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  • American Society on Aging – MediCaring.org
    Society on Aging annual conference this week Posted by Janice Lynch Schuster on March 11 2013 No Responses Tagged with advocacy American Society on Aging care transitions community mobilization frail elders Marshall Ganz public narrative Mar 11 2013 Meet us in Chicago Tomorrow marks the start of the annual American Society on Aging meeting and Joanne Lynn MD MA MS Judy Peres LCSW and Janice Lynch Schuster MFA will be there as faculty members authors and participants On Thursday and Friday you can catch Janice and Joanne at 1 p m in the Main Exhibit Hall where we will wo man the Authors Island exhibit Purchase a signed copy of our book Handbook for Mortals Guidance for People Facing Serious Illness which offers practical advice and human comfort to patients and loved ones Friday early birds can participate in Joanne and Judy s workshop Community Control of Integrated Services for Frail Elders A Sustainable MediCaring Model a 60 minute Workshop to be held in Columbus IJ East Tower Gold Level Hyatt Regency Joanne and Judy will describe our strategy for making it safe to grow old and ways we can improve aging services to effectively meet the complex needs of frail elders and their loved ones At 11 a m Friday Joanne and Janice will present their workshop Four Kinds of People Caregiving and the Women s Movement Regency D West Tower Gold Level Hyatt Regency The talk will inspire you to act up a little or a lot in your own community with a focus on using public narrative theories to engage partners and push for improvement It will be an exciting week If you d like to catch up with Medicaring coffee always welcome send us an email at email protected and we ll see what we can

    Original URL path: http://medicaring.org/tag/american-society-on-aging/ (2016-04-30)
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  • community organizing – MediCaring.org
    and Janice Lynch Schuster went well and were well received Judy and Joanne introduced participants to the Medicaring plan a five part approach to redesigning how we care for frail elders You can read about this in more detail in a post Joanne Lynn wrote for the Altarum Institute Health Policy forum a few months ago http www altarum org forum post call action boomers we grow old Janice and Joanne delivered a talk aimed at motivating participants to speak up and speak out to recognize when things are going poorly in care and services and to respond in ways that improve the situation The talk focused on a fascinating theory of community organizing developed by Marshall Ganz of Harvard public narrative and telling the story of I Us Now to galvanize change We would enjoy hearing from others who were at the conference who would like to share details of their presentations with Medicaring readers Just send an email to email protected and we will respond to you MediCaring is a service of the Center for Elder Care and Advanced Illness at Altarum Institute Follow Us To receive our email newsletter send a request to email protected Tweets by medicaring Care Transitions News Ringling Bros circus elephants set for final act Sunday USA TODAY April 29 2016 PMH announces Annette Schnabel as president CEO Bureau County Republican April 29 2016 College baseball Weekend Preview April 29 May 1 NCAA com April 29 2016 AbbVie Doubles Down on M A Bloomberg April 29 2016 Aspen Valley Hospital reaps awards for patient experience Aspen Times April 29 2016 Optimizing care transitions the role of the community pharmacist Dove Medical Press April 26 2016 3 lessons to improve patient care transitions FierceHealthcare April 21 2016 Dave Alfano Launches Caring Transitions of Central

    Original URL path: http://medicaring.org/tag/community-organizing/ (2016-04-30)
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  • Multidisciplinary Teams Essential to MediCaring Work – MediCaring.org
    therapists speech pathologists physician specialists nutritionists pharmacists dentists home health aides lawyers clergy and others can be included on the team as needed Depending on the elder s specific need any member of this core team can respond to the elder s needs for care and coordinate treatment and services MediCaring builds on and ensures primary care for elders whose needs are complex and challenging Such care is not the primary care we hear about in discourse that has become so common a physician who provides routine prevention and screening offers education about chronic disease self care and coordinates services by specialists Rather MediCaring is primary care on steroids necessitating a high functioning team that can deal with very complicated puzzles of needs and responses Core team members would hold biweekly meetings to discuss elders in their care and review and update plans of care Care would be delivered accordingly During each visit with an elder the visiting provider would conduct a medication review and pain and symptom assessment as well as to assure that the full range of biopsychosocial needs specified in the care plan were being met MediCaring uses geriatric principles and palliative care standards and approaches but is not limited to the medical aspects of service to the frail elderly population Indeed a major part of the endeavor is to shift resources from wasteful and unnecessary medical care toward greatly needed social supports that are mostly provided outside of the medical profession and even outside of the nursing profession MediCaring Community teams aim to be all inclusive in order to meet the unique care needs of frail elders key words Joanne Lynn Janice Lynch Schuster Judy Peres MediCaring book interdisiplinary team multidisciplinary team Tweet Pin It Leave a Reply Cancel reply Your Comment You may use these

    Original URL path: http://medicaring.org/2014/05/14/multidisciplinary-teams-essential-to-medicaring-work/ (2016-04-30)
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  • interdisciplinary teams – MediCaring.org
    not the primary care we hear about in discourse that has become so common a physician who provides routine prevention and screening offers education about chronic disease self care and coordinates services by specialists Rather MediCaring is primary care on steroids necessitating a high functioning team that can deal with very complicated puzzles of needs and responses Core team members would hold biweekly meetings to discuss elders in their care and review and update plans of care Care would be delivered accordingly During each visit with an elder the visiting provider would conduct a medication review and pain and symptom assessment as well as to assure that the full range of biopsychosocial needs specified in the care plan were being met MediCaring uses geriatric principles and palliative care standards and approaches but is not limited to the medical aspects of service to the frail elderly population Indeed a major part of the endeavor is to shift resources from wasteful and unnecessary medical care toward greatly needed social supports that are mostly provided outside of the medical profession and even outside of the nursing profession MediCaring Community teams aim to be all inclusive in order to meet the unique care needs of frail elders key words Joanne Lynn Janice Lynch Schuster Judy Peres MediCaring book interdisiplinary team multidisciplinary team Care Management Effort Integrates Care for Low Income Elderly Patients Care Transitions 1 Response Sep 26 2011 AHRQ Innovators Exchange features information and a video about a pilot study to improve care for low income elderly patients with chronic illnesses http www innovations ahrq gov content aspx id 1746 Conducted by Ohio based Summa Care under the leadership of Practice Change Fellow http www practicechangefellows org and Advisory Board Member Kyle Allen DO AGSF the project reports that 70 of participants reported improved health and 93 rated their experience as good or excellent one year after participation The program led to cost savings of approximately 600 to 1000 per patient per month as a result of decreased hospitalizations Summa Health is now conducting a three year randomized controlled trial to confirm these results Summa Health System developed a program called the Frail Elders Care Management Program The project involved interdisciplinary teams that provide integrated medical and social care management to low income elderly in patients who have chronic illnesses The program aimed to ease the transition from hospital to home provide preventive care identify new and emerging problems reduce readmissions and prevent functional decline Most participants were over the age of 65 had several chronic conditions and impaired activities of daily living and had one or more problems that required an intervention For example nearly 40 of patients took more than 10 prescriptions and nearly 50 had experienced one or more falls The project featured an interdisciplinary team whose members included a geriatrician an advanced practice nurse a registered nurse care manager a social worker and a geriatric pharmacist Other clinicians were called on as needed Primary care physicians who then received

    Original URL path: http://medicaring.org/tag/interdisciplinary-teams/ (2016-04-30)
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  • multidisciplinary teams – MediCaring.org
    members should include at the very least a physician nurse practitioner nurse and social worker Other direct providers such as physical therapists respiratory therapists speech pathologists physician specialists nutritionists pharmacists dentists home health aides lawyers clergy and others can be included on the team as needed Depending on the elder s specific need any member of this core team can respond to the elder s needs for care and coordinate treatment and services MediCaring builds on and ensures primary care for elders whose needs are complex and challenging Such care is not the primary care we hear about in discourse that has become so common a physician who provides routine prevention and screening offers education about chronic disease self care and coordinates services by specialists Rather MediCaring is primary care on steroids necessitating a high functioning team that can deal with very complicated puzzles of needs and responses Core team members would hold biweekly meetings to discuss elders in their care and review and update plans of care Care would be delivered accordingly During each visit with an elder the visiting provider would conduct a medication review and pain and symptom assessment as well as to assure that the full range of biopsychosocial needs specified in the care plan were being met MediCaring uses geriatric principles and palliative care standards and approaches but is not limited to the medical aspects of service to the frail elderly population Indeed a major part of the endeavor is to shift resources from wasteful and unnecessary medical care toward greatly needed social supports that are mostly provided outside of the medical profession and even outside of the nursing profession MediCaring Community teams aim to be all inclusive in order to meet the unique care needs of frail elders key words Joanne Lynn Janice Lynch

    Original URL path: http://medicaring.org/tag/multidisciplinary-teams/ (2016-04-30)
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  • Think Globally, Improve Locally: The Case for Local Management in Care of Frail Elders – MediCaring.org
    assessing monitoring and managing services How might this begin to work In a community of 50 000 people it is reasonable to expect that about 500 frail elders need services at any point in time Imagine how different frail elders lives would be if each one had a comprehensive longitudinal care plan developed in concert with a multidisciplinary MediCaring team That team would have ready access to those plans and a commitment to ensuring that priorities were known and addressed That team would also track outcomes and shift course to correct gaps Such an approach would be a real advance in delivering reliability quality and efficiency in care Those care plans could be used to evaluate a community s overall services system both in terms of quantity and quality Planners and providers could readily see for example instances in which a particular service was oversupplied and overutilized when a less costly service could have met the need Consider for instance that our community has so many nursing home beds that it is simply routine and expedient to house people in those beds and not in the community Aggregating care plans and using them in system planning would allow for ongoing monitoring that could in turn enable system managers to more readily address variations and anomalies that affect utilization and outcomes For example perhaps the 50 people who had a major fall with injury last year had widely varying response ranging from some who received many tests and procedures followed by rapid institutionalization to those who got short term treatment focused assessment including in home evaluation and modifications and supports in the home If the more streamlined treatment group were found to have equal or better outcomes and was in other ways similar to the other cohort perhaps clinicians responsible would decide to change their practice patterns Taking a broader view we could begin to plan for greater efficiencies Consider another example Let s assume that a dozen people in one apartment building need home care aides Rather than sending in a dozen workers for morning activities and another dozen for evening with a 3 hour minimum work requirement for each perhaps we could move a few around within a small area say a few square blocks or miles and cover all service needs with half as many aides who would also know with greater certainty how many hours they would be working It is also possible with a more efficient system to pay these workers higher wages and concentrate their time on providing services rather than driving or commuting between far flung homes Periodic review of aggregated care plans would also make it possible to rapidly identify and investigate ineffective services that are being recommended For example many persons with a vertebral fracture do not need multiple scans and procedures Likewise an elder with attentive family in the area is unlikely to need grocery delivery However there is no such planning monitoring and rational management of the services for frail

    Original URL path: http://medicaring.org/2014/05/01/think-globally-improve-locally-the-case-for-local-management-in-care-of-frail-elders/ (2016-04-30)
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  • Joanne Lynn – Page 2 – MediCaring.org
    pay for services Fourth Americans must be educated about how to make smart financial and health care decisions earlier in life so that the odds of postponing a long term care event are increased and the odds of being financially ruined by such an event are decreased The December issue of The Atlantic features an essay by Jonathan Rauch The Hospital Is No Place for the Elderly The information will not surprise those immersed in these issues but it provides a clear and compelling story that might attract others and provide a basis for understanding what is wrong with the current system and how it might change Rauch quotes Dr Lynn who describes the frailty course And finally yesterday s New York Times included Dr Pauline Chen s take on a new book The American Health Care Paradox by Dr Elizabeth H Bradley and Lauren A Taylor on how it is that America can spend so much money on health care and come up with less than remarkable outcomes As Chen writes the reason the richest country in the world doesn t have the best health is because it takes more than health care to make a country healthy Chen writes the most thought provoking writing focuses on America s previous attempts to integrate social services and health care delivery It is a sobering list of near misses and what if s testimony to the intractable power of cultural attitudes It is all worth considering Share your thoughts too on what you make of this work and where we need to head key words Joanne Lynn Jonathan Rauch Pauline Chen Elizabeth Bradley Lauren Taylor frail elders JAMA Theme Issue features MediCaring article by Dr Joanne Lynn Posted by Les Morgan on November 12 2013 No Responses Tagged with JAMA Joanne Lynn Medicaring MediCaring4Life Nov 12 2013 The new theme issue of JAMA Journal of the American Medical Association features a dozen opinion pieces that address critical issues in US health care including Reliable and Sustainable Comprehensive Care for Frail Elderly People by Dr Joanne Lynn director of the Center for Elder Care and Advanced Illness at Altarum Institute In her Viewpoint essay Lynn describes the MediCaring model for improving care for frail older adults by integrating health and social services with monitoring and management by local communities Today she joined JAMA editor in chief Howard Bachner M D Hamilton Moses III M D Ezekiel Emanuel M D and Ph D Joshua Sharfstein M D for a briefing at the National Press Club in Washington D C Dr Lynn is among the audience in the cover art included here A limited number of downloadable copies of the article are available via a JAMA E print link on the page covering this story on the Altarum web site You can watch a 35 minute video of Joanne Lynn s remarks via the YouTube video shown below You also can download the PowerPoint presentation that she speaks about in the video You can also view a YouTube video of the entire press conference Lynn said We almost all get to grow old it s the terrific success of modern medicine Indeed she noted that those lucky enough to grow old including millions of Boomers now on their way face a health care system not designed or equipped to meet the essential needs of very old people for continuity of care community based services access to nutrition and transportation and help for family caregivers Lynn writes that requiring a comprehensive realistic assessment of each frail elderly person s situation and development of a shared plan of care is the keystone of highly reliable effective and affordable care These care plans would inform and direct a person s care and build the delivery system we need in advanced old age Anchoring the effort in the communities where people live will make them more effective and will allow savings from more efficient medical care to be used to support social services a plan that Dr Lynn calls MediCaring ACOs Lynn concluded today s remarks with a sense of urgency and a call to action It s not a hotshot pill anymore it s how people are going to live with these conditions she said We have about a decade to get it right In earlier posts for Altarum s Health Policy Forum Lynn has written about her vision for creating and testing the MediCaring model And in a recorded session she highlights just how that vision might play out viaa proposal to demonstrate MediCaring4LIFE in 4 communities around the country That proposal is now under review at the Centers for Medicare and Medicaid Innovation key words Joanne Lynn JAMA MediCaring Medicaring4LIFE National Family Caregiver Month Center for Elder Care and Advanced Illness Work to Make Life Better Posted by Janice Lynch Schuster on November 12 2013 No Responses Tagged with Altarum Institute Caregiver Corps family caregivers Joanne Lynn Medicaring Nov 12 2013 By Janice Lynch Schuster November is National Family Caregiver Month in which the nation turns however briefly to honor and reflect on the essential role family caregivers play in delivering essential care to millions of adults While caregivers are essential to bridging the gaps in our fragmented health care system their contributions are often diminished and overlooked and are rarely reimbursed Caregivers are key to providing basic medical care but are even more vital for the love hope companionship and devotion they bring to the people they serve At the Center for Elder Care and Advanced Illness several current efforts offer the potential to improve life for our frail elders and in doing so make the world a little easier for their caregivers Chief among these is ongoing work to promote MediCaring a model that would provide important medical treatment and health care while also focusing on what frail elders and their families need even more things such as continuity of care community based services access to nutrition and transportation and help for family

    Original URL path: http://medicaring.org/tag/joanne-lynn/page/2/ (2016-04-30)
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  • Learning from Reviewing Readmissions: Tools You Can Use – MediCaring.org
    to learn You might start with the IHI form and then try filling out the other two to see what additional elements you might consider Call a few patients or families or if that is not appropriate call the main attending physician in the community Try to gain some insight from the perspectives of people involved Keep track of the time it takes to do this review If you can get someone to pull the charts the work to this point will take about two or three hours Of the time involved what seemed most productive and what was most illuminating Then put together your own form starting with whichever one is most suited and adding or deleting the elements to end up with the ones that you found to be most useful Test that form on another two or three records perhaps asking a colleague to do those to learn what instructions are needed and whether another perspective identifies other things that are very important to include My prediction would be that you ll find some remarkable stories people in fragile condition whose community doctors did not really know they were out of the hospital or doctors who were unfamiliar with the patient s situation and medications people who could not afford the treatment prescribed and people who simply greatly misunderstood what they were to do I recall the patient who told me about having to eat fresh vegetables for his heart whereupon he opened a fresh can of peas every day Those stories will greatly help you galvanize the will to move ahead And you ll have a process and form that you can persuade the quality improvement team at each hospital to do Perhaps at large hospitals five each week for four weeks and at small hospitals five in the month Within a month you d have enough data and stories to build the endeavor and continuing to collect the data provides rapid feedback about progress Pick a lead intervention or two and get it tested and underway You are likely to find a certain sense of chaos that there is a lot of catch as catch can processing with thorough unreliability on all sides If this is the case your coalition might well work on standardizing the process simply so that it is reliable You may find that the issues affecting the frail elders are different from those affecting younger populations more complexity and fragility in the elders and more lack of access or barriers arising from mental illness in the younger Whatever you find this is the root cause analysis that you ll need to decide priorities and to apply for CCTP funds Key words root cause analysis reviewing readmissions discharge record review quality improvement tools CCTP funding Tweet Pin It Leave a Reply Cancel reply Your Comment You may use these HTML tags and attributes a href title abbr title acronym title b blockquote cite cite code del datetime em i q cite s

    Original URL path: http://medicaring.org/2011/08/08/learning-from-reviewing-readmissions-tools-you-can-use/ (2016-04-30)
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