurse practitioners with specialized training as Senior Care Managers. Working closely with the PMAS, these Senior Care Managers will ensure that senior patients with complex medical needs receive additional support beyond their clinic visits. Their work will include brokering outside resources such as durable medical equipment and home nursing support, and will focus on critical care transitions, such as post-hospital discharge. . Flexible schedules – open time in the mornings and panel-specific appointments in the afternoon – will increase the Senior Care Managers’ accessibility to older adults. Home visits may also be provided for some seniors.
- La Clínica will continue to develop and enhance innovative, senior-specific services that include:
- Group visits and classes for certain conditions. For example, health educators offer a class on preventing falls and clinicians conduct group visits for diabetic patients. Studies have found the group visits for certain conditions to be an effective approach that has the added benefit of creating a patient support network that helps overcome the social isolation that many seniors experience.
- Enhanced senior day clinics, with blocks of time set aside specifically for senior patients, and senior-specific health promotion activities.
- Senior Patient Navigators – specially trained promotores who help seniors navigate their clinic visit and post-visit follow-up. An early pilot test found the use of a navigator helped overcome some of the confusion seniors can experience about care instructions and thus ensure they are doing what they need to do to maintain their health after their visit.
Finally, Harder + Company – a consulting firm that is expert in data-driven analyses that help nonprofits, public agencies, and foundations understand the results of their programs and initiatives – is working with La Clínica leadership to develop and implement an evaluation that will guide La Clínica’s efforts to continually improve this program. Numerous methods are likely to be used, including:
- Staff and provider interviews on the workability of the processes put in place.
- Patient surveys about their level of satisfaction with this new approach.
- Establishment of key baseline clinical measures, rooted in similar efforts across the country, and drawn from data that La Clínica is collecting.