ElderPAC: Sewing a “Program of
All-Inclusive Care for the Elderly”
Quilt from Community-Based
Patches
Campaign for Better Care Webinar
June 30, 2010
University of Pennsylvania
Jean Yudin, CRNP, Jeanette Gallagher, MSW
Philadelphia Corporation for Aging (PCA)
Susan Meyer, MSW, Wendi Botnick, MSW
Long Term Care:
Deconstructing a Nursing Home
Complex Health Management
Independence at
Home
HCBC waivers
Supportive Living Services
Housing
Elder PAC: Elder Partnership for
All-Inclusive Care
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Combines community-based Long Term Care (CB-LTC)
services (through Philadelphia Corporation on Aging),
the local Area Agency on Aging (AAA) with medical
care (In-Home Primary Care Program) in an integrated
academic health system.
Links to Home Health Agency services through both AAA
and CMS funding
Now includes the Waiver, Options,Family Caregiver
Support, and Bridge programs
Service Bundle varies by program– from $14,000$34,000 /year as caps– average is $23,000/year
Pre-Elder PAC
3 Nurse Practitioners
Managers
180 patients
Case Manager
60 PCA consumers
providers
39 Case
at PCA
50
Elder-PAC
Philadelphia
Corporation
for Aging
Senior Centers
Elder
Caregivers
Home Health
Agencies
In-Home Primary
Care Program
Integrated Service Delivery
 Primary
Care
 Acute, Rehab, LTC
 Home Health Services
 AAA / Aging Network
 Care Management
UPHS In-Home Primary Care
Program
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Active census of 130 homebound elderly patients in InHome Program; 19 homebound elderly patients in
Medicare Advantage
Primary Care provided by NP/SW/MD teams
Majority of patients receiving PCA services when they
enter the In-Home Program
Majority of patients receiving skilled home health
services, including chronic care coordination.
ElderPAC Team Members
 Case
Manager from the Options/Waiver
Programs of the Philadelphia Corporation
for Aging
 Social worker from Geriatrics
 Geriatric Nurse Practitioners (GNP)
 Physicians from Geriatric Medicine
Home Visit Activity
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Social Worker
-- Makes initial contact
-- Social/service map
-- Usually bi-weekly contact
NP-Physician teams
see patients every 6-8 weeks (6 NP/2 MD visits/yr)
Physical exams, diagnostic studies
Home environmental modifications
Evaluate and strengthen social supports
Ensure contact with appropriate community agencies
-- CONSUMER CHOICE (sort of)
Weekly team meeting /monthly with community
agencies
2009 average 7.5 visits/pt (6 NP:1 MD)
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Supportive Living Service Integration
 Environment
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Information for modification and repair
programs
Durable medical equipment
Stairglides
 Transportation
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Shared Ride
SLS
Non-Emergency Ambulance
MA / Wheels
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Socialization
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Information, lists and application process for:
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Counseling / Mental Health
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Senior Centers
Adult Day Care
Senior Companion
Friendly Visiting
Community Mental Health Center / Base Service Units
Home Health Aides / Personal Care Aides
Safety
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Emergency Response Systems
Locks / Windows Program
Financial Management
Older Adult Protective Services
Medical / Health:
Switching between AAA and CMS
 Home
Health Agencies
 Registered Nurse
 Physical Therapist
 Occupational Therapist
 Speech Therapist
 Home Health Aide
 Incontinence Specialists
JW
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78 yo AA woman,
Lives independently in
neighborhood for past 50 years
2-story row home
Son involved but lived 20 miles
away
Oxygen dependent
Held and personally catered
annual block party
Multiple cats with fleas
Medicare risk score 4.6
Personal goal to survive to 80th
birthday
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491.21
518.83
327.3
440.2
585.3
404.11
416.8
428.3
427.89
358.8
274.0
285.29
721.9
366.9
530.81
389.9
COPD
Resp Fail 02
Sleep Apnea
PVD
CKD
HTN c CKD and HF
Pulmonary Htn
Diastolic CHF
SVT
Neuropathy
gout
anemia
Cervical spondylosis
cataract
GERD
Hearing loss
JW Hospitalizations Pre/Post
Housecall Management
Start
Housecall
COPD/ICU
COPD
COPD/ICU
2004
2005
COPD
COPD/ICU
COPD/ICU
2006
ED
2007
80th birthday
2008 2009
Conclusions
 All-Inclusive
management of medically
complex, homebound patients can result
in substantial savings compared to similar
Medicare beneficiaries.
 Independence At Home can provide
funding for housecall practices caring for
medically complex patients by
guaranteeing a share in those savings.