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December 2013 Policy Study, Number 13-12


Iowans Want to Age in Place


Innovative Care Options – Adaptation and Alignment of Existing Resources



The greatest barrier to increasing access to HCBS has been the lobby of the nursing-home industry. Despite the fact that the desire to age in place and receiving care in one’s home is less costly, more desired, results in better health outcomes, and is supported by the Olmstead decision and the BIP-grant funding for Iowa, the nursing-home industry fears the loss of “heads on beds” which will affect their bottom lines. They might be pleasantly surprised if they would align their business models with the desires of elderly Iowans. Typical to Iowa is that nearly every small town has a little care center out at the edge of town. We have all heard the story of the retired farmer and his wife who moved to town because they now have health conditions that make it difficult to remain in their home without assistance. They are moved to the nursing home to receive that care because other HCBS options in their little rural Iowa town are limited.


One new business model for the nursing-home industry to consider is to resign themselves to loss of “heads on beds” and adapt themselves to this change by converting a wing of their care facility and turning it into an adult-daycare program or applying to be a PACE site as they coordinate care with local primary care providers or regional Medicare ACOs and the statewide Medicaid ACO. They should invest in some small vehicles and additional telemedicine equipment and send their Certified Nursing Assistants (CNAs) and Registered Nurses (RNs) out into the community to provide HCBS and fill these gaps in needed services.


They will still be able to bill Medicare and Medicaid and other private insurance as they have been, but the types of services they bill for may change. Also, by aligning their business model with the goals of their regional Medicare ACO to achieve the 33 ACO quality measures, they could reduce the 30-day readmission rate through medication reconciliation, increased care coordination, and assistance with discharge planning.[81] These are the three key components of reducing the hospital 30-day readmission rate as noted by AHRQ in 2013.[82] This alignment would further provide an avenue for the nursing-home industry to participate in the shared- savings incentives of the Medicare ACO model.


Another opportunity to align and adapt existing resources to the changing demographic landscape of our aging state is at the intersection of two generations. Currently the United States has an unemployment rate among young adults (age 15-25) of 16.2 percent and rising.[83] Students attending community colleges or universities often come out of their programs without any practical experience in their new field. Additionally, there is growing need to provide for the rural elderly in Iowa to receive care in their homes so they may “age in place.” So in a sense there is an opportunity here for those in the spring of their lives to serve the needs of those in the autumn of theirs. By requiring just three service-learning credit hours for all students in various curriculum programs, the needs of rural elderly could potentially be met at a tremendous overall social savings.


A program that utilizes student labor in coordination with an ACO based in a hospital system could supply the trained and precepted labor force needed to carry this out. Students in medicine, physician assistant, physical therapy, occupational therapy, nursing, social work, pharmacy, and public-health programs would be engaged in activities related to discharge planning, care coordination, medication reconciliation, patient and caregiver education/ communication, and preventative services. Financially, the program would be sustained by the tuition funds charged for the service-learning credits and would support licensed preceptors in pharmacy, nursing, social work (SW), occupational therapy (OT), physical therapy (PT), and public health (PH). In addition, many of the services provided under the guidance of a licensed preceptor can be billed to private-pay insurance, Medicare, Medicaid, or included as part of the costs associated with either a capitated payment from CMS to an ACO or realized as a part of their Medicare shared-savings incentives.[84]


Once appropriate background checks have been conducted and liability coverage extended to the students, they would complete a 40-hour training related to their specialty as well as gerontologically appropriate health strategies that can be applied during their service times. Students would be required to spend eight hours each week over the course of the remaining 12 weeks of the semester in the personal homes of the elderly who have been recently discharged from a hospital stay for pneumonia or congestive heart failure (CHF).


Specifically, students in professional programs would be utilized to address length of stay, the 30-day readmission rate, patient satisfaction, and the completion rate of discharge summary within 48 hours as they utilize strategies and programs that address the contributing factors related to these outcome measures. For example, social-work students will work with discharge planning policies and processes instituted at the organizational (hospital) level to coordinate care transitions from hospital to home with the goal of utilizing HCBS providers whenever possible. In addition, these students would be trained in options counseling and Medicaid case-management processes as they work to ensure patients are ready for discharge and are connected to all services and supports they may need to make a successful transition from the inpatient setting.


Nursing students would impact patient satisfaction as they help patients ready for discharge, expedite the discharge process, teach home-care instructions to the patient and caregivers, and follow up with the patient and caregivers within 72 hours by phone.[85] Additionally, nursing students may also conduct wound checks, weekly or bi-weekly health inventories to include weight, blood pressure, pulse, basic physical exams, and compliance with their prescribed medication and diet regimens. Based on findings, they may make referrals to the social-work students, pharmacy students, PT/OT, or the patient’s regular primary care physician for further follow-up. Students may take advantage of tele-medicine/tele-health innovations with the use of iPads equipped with Skype software. These students may then interact with both the patient and a licensed preceptor at a distance.


Pharmacy students under the supervision of a licensed pharmacist will ensure the patient has their prescribed medications and check to identify drug interactions or overlaps that may have occurred due to the recent hospital admission. In addition, pharmacy students would be responsible for filling all patient prescriptions prior to discharge. The pharmacy student will conduct a patient and caregiver education appointment prior to discharge and again once the patient is at home, within three days of discharge, insuring medication is being taken as prescribed as well as watching for possible drug/drug and drug/food interactions. The student will conduct a phone questionnaire to determine whether an in-person intervention is necessary within two weeks post-discharge.


Public health students would be precepted by a licensed PH social worker or PH registered nurse and the following population health management and patient health education/interventions conducted: 1) advising smokers to quit, then discussing smoking cessation medication and strategies; 2) administering influenza and pneumovax vaccines; and 3) verifying that medication reconciliation was completed upon or within 30 days of hospital discharge.[86] Occupational therapy provided support for older adults experiencing physical and cognitive changes, often as a result of a recent hospitalization.[87] OT and PT students may offer exercise assistance, companionship for walking, or other activities to improve physical health and fitness and improve ability to perform both ADLs and IADLs.


Some key assumptions are that the PPACA sets the policy platform for CMS to offer payment incentives when quality indicators such as reduced 30-day readmission rates are met. Additionally, the professional programs in higher education would have to require three service- learning credits as part of their curriculum to supply the labor force. Also, hospital and school administrators would need to be amenable to having precepted students carry out the program tasks. Assuming that enough licensed preceptors are available to supervise the students, many of their precepted services could potentially be billed through private pay, Medicaid, and Medicare insurances. With tuition funds covering some administrative and supervisory fees, the transportation, telecommunication, and other related costs would need to be funded through a combination of higher-education service-learning grants and insurance billing. In a teaching hospital setting, assumptions that students will be a part of some component of a patient’s care are made.


Some potential barriers to a program such as this are the same as what the assumptions are based on – having enough money and personnel to run the program. Another potential barrier could be having “students” performing many of these tasks and having the patients and their caregivers perceive less than adequately trained or experienced personnel are “practicing” on them. Feeling like a “guinea pig” or “training ground” can make many patients and their families feel uncomfortable. If this barrier is realized early on in the process evaluation, then administration will need to staff additional licensed personnel to make face-to-face contacts with the patients ahead of, or in tandem with, the students.


Grant funding opportunities exist with several non-profit organizations and trusts that support service learning in higher education innovations, and an additional start-up funding option would be for the hospital-system-based Medicare ACOs and the State Medicaid ACO to support this type of innovation in collaboration with the Iowa Board of Regents.


If nothing else, a demonstration project in one area of Iowa could give important feedback on whether or not such a program could be successfully implemented and create a win-win-win situation for the state’s budget, the patients who want to “age in place,” and the students who would gain valuable real-world experience to help them secure paying positions in our expanding health care sector of the economy. This is a good idea whose time has come. It deserves a try by our politicians and health care educators and administrators.




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