Nutrition and Healthy Aging in the Community Workshop Summary (2012) / Chapter Skim
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4 Transition to Community Care: Models and Opportunities
4 Transition to Community Care: Models and Opportunities
Pages 63-82
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From page 63... ...
Schoeps, Lori Gerhard, and Heather Keller each provided a discussion of specific models of transitional care and providing services in the community setting. The models discussed were the following: • Centers for Medicare & Medicaid Services Innovation Center Models -- Patient Care Model -- Seamless Coordinated Care Model -- Community and Population Health Models • Veterans Directed Home- and Community-Based Services Program • Canadian Models of Screening and Assessment in the Community • Evergreen Action Nutrition Program in Canada INNOVATIONS IN CARE TRANSITIONS: AN OVERVIEW Presenter: James A
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From page 64... ...
The Seamless Coordinated Care Model involves coordinating care across the entire spectrum of the health community to improve health
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Initiatives under the Seamless Coordinated Care Models that attempt to address this issue include the Multipayer Advanced Primary Care Practice demonstration project, the Pioneer Accountable Care Organizations (ACO) Model, and the Comprehensive Primary Care initiative.
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. Lessons learned from the QIO 9th Scope of Work Care Transitions Theme include the importance of community collaboration, tailoring solutions to fit community priorities, including patients and families in decisions, and public outreach activities.
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The final category of partnerships, the "marathoners," combines the seamless care initiatives of Bundled Payments for Care Improvement and ACOs. Summary Hester concluded by suggesting issues to be contemplated when considering care transitions: • Examine how to build effective hospital-CBO partnerships and create an infrastructure of local CBOs where it does not exist.
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The VHA has 153 medical centers and 950 community-based outpatient clinics, 135 nursing homes, and 47 residential rehabilitation treatment centers. It is also affiliated with 107 medical schools, 55 dental schools, and 1,200 other schools for training and education purposes.
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Do Noninstitutional Long-Term Care Services Reduce Medicaid? The channeling demonstration gave way to the idea of the "woodwork effect." That is the concept that if access to home- and community-based services is expanded, the increased participation combined with continued nursing home expenditures raises the total cost of providing services to older adults for long-term care.
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From page 70... ...
The results of this research began to inform AoA's and VHA's ongoing work. Chronic Care Model and Evidence-Based Care Transition Research The Chronic Care Model developed by Edward Wagner (see Figure 3-1)
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. HHS has contributed funding to this program since 2003, most recently under the American Recovery and Reinvestment Act, establishing CDSMPs for people with multiple chronic conditions in 45 states, the District of Columbia, and Puerto Rico.
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Schoeps concluded by saying that the veterans-directed program has been well received by veterans and their families. IMPROVING COMMUNITY NUTRITION CARE FOR OLDER ADULTS IN CANADA Presenter: Heather Keller Transition care in Canada is somewhat fractured according to Heather Keller, a professor in the Department of Family Relations and Applied Nutrition at the University of Guelph in Ontario and a research scientist with the RBJ Schlegel-University of Waterloo Research Institute of Aging.
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From page 73... ...
Tertiary prevention seeks to keep individuals who have already developed a chronic condition from declining in health, which Keller said is the goal of home care programs in Canada and nutrition programs for older adults in the United States. Tertiary prevention involves social service agencies, outpatient clinics, home care, and hospitals and includes typical medical model services, such as referrals to registered dietitians.
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2007. Promoting food intake in older adults living in the community: A review.
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. Initially, the health care professional reviews risk factors that may contribute to impaired food intake, such as poor appetite.
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Community Services in Canada Keller noted that Canada does not have an elder nutrition program comparable to that of the AoA. She explained this may be in part because the base-level annual income for persons over the age of 65 in Canada is $15,000 and perhaps this supports free medical care, medications, and access to home care if eligibility criteria are met.
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From page 77... ...
The Evergreen Action Nutrition Program is an example of a successful community education and secondary prevention program in Canada. It was developed to provide some of the services and information that seniors want -- food workshops, cooking classes for older men, and information 3A person-centered assessment system, focusing on the person's functioning and quality of life by assessing needs, strengths, and preferences, that informs and guides comprehensive care and service planning in community-based settings (http://www.interrai.org/section/ view/?
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From page 78... ...
" • Exploring the use of a social care model versus a medical need model for home care services DISCUSSION Moderator: Julie Locher The discussion focused on nutrition in transitional care and patientdirected care of the frail. Nutrition in Transitional Care Gordon Jensen asked about concrete plans for transitional care -- specifically related to nutrition concerns -- from acute care, subacute care, or chronic care back home to independent living for people at high risk of readmission.
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From page 79... ...
Although hospitals and home health care agencies are required to have RDs on staff, in the community setting the mechanism for an RD to independently request reimbursement is cumbersome and the amount so minimal it is not to the dietitian's benefit to seek reimbursement. Hester pointed to the Section 3026 Community-Based Care Transition Program as an ideal vehicle for a local community organization in partnership with the hospital to design a nutrition intervention.
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2011. The Care Transitions Program®.
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2001. Chronic disease self-management program: 2-year health status and health care utilization outcomes.
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