Notes and Disclaimers:
- Projects shown may also be operating in other states (see the Geographic Reach)
Project Title: "Avera Virtual Care Center: Improving Care & Reducing Costs for the Vulnerable Elderly Population"
Geographic Reach: Iowa, Minnesota, Nebraska, South Dakota
Estimated Funding Amount: $8,827,573
Summary: The Avera Virtual Care Center project will test the virtual wrapping of a set of comprehensive, resident-centered, geriatric care services around the long term care population. The project will operate in facilities located in South Dakota, Minnesota, Iowa and Nebraska. The three primary drivers of this project include: building the assessment capability and toolkits of the long term care team of care providers; providing long term care facility residents with routine and early access to appropriate goal-directed care; and improving management of care transitions. A Virtual Care Team will host INTERACT II training sessions and skill building workshops for long term care staff and will facilitate widespread implementation of INTERACT II tools and treatment algorithms to support earlier identification of urgent issues. The INTERACT II implementation will be further supported by high-quality care planning resources and training to promote alignment of resident care goals and treatment plans. To address the geriatric care access gap, the Virtual Care Team will offer daily rounds, comprehensive geriatric assessments and urgent care visits to address resident health needs in a timely manner. These services will be provided out of a centrally staffed telemedicine hub, spreading the expertise of one team over 30 long term care centers. To maximize safety and continuity across transitional points in care, the Virtual Care Center team will promote the adoption of standardized tools and processes.
Project Title: "Person Centered Care Connections"
Geographic Reach: Minnesota
Estimated Funding Amount: $3,347,584
Summary: The CareChoice Cooperative project will test Person Centered Care Connections, which will build on and expand another successful CareChoice project, Resident Centered Care Connections, in an effort to reduce unnecessary hospitalizations and total cost of care by using four essential care components to address problems and gaps in nursing home post-acute and long term care. These four components are INTERACT (Interventions for Reduce Acute Care Transfers), POLST (Provider Orders for Life Sustaining Treatment), palliative care and enhanced discharge planning. INTERACT is an evidenced-based process for reducing hospitalizations from nursing homes by improving communication among caregivers and between the nurse and medical provider. INTERACT empowers nursing assistants to recognize and report changes in patient and residents’ condition and promotes concise and thorough communication between the nurse and medical provider when relaying changes in patient and residents’ condition. POLST encourages informed decision-making about goals of care and desired treatments and makes these patient and residents’goals and desires actionable physician orders for care providers. Palliative care is an approach that endeavors to provide care consistent with the patient and residents’ defined goals of comfort, pain and symptom relief. It increases quality of life for people with chronic or life-threatening illnesses. The proposed enhanced discharge planning process includes using evidence-based components of Project RED (Re-engineered Discharge) and available technology to create an efficient system for nursing home staff to do the comprehensive education and preparation needed by patients and families to promote a successful patient and residents’ transition from care setting to home. Together, these four components of care have proven effective in reducing hospital admissions, enabling patient determined goals of care and improving palliative care for the patient and residents’ of CareChoice nursing homes over the past three years.
NATIONAL HEALTH CARE FOR THE HOMELESS COUNCIL
Project Title: "Medical Respite Care for People Experiencing Homelessness"
Geographic Reach: Minnesota, Oregon, Connecticut, Washington, Arizona
Estimated Funding Amount: $2,673,476
Summary: The National Health Care for the Homeless Council (NHCHC) is receiving an award to test a model that will provide medical respite care for homeless Medicaid and Medicare beneficiaries, following discharge from a hospital with the goal of improving health, reduce readmissions, and reduce costs. Medical respite care is defined as acute and post-acute medical care for homeless persons who are too ill or frail to recover from a physical illness or injury on the streets but are not ill enough to stay in a hospital;these programs can provide a cost-effective discharge alternative for hospitals and provide patients with a place to receive ongoing post hospital care while working on their health and housing goals. The service model will incorporate evidence based practices including transitional care, patient centered self-management goal setting, and case management to address socio-economic and other factors affecting health outcomes and access to timely and appropriate care.