Mechanisms for Organizational Behavior Change to Address the Needs of People Living with Alzheimer's Disease and Related Dementias Proceedings of a Workshop (2022) / Chapter Skim
Currently Skimming:
5 Evidence on the Effect of Existing Models and Research and Innovation to Address Gaps in Data and Evidence
5 Evidence on the Effect of Existing Models and Research and Innovation to Address Gaps in Data and Evidence
Pages 47-60
The Chapter Skim interface presents what we've algorithmically identified as the most significant single chunk of text within every page in the chapter.
Select key terms on the right to highlight them within pages of the chapter.
From page 47... ...
. MFP aims to provide choice to individuals with ADRD regarding where to live and receive services by strengthening Medicaid's ability to support people who want to transition out of institutions such as nursing homes or skilled nursing facilities.1 This is done by eliminating barriers at the state level that restrict the use of Medicaid funds and strengthening the ability of Medicaid programs to provide home- and community-based services (HCBS)
|
From page 48... ...
At that point a transition team is assembled. This team includes the patient, family members, nursing home staff, regional transition coordinators, community program care managers, housing coordinators, and others, depending on the individual's unique needs.
|
From page 49... ...
COPE is driven by occupational therapists (OTs) , who develop action plans with the caregiver and complete up to 10 home visits over the course of 16 weeks.4 The program also includes a home visit from a nurse practitioner who assesses dehydration, pain, and other symptoms and takes biological samples for lab tests.
|
From page 50... ...
Hansen led the PACE program in San Francisco for 25 years.5 PACE serves individuals residing within its service areas who are age 55 or older who are certified as needing nursing home care but who are still able to live safely in the community with support from PACE services. PACE clients have functional losses and complex health issues, with an average of 5.8 chronic comorbidities; 46 percent have ADRD.
|
From page 51... ...
CARE MODELS FOR OLDER PEOPLE AND PEOPLE WITH ADRD: WORLD HEALTH ORGANIZATION VISION AND CURRENT KNOWLEDGE Hyobum Jang, technical officer in the Ageing and Health Unit of the World Health Organization (WHO) discussed an international perspective on efforts to improve quality of care and supports for people with ADRD and their caregivers.
|
From page 52... ...
The country recently initiated a national system of care for older people that includes coordinated social and health care services in the home setting, specialized teams focused on restoring patients' functional independence in the long-term inpatient setting, specialized care centers for older people that focus on a person-centered approach, and community-based residential care services to help patients transition from acute care to the home (WHO, 2021)
|
From page 53... ...
.10 A general practice liaison nurse visits the home, identifies needs, and coordinates care among providers, with patients and caregivers actively participating in care planning and management. Care is delivered in the most appropriate settings by multidisciplinary teams.
|
From page 54... ...
This complicates analyses to determine whether the service might lead to long-term savings. He said that in 2024 additional CPT codes will be released that address informal caregiving, include caregiver training provided by OTs or PTs to enhance patient functional performance, caregiver behavior management training, and telemedicine.11 Alternative payment mechanisms (APMs)
|
From page 55... ...
DISCUSSION How the Models Support Care Transitions Across Settings Inouye asked the speakers to discuss how the various models addressed care transitions for people with ADRD. Robison explained that MFP is focused on improving the quality of care during transitions.
|
From page 56... ...
All of the resources provided in MFP are focused on establishing a care plan to support the person when they reenter the community. The program requires participants to transition into an existing community-based program, such as the Connecticut Home Care Program for Elders.16 The community-based program assigns a case manager who contacts the person monthly, visits semiannually, and is involved during subsequent care transitions and hospitalizations.
|
From page 57... ...
Jang noted that while none of the international models are perfect in their approach to care transitions, one consistently important feature is care coordination. Care coordination enables the person with ADRD to be referred to appropriate health and social services without requiring the family to identify these services themselves.
|
From page 58... ...
Additionally, patient surveys ask about patients' overall perception of care and whether they felt that care included shared decision making.19 Hollmann suggested that patient surveys provided when patients leave the hospital should include a question that asks, "Is the care you are receiving consistent with your expectations and goals? " He noted that individuals may prefer less expensive care options, such as avoiding hospital stays or establishing advance directives.
|
From page 59... ...
However, this informal economy contributes to additional disparities, with paid informal caregivers largely being people from historically marginalized communities or immigrants. Advocating for these caregivers is one goal of the UN Decade of Healthy Aging,20 he added.
|
From page 60... ...
The nurse practitioner can detect undiagnosed conditions through lab tests and share that information with the primary care provider. However, COPE is a one-time program that does not continue through the duration of the disease, while the person with ADRD continues to change over time.
|
Key Terms
This material may be derived from roughly machine-read images, and so is provided only to facilitate research.
More
information on Chapter Skim is available.