Health

HEALTH • Spring 2016 15 Cross-referencing PACE provides interdisciplinary health specialists who get to know each patient, their medical issues, living arrangements, medications, etc. Team members vary accord- ing to the patient's needs, said Kristine Bostek, vice president of senior care services at Fallon. The team is comprised of a pri- mary care physician and nurse, perhaps a social worker, occu- pational therapist, home-health aide, dietician or transportation staff member. The approach is completely customizable. "Somebody comes in, and we create a care plan – both physi- cal and social – and decide how often we incorporate the caregiver into their sched- ule. When someone has an episodic event [such as a fall], they may need more services. They may increase time with a therapist," Bostek said. "Once they are back to their baseline, we go back to their original schedule." The Fallon PACE centers are places to not only see healthcare providers but also get specialized care, rehabilitation therapy and social service assistance. Some members come only for appointments, other come for the daily coffee social, computer access, outdoor recreation, group discussions and more. Tufts' dementia supports Tufts Health Care, with 105,000 Massachusetts clients, has 2,000 customers in its Senior Care Option and has had a Medicaid focus for decades, said Patty Blake, senior products division president. In addition to meeting regular medical needs of older people through its Medicaid Advantage pro- gram, Tufts works to tackle an area that can unfortu- nately come along with an older population – dementia – through a unique partnership with the Alzheimer's Association of Massachusetts. Dementia can go beyond a diagnosis and snowball over time, said Blake, resulting in even more issues and costs. "Dementia or Alzheimer's will multiply other things, like how a patient takes their meds, follows doctor's orders or goes to appointments – all can be impaired," said Blake. "It's becoming a huge problem … a challenge for those who are diagnosed and their families. The longer people live, the more we'll see this as an issue." Accessibility to wellness initiatives and preventa- tive care can keep other problems and costs from escalating, she said. The free Tufts Health program for members includes an in-depth consultation, needs assess- ment, individualized care plan and follow-up with the patient's primary care physician, care manager and, of course, caregivers, who are offered resources and support. In addition to dementia, Medication reconcilia- tion is another area of focus for Tufts – such as when a senior has been hospitalized and additional medi- cation is prescribed, said Blake. Prescriptions can duplicate each other, or counteract with something else the patient is taking. Boxborough ..............................212.1% Hubbardston ............................ 263.7% Charlton .................................. 193.1% Phillipston ................................ 187.4% Douglas .................................... 181.4% Hopkinton .................................176.1% Harvard ....................................175.3% Bolton ...................................... 174.6% Ashland ................................... 160.7% Brimfield ................................. 140.0% Sturbridge ................................. 88.5% Marlborough ............................. 65.5% Worcester ................................. 29.0% Framingham ...............................27.2% Paxton .......................................27.8% Lexington ...................................21.7% Fitchburg ...................................19.6% Source: Mass. Executive Office Of Elder Affairs These are the select Central Massachusetts cities and towns the state expects to have the largest growth in those aged 60 or older. Expect growth in 60+ citizens Community from 2000 to 2020 AGING COMMUNITIES It can be very, very confusing, for a patient, she said, and it's important someone is there monitor- ing, ensuring they don't have a flare up; and if they do, addressing it quickly, so they don't end up back in the hospital. Senior Care Options – in which half of seniors in the program are nursing-home eligible – also has services for housebound seniors, who can have Richard Burke, presi- dent and CEO, Fallon Health depression, language or socio-economic barriers, among other issues, Blake said. Care teams include a pharmacist, behavioral health clinician, nurse care managers, dementia advisers and geriatric consul- tants. Nursing homes not sole solution There is a growing awareness regarding the cost of health care, especially in nursing homes, said Andy McClure of Senior Whole Health (SWH) of Cambridge, which has about 1,000 clients in Central Mass. "We can provide services without the member being in a nursing home, and as those in the health- care community have recognized that demographics are aging, there's been more interest in Medicare," McClure said. The goal is to not only keep patients out of nurs- ing homes, but also lower hospital readmission rates and the number of doctors' vis- its, said McClure. As director of quality improvement, McClure looks to huge datasets to find mem- bers who could benefit from intervention. This ensures sys- tems are in place that consis- tently produce better, measur- able results in this arena. SWH combines some PACE program aspects with a more network model of care. "A lot of what we are trying to do is supplement delivery sys- tems," said McClure. "We don't replace the doctors, but support." This can mean using data to find patients who aren't filling prescriptions and reaching out with daily-dose pillboxes, multi-month deliveries or bubble packs where meds are packaged for each day, he said. Filling in gaps McClure points to a SWH campaign at the end of 2014, where 500 of 800 women who were over- due for mammograms agreed to go have the exams. Three were diagnosed with Stage-1 breast cancer. "We facilitated that, got it at an earlier stage for a better outcome," he said. As for the 300 patients that didn't get the scans, they may have had not only language barriers but cultural barriers, said McClure. Some cultures are more fatalist and have reluctance around getting cancer screenings. "Having a nurse from that culture able to treat that patients really helps with that," he said.. The national Office of Disease Prevention and Health Promotion projects that more than 60 per- cent of Baby Boomers will be managing one more chronic condition by 2030. The group also foresees changes in family structure that will lead to fewer family caregivers, rising obesity levels and a short- age of healthcare workers, with less diversity. "We have to make sure we are managing from a preventative perspective," said Bostek. Kristine Bostek, vice president of senior care services, Fallon Health

• Cover