WEBINAR: Community Care Transitions Models – Integrating Low Income Senior Housing with Service
Wednesday, June 3, 2015
11 a.m. CDT
Pending CE's: 1.2 Nursing, 1.0 CCMC
We know that successful care transitions models look well beyond the acute hospital discharge, and into the post-acute setting and community. In this webinar we will explore the critical role that low income senior housing can plan. Seniors in low-income housing are a very high risk population. The majority are dually eligible for Medicare and Medicaid, they often have limited social supports, and are more likely to describe their health as poor. We now have data from both CMS (Centers for Medicare and Medicaid) and from HUD (Housing and Urban Development) that reinforce this.
LeadingAge has developed a learning collaborative, along with a resource tool kit, to describe how integrating services, supports and care transitions into affordable housing can yield remarkable results. During this webinar we will review the various components to the model, discuss challenges and opportunities related to payment, and review some successful provider examples.
As health care systems are moving to bundles and other models of shared savings, and states are rapidly looking to managed Medicaid, the “learning’ has been that improving care, reducing hospital readmissions and controlling costs can start by looking to see where the highest cost/risk senior live and integrating relatively simple programs such as care coordination, medication reconciliation, and identifying resources for transportation and meals. Sometimes the solutions to our most complex patients “are right in our own backyard”.
- Identify key risk factors related to readmissions for seniors living in low income housing
- Describe at least 4 potential components of housing-with-services
- Review resources that can be used by physicians, nurses and hospitals to integrate with service coordinators in low income housing
- Describe at least 2 models that have successfully implemented housing with services models
Cheryl Phillips, M.D., is the Senior VP for Advocacy and Public Policy at LeadingAge in Washington, D.C. Prior to this role she was Chief Medical Officer of On Lok Lifeways, the originator of the PACE (Program of All-Inclusive care for the Elderly) model based in San Francisco, CA. She has also served as the Medical Director for Senior Services and Chronic Disease Management, for the Sutter Health System, a network of doctors, hospitals and other health providers in Northern California. As a fellowship-trained geriatrician her clinical practice focused on nursing homes and the long term care continuum. In addition to being a hands-on medical director of multiple nursing homes in California, she oversaw the network development and quality oversight for Sutter’s Sacramento-Sierra region post-acute care.
Dr. Phillips is a past president of the American Geriatrics Society, the organization representing health care professionals committed to improving the health of America’s seniors; and is also a past president of the American Medical Directors Association, the physician organization for long-term care. She serves on multiple national boards and advisory groups for chronic care including the CMS Quality Assurance and Process Improvement (QAPI) Technical Expert Panel in Long Term Care, the National Quality Forum MAP Coordinating Committee, and has provided multiple testimonies to the U.S. Senate Special Committee on Aging. She served as a primary care health policy fellow under Secretary Tommy Thompson, and was appointed by the Governor as a California Commissioner on Aging and appointed to the Olmstead Advisory Committee for California. Currently, Dr. Phillips is the immediate past co-chair of Advancing Excellence, the campaign for quality improvement in nursing homes.