Medical Home Visits: After the Physician Team Leaves

Cindy Hasz, Director

Grace Care Management

November 10, 2004

Physician Team to Care Manager

– Referral from Physician Team to Community Care Team

– Assessment, ID needs, Care plan, care coordination, on-going reassessment

– Multidisciplinary team– Feedback system

ACUTE SYSTEM - Long Term Care - CHRONIC SYSTEM

Vertical Horizontal

Institution centered - Starting Point - Patient centered

Facility-Stationary Residence-Mobile

Crisis based Maintains Normalcy

Single-system based - Method of Delivery- Partnership based

Managed Care Care Management

RIGID - Character of System - DYNAMIC

Fixed-Slow-Inefficient Flexible-Fast-Efficient

Emergency Resolved - Functional Outcome - Health Level Sustained

SHINING A LIGHT ON TWO SYSTEMS

CURRENT MEDICAL SYSTEM

COMMUNITY CARE

MANAGEMENT

When Necessary, Patient Enters Acute System

Emergency Resolved, Patient Returns to Chronic Care

Community Care Management Allows for the Best Utilization of Both

Systems

ACUTE

CHRONIC

Community Care Management provides “Circulation”

necessary for the appropriate care for the patient

Chronic Care Management: Proactive: stabilize at home Prevents acute care use & $$ Based on Quality of Life: dignity, choice Need for recognition of value by Public

funding sources Private sources: LTC insurance,

families, private pay Improved outcomes

Client Referral Patterns

Mr. Z

92 yo, lives alone, only son out of state HTN, dementia, risk for “undue influence” APS referral, has assets, at risk for self-

neglect Cognitively unable to follow treatment plan Needed assist w/ADLs and IADLs Placement vs. home care?

Mr. Z today

In-home care carries out tx plan Controlled HTN, adequate nutrition,

safety, “Gracie”, companionship Cost is $60/day or $2000/month Mr. Z is happy and healthy at home!

Community Care Management:

Choice

Dignity

Quality of Life.Inland Comprehensive Health Care Community Care Management, Serving the Unincorporated, Rural Regions of San Diego County