REFORM IN MOTION

Lessons from the SeniorChoices Long Term Care Demonstration 

May, 2007

Village Care of New York

Herbert H. Fillmore
Executive Vice President SeniorChoices

Arthur Y. Webb
President & CEO

Support for this report provided by a grant from the New York State Department of Health to Village Center for Care, Grant Number:   C-012150

Initial Report (October, 2005- March, 2006)

Suggested citation:

Fillmore, H., Webb, A., Reform in Motion, Lessons from Village Care’s  SeniorChoices Long Term Care Demonstration Project, http://www.vcny.org, 2007

Copyright 2007 © Village Care of New York.

Acknowledgements

We would like to thank the following individuals and entities for their contributions to this report, and/or the work of SeniorChoices.  The Board of VCNY, Charles Persell, Board Chair,  Msgr. Chuck Fahey, SeniorChoices Committee Chair, Allison Nidetz, VCNY PACE administrator, Neil Pollack, VCNY Village Nursing Home Administrator, Natalie Zarrillo, VCNY Care Advocate, Renee Cottrell, Director, Lightbulb Project, Kathy Triche, PhD, Director NNORC, Ellen Flaherty, PhD, VCNY VP for Quality, Allison Silvers, VCNY Director of Strategic Grants and Business Development, Lou Ganim, VCNY Director of Public Relations, Emma DeVito, COO & EVP of VCNY, the other members of the executive team at VCNY, the staff of the Village Nursing Home who participated in the architectural design sessions and Building for the Future Committee, staff and leaders of 1199 SEIU, the leaders and staff of the New York State Department of Health,  the The Fan Fox & Leslie R. Samuels Foundation

for early support of our NNORC  work, the Tuttle Foundation for support of the Lightbulb Project, the New York State Health Foundation for support of Day Rehab,  Diana Sung and her team at Perkins Eastman Architects, Alex Stark, Feng Shui consultant, Manny Halperin, Ergonomics consultant,  the staff and leadership of the Caring Community, Saint Vincent’s Manhattan, the Rusk Institute Rehabilitation Network, our many other community partners, and the seniors of lower Manhattan who inspire and teach us every day.

Foreword   

Arthur Y. Webb, President & CEO, Village Care of New York

Our board and staff have been deeply engaged in preparing Village Care to lead and manage change. In preparing this report, it gave us a chance to step back and   see what we have done over the past 18 months. We are proud of our work and the leadership that our staff demonstrates everyday.

Trying to balance our day to day work while introducing a major transformation was extremely challenging. During the past 18 months, it has taken all the patience, persistence, and promotion by our board and senior executives to make progress on our promise of a better day for seniors in our community.

The people we serve everyday are always in the front of our thinking. Indeed, if the seniors do not see value in what we are doing, then it really does not matter what new services or reform we produce. It is all about meeting needs at the local level. Being in tune and staying in touch are key to our efforts.

There are two essential lessons from our work that are reflected in this report: first is a vision of what the system of care will look like 10 years from now; and second is the absolutely essential requirement of having ALL staff at all levels of the organization deeply engaged and committed to this vision. On both counts we are making strides.

Village Care
SENIORCHOICES DEMONSTRATION

Executive Summary- First 18 months

Under legislative demonstration authority established in 2005 in Public Health Law section 2807-x, Village Center for Care (VCC) has embarked upon a four-year initiative to implement an integrated residential and community long term care system named SeniorChoices. This report documents the progress and lessons learned from our first eighteen months of operations.

Our most significant milestone was the creation of a new model for skilled nursing facilities. We also made strides in shifting the overall focus of our senior services from institutional to community-based care and from care provision in single sites to care provision and management across time, place and discipline.

Creating a new, state-of-the-art facility required a dedicated team of clinical and administrative staff, nationally recognized architects, Perkins Eastman, a construction firm, “green” consultants, and engineers.  This team balanced cost, design, clinical needs and customer preferences to design a state-of-the-art nursing center. 

This facility, named the Village Center for Rehabilitation and Nursing (VCRN), will maximize independence, dignity, and quality of care. More than 50 percent of the rooms will be private. Dining areas are “home-like.” The rehabilitation space offers the best equipment available. On two special residential floors, end-of-life, palliative care will be delivered in a calming environment that will allow family and friends to gather for the last journey of life.

Another important feature of this facility will be the utilization of the latest information technologies, including an Electronic Medical Record (EMR) and decision support system to improve clinical care, promote worker empowerment and assist with care management and transitions within and across the system of care we are building. An additional key technology will be the advanced wireless communication devices deployed throughout the building for all staff to promote teamwork and more responsive customer service. 

In anticipation of the new facility, we also undertook extensive work to define new roles for frontline workers. To this end, 1199 SEIU acted as partners in laying out a process to define these new roles, develop needed training and prepare transition plans for current job-holders. 

In addition to our work on a new nursing home model we also designed and implemented a new set of specialized residential and community services—often in partnership with others—that offer specialty care in response to the needs expressed by consumers and professionals in the community. 

These efforts will provide alternatives to traditional long term residential beds.  We doubled the number of short-stay rehabilitation beds at the Village Nursing Home to 70 beds, with new specialties in cardiac, wound, orthopedic and stroke care as part of the Rusk Institute Continuing Care Network.  New specialized dementia, Parkinson’s, and behavioral services were introduced into community programs.  We developed a short-stay day-rehabilitation program for the interdisciplinary post-acute care of individuals in a day care setting. We implemented a new Neighborhood Naturally Occurring Retirement Community program to provide case finding, health screening and referral services to seniors who are isolated and underserved.  One hundred and twenty five Long Term Home Health Care Program (LTHHCP) “slots” were opened in Manhattan. We submitted an application for 80 Assisted Living Program (ALP) beds. Finally, we secured the authority to pursue a Program of All Inclusive Care for the Elderly (PACE) license, and planning is well underway for that program to open at the end of 2008.

Lessons for Village Center for Care as a provider

1. Building specialized capacity to serve complex cases is required to meet emerging needs: One of the most exciting and productive lessons came from implementing specialized services. This specialization increased our capacity to serve complex patients in multiple settings and established a platform for future growth.  Consumers and other providers are demanding specialization. As care moves into the community, it is necessary to take some of the specialty services that were housed in institutions and make them available in the community.

2. Involving the Community: The Village Nursing Home was “saved” by the community 30 years ago. We have very strong ties to our community. We worked closely with the community in the design of the new nursing home and exploring alternatives to institutional beds. We learned that our community and families are not averse to moving away from institutional-centric approaches, but they are cautious, and want the alternatives to feature strong clinical care, a full set of choices, and demonstrate the ability to help seniors negotiate transitions.

3. Building Community Services Requires New Ways of Doing Business: VCC has opened many new programs with the goal of offering a wider array of choices. We found that getting approval, maintaining compliance and achieving fiscal viability is extremely hard while simultaneously transforming our organization to manage more services across a number of non-institutional settings.

4. Importance of Partnerships:  The needs of seniors are complex and must be met in a variety of settings. A truly comprehensive system will provide integrative mechanisms across those settings. It will begin by building on clinical partnerships and grow those into program partnerships. We have seen success in this area with NYU/Tisch/Rusk, St. Vincent's Hospital and Medical Center, the Caring Community, specialty associations and specialty providers.

5. Quality Outcomes for Systems are Needed: We need new quality measures to track and evaluate the transition of patients across settings. We will be developing these measures and others that are good indicators for the quality of care advocacy.

Lessons for Policy Makers

1. Regulatory and Licensing need to move at the pace of change: The major lesson is that the governmental approval process needs to be examined to bring it into line with system building at the provider level. Building an integrated residential and community care model requires having all the pieces in place in a timely manner.  

For example, we are downsizing our community’s skilled nursing capacity from 200 beds at VNH to 105 beds at VCRN. However, the individuals who would have been admitted to the 95 decommissioned beds still have a need for care.  Many of those individuals have advancing memory loss and need some congregate residential care, albeit not 24 hour skilled nursing. Our solution for this issue is to create a specialized Assisted Living Program (ALP) in the community. The regulatory approval process for that ALP will need to be brisk if that program is going to be “on line” when the existing nursing home closes and the ALP beds are needed. This problem of trying to synchronize the regulatory approval process to “bring up” new programs while rightsizing older ones is not unique to us.

2.   Construction cost bed caps need to be revised: Real estate and construction cost escalations are extreme in Manhattan and current reimbursement methodologies do not recognize these realities and will restrict the replacement and growth of new centers for care.

3.   Certain building requirements need to be re-examined: There are some regulatory requirements that contribute to unnecessary costs. In this environment, even marginal unnecessary regulatory requirements can have a large dollar impact.

4.   Capacity to serve SNF patients in the community: Dollars are needed for diversion and SNF outplacement for residents seeking to return to community: examples include rent deposits, potential modifications to the home and brief rent supplementation while securing additional funds. The most common barriers to diversion and resident outplacement are lack of housing and patients’ mental health conditions. Regulations and payer policies limit efficient/effective combination of resources (example: limited ability to provide coordinated medical day and home care)

5.   Dementia care cannot be managed in the home over long periods of time: We are finding that in an urban environment we cannot create sufficient safe capacity in the home. There is not sufficient “social capital” in the community or among relatives and friends to fill the needs for supervision, and scattered housing is economically inefficient. We need dedicated ALP beds to serve the dementia population and transfer the expertise we have gained in the nursing home to this setting, where most of our residents could live safely.

6.   A new licensed entity is needed to promote comprehensive coordinate systems of long term care, the Long Term Care Integrated Delivery System (LTC IDS).

Reform in Motion-- Lessons from the SeniorChoices Long Term Care Demonstration

Introduction

In late 2005, Village Care of New York embarked on a four-year New York State sponsored demonstration initiative to explore long-term care reform through implementation of an integrated residential and community care model.  This new model, called SeniorChoices supports five distinct goals:

• Create a new role for residential care.

• Build community capacity that supports diversion and transition.

• Create systems that integrate care across all settings.

• Transform and transition the long-term care work force.

• Evaluate the progress and success of the various ventures.

SeniorChoices is a direct outgrowth of the Village Care Board’s vision to:

• make growing old in the community a better proposition by offering seniors access to services and supports that are accessible, affordable, safer, preferential and that effectively combine medical and non-medical interventions; by

• creating a consumer-focused comprehensive care model with consumer focused care management to help seniors access services within the network; and by

• being a strong advocate for seniors within the community and within larger public arenas.

That vision and the principles embodied therein are the guiding force for this demonstration. The first year and a half of the demonstration, which is authorized under Public Health Law 2807-x (Long-Term Care Demonstration Projects, see Appendix A), and undertaken with the support and collaboration of 1199 SEIU United Health Care Workers East, focused on creating new services and staff competencies at the existing nursing home,  gaining a more complete understanding of consumer needs and preferences, creating the new role of a care advocate, building partnerships, creating community-based specialties, and finally, designing a new kind of residential health care facility within the continuum of health care to respond to  frailty and illness in our society.

This report details the progress that has been made in each of the SeniorChoices Demonstration’s five major focus areas, including successes, challenges, lessons learned and next steps.  Also discussed is a policy proposal arising from Village Care’s experiences that could reform the way long-term care is delivered in New York State.

1. Creating A New Role for Residential Care

The SeniorChoices model includes significant changes to Village Care’s residential and community-based programs, including reduction of Village Nursing Home’s total skilled nursing facility (SNF) treatment capacity from 200 to 105 beds.  At the same time, the remaining capacity would be moved to a new, state-of-the-art facility where care would be transformed to provide intensive rehabilitation to maximize transitions back to community living along with a capacity to provide palliative and end-of-life care and services.

Under this model the residential setting will move from being the focus of long-term care services to being a part of many specialized services and settings.  This will be a dramatic shift and will mean that “everything that can be done in the community will be done in the community” to help and encourage individuals age in place. The SNF will be a specialized facility designed for short stays whether for rehabilitation/restoration or end-of-life.

This type of facility must be agile at facilitating transitions in and out, providing state-of-the-art services, and assessing and responding to consumer preferences.  In order to accomplish this, it requires considerable re-thinking of the traditional design of a residential facility, new and altered support systems and significant reconsideration of work force functions in  this integrated role.

Village Care is building a new facility to embody these changes but long before there are new residents in that setting the organization’s capacity and expertise must be well honed to take on the management of ever-more complex patient needs. To that end, Village Care is reducing reliance on traditional long-term residential beds and refocusing existing SNF services to address specialized needs.

Policy Implication: Form follows reimbursement. Reimbursement influences facility design. VCRN is a case in point.

1.a. Creating a New Role at the Existing Facility, Village Nursing Home

Because of the growing complexity of patients in need of both residential and community services, Village Care designed and implemented a new set of specialized residential and community services, often in partnership with others, that offer specialty care in response to the needs expressed by consumers and reflected the expertise of professionals.   To this end, Village Care has doubled the number of short-stay rehabilitation beds at the Village Nursing Home to 70 beds on average, with new specialties in cardiac, wound, orthopedic and stroke as part of the New York University Hospital/Tisch/Rusk Institute Rehabilitation Network. 

A new specialized dementia program was also opened in Village Nursing Home (VNH) and in one of Village Care’s adult day health programs.  The two programs have been able to support each other in cross training and some patient management. The same was true in the arena of behavioral health.

The behavioral health capacity in medical day care was expanded significantly along with new ties to other community behavioral health providers improving the ability to admit patients into the SNF with complicated behavioral health histories with the assurance that we could manage those needs not only in the SNF, but also in community settings. These were patients who might have been turned away previously.

Resident families and care providers (hospitals, physicians, and ancillary services) were notified of the many changes in the nursing home, including the shift from long stay to shorter stay on two floors. This “rightsizing” was generally well received, although there has been some apprehension regarding the long-term care needs of potential SNF residents who might someday no longer be served in a traditional institutional setting. 

Although few people look forward to a nursing home stay, most see it as a trusted and reliable community resource when a loved one needs care and it is a setting they are more familiar with and understand better.  They needed assurances that care would be there when it was needed.  In response, Village Care worked with these stakeholders on new approaches to clinical coordination in the community for more frail patients and on the design of new critical services to fill the gaps that would be left by fewer long-term beds

Provider Lesson: Specialization of LTC expertise in the community and institutions makes accepting and transitioning complex patients possible.

The existing VNH facility underwent several important physical and staffing transformations during this period. The short-stay and therapy floors were remodeled to general acclaim by patients and visitors. A new 40-bed residential dementia unit was created to consolidate staff expertise in an enhanced environment for persons living with debilitating memory loss.  The new competency that has been developed in memory loss care will serve the organization well in the planned transition of this service and the staff to a specialized assisted living facility.  

Staff was selected for the dementia floor based on their desire and aptitude to participate in specialty training on resident-centered care philosophies and dementia programming techniques.  The goal of this training was to place more accountability and flexibility in the hands of the employees who provide the direct care to these residents, to provide continual therapeutic support and improved customer service. 

New nursing and medical processes were designed and implemented to manage the increased clinical complexity of the expanded volume and range of short-stay patients. Admissions and discharge procedures were revamped (including the introduction of a patient concierge for the short-stay floors). Housekeeping and dietary services were also modified to respond to increased clinical and patient demands. All of these changes involved many staff hours (at all levels in the organization) working in teams to anticipate and plan for new processes.

With the increased volume of short-stay admissions came a new type of patient for VNH. These patients were often younger, more active and more vocal about what they wanted in service and amenities. They have also been very clear about their intentions to go back home after their rehabilitation. “Residents” have become “patients,” a change in nomenclature that symbolizes the evolving relationship to the consumer and the community. Culture change efforts with the staff place an emphasis on understanding the perspectives of these new “patients” and empowering staff to respond to in a timely and effective fashion.

The staff were also trained in receiving patient and referring agency’s comments on satisfaction and care, and coached to embrace those comments, positive or not, as precious insights to be worked on. By removing defensiveness from the equation it was possible for staff to keep looking forward and treating the new services as a work in progress that could keep getting better.

Finally, the physical medicine (PT/OT/SLT) floors at VNH were redesigned and re-equipped to provide higher quality subacute cardiac, stroke and orthopedics rehabilitation services.  An essential part of the redrafted rehab program included formalizing VNH’s relationship with the Rusk Institute for Rehabilitation. Through the Rusk affiliation, Rusk professionals provide VNH staff with the consultation, training, education and guidance required to enhance the physical medicine program, and further propel “rightsizing” efforts.  Our enhanced physical medicine program should further the effort to divert short-term patients from long-term residential care, and help transition patients back to the community.

1.b. Creating a New SNF Model and A New Facility—The Village Center for Rehabilitation and Nursing     

Central to the SeniorChoices demonstration is the design and construction of a new, smaller (105-bed) residential health care center that focuses exclusively on end-of-life care and short-term rehabilitation.  During this reporting period, Village Care secured zoning approval from the City planning officials for the new facility and completed 100 percent of the planning for the design of the new physical plant and its infrastructure.  Those plans were submitted to the DOH and almost all outstanding issues are resolved at the time of this report. (See Appendix D for elevations and floor plans.)

The new Center for Rehabilitation and Nursing will be the skilled residential care component of SeniorChoices, replacing Village Nursing Home and will embody the promise made to all patients:  “We are your partner in healing body, mind and spirit.” Our promise holds true whether the patient is coming for a short stay to receive rehabilitation with every likelihood of returning home, or whether they are in our care for end-of-life services.

Not all of these changes are readily accepted by the State reviewers who must sign off on the plans and balance old regulations and interpretations against new design approaches. This has led to delays in processing our project. Nevertheless, overall the facility has achieved its primary goal of a more home-like and holistic healing environment.

The meditation room on the first floor, the large contemplative bamboo garden and the green rooftop patio will also be places of comfort and healing. These areas, in particular, were evaluated closely and designed using Fng shui principles.

Much of our success in achieving the healing partnership with residents will depend on a motivated, efficient, effective and satisfied staff.  The structural design of the facility includes overhead lifts in many rooms for smooth, safe transitions of frail patients with minimal stress on staff.  The interior design is conducive to the easy and free flow of patients and staff on floors throughout the facility.

Fortunately, Village Care is in a unique position where it has access to capital funds to invest in this project. However, the opportunity cost of doing so is an irreplaceable diversion of capital from other community care service projects that are also needed. Traditionally in long-term care, it was possible to leverage assets and build improved services because payers adequately recognized the capital costs of new projects, but it is clear that capital reimbursement methods lag behind the realities of contemporary markets, making it difficult, if not impossible, it is to build or rebuild infrastructures whether those are brick and mortar residential settings or community based, particularly in high-cost urban areas.  Village Care will be working with others and the State in 2007 to address this.

2. Building Community Capacity that Supports Diversion and Transition

Because of the SeniorChoices demonstration, in two years, the lower west side of Manhattan will lose 95 SNF beds. The seniors who would have come to the Village Nursing Home seeking placement in those beds are not going away.  This demands that a way be found to serve more SNF-eligible seniors in the community, or those seniors and their families will be hurt by these changes.  Village Care has assured its community, and their representatives, that it will continue to meet care needs, but we will do so in a different way.  This end is being pursued in active partnership of the State Department of Health.

Village Care has proposed, as part of the SeniorChoices demonstration, to receive authority to create a purpose-built Medicaid funded ALP for dementia residents.  The capital and operating reimbursement under the ALP program would make this program feasible and would create a model for serving this population.  We will be working with the Health Department to resolve any challenges this model may present for existing regulations and program standards. The intention is to retain the investment made in the dementia program, especially the staff, at VNH and offer to transfer those staff to this new setting when VNH closes.

2.b.iv.   Building Community Capacity – Innovative Approaches – Day Rehab

Rehabilitation services are increasing as new technologies and new consumer demands change the market place. Some of this increased demand is met in acute, sub acute, home, and outpatient settings. However, despite a number of alternatives there are still large numbers of stroke survivors re-admitted to the hospital within one year of discharge, and the same is true for congestive heart failure cases after six months of discharge.   Recognizing, these issues, Village Care was awarded a grant by the New York State Health Foundation (NYSHF) (monies supplied from the conversion of Blue Cross Blue Shield to for-profit) for a project to address these concerns.

Seniors and their caregivers who have experienced stroke and congestive heart failure, and to a lesser extent orthopedic trauma, must make many adjustments to lifestyle including nutrition, medications, exercise, weight loss, etc.  They must also follow a rehabilitation schedule complicated by often-present post trauma depression. Given these challenges to someone trying to return to full health, relapses are not surprising. Current options for post-acute care are limited in their ability to prevent health decline and recurrence for some individuals.

Specifically:

Given these issues, Village Care is taking a new approach to post-acute rehabilitation called “Day Rehab”  in conjunction with the Rusk Institute Rehabilitation Network.  Enrollees will attend adult day health care three times a week over an average period of eight weeks for a special interdisciplinary program that includes:

By using this model Day Rehab endeavor for post-stroke and cardiac-event individuals, Village Care expects to accomplish these outcomes: 

            The program begins enrolling participants in June of ’07.

2.b.v.   Building Community Capacity – A Case Study in Medical Adult Day Care

Building community capacity involves new programs but it also involves identifying the barriers to accessing existing services. We found patient habits and agency turf protection to be very real barriers in trying to expand use of one community service—medical adult day health care.  

Village Care operates two medical adult day health care (ADHC) programs. These programs have succeeded with individuals who otherwise would be in a nursing home. Nevertheless, these programs, like most others in New York,  typically  struggle for census where there is an abundance and custom toward using either SNF or in-home services.  The care offered by the ADHC is more comprehensive, interdisciplinary and less costly than the same time spent in home services, but it is rarely part of the service package offered to patients receiving home care. 

It need not be an either/or situation. There are numerous examples of improved quality of life and better clinical outcomes when day care is provided in concert with home care. Village Care set out to test this combined approach by working with the HRA/CASA 3 Manhattan unit, which is the gatekeeper for Medicaid home care.  CASA agreed the concept was a good one and began identifying individuals who could benefit from a combined ADHC home care approach. 

Approximately 40 candidates were engaged by the program more or less fully.  Unfortunately, what we found if a potential client had begun any kind of home care, they believed (incorrectly) other services like day care might threaten their continued access to any home care.

Home care agency staff were not inclined to assist in educating their clients on the benefits of combining alternative services. Nor were agencies interested in working to make sure that home care staff hours were coordinated with the day care hours.  That type of coordination involves increased logistical planning for staff… and usually will result in some diminution of billable hours to the home care agency.

Village Care has its own home care agency, Village Care Plus, Inc., as part of SeniorChoices, which has stated a willingness to collaborate in an integrated home care/ADHC program, but unfortunately Village Care is not able to secure a contract with CASA for the Village Care Plus because no new contracts have been awarded in our geographic area for a long time.

Policy Lesson: As providers increasingly build systems of care, public payers and regulators need to also view service contracting, payment, and regulation from a system  perspective.

3.         Integrating  Care Across Settings

Village Care is pursuing three major approaches to systems integration.  First, is to create a managed care option – the Program of All Inclusive Care for the Elderly (PACE) and to also participate in a Medicare/Medicaid Advantage Plus program.  Second, is to create partnerships with other providers in the community.  Third is creating a care advocate program.

3.a.i.     Integrating  Care Across Settings – PACE

Nationally and in New York State, the long-term care providers who are also PACE providers have clearly demonstrated success in improving quality of community care and a dramatic drop in use of hospitals and nursing homes. PACE  effectively combines Medicaid and Medicare to meet the needs of enrollees.

Over the next three years, SeniorChoices will expand its services to serve over 2000 individuals each year by strengthening community services and building a new type of SNF that supports community- based care.

The one piece is missing link for SeniorChoices is a fully responsive consumer system for the most frail, with the power and flexibility that a capitated carefully managed care program affords. A MMLTC/PACE program would be the means to those ends. It would ensure that care would be coordinated so the right care would be delivered in the right place at the right time.  Senior Choices has hired an administrator and medical director for the PACE, secured various consultants, and is on schedule to submit the application by the end of 2007.

3.a.ii.    Integrating  Care Across Settings – Partnerships

The needs of seniors are complex and must be met in a variety of settings. The true system will provide integrative mechanisms across those settings. It will begin by building on clinical partnerships and growing those into program partnerships. SeniorChoices has seen success in this area with hospitals, social service providers, mental health agencies, specialty associations and specialty providers. In the coming year staff will be working on increasing the formal mechanisms for referral and patient management.

3.a.iii.   Integrating  Care Across Settings – Care Advocacy Lessons

           

Integration of care across time, place and discipline can be achieved through “systems” and through individual professionals dedicated to coordination and integration. When systems fail, individuals can make the difference.  Recognizing this, a Care Advocate program was begun in 2006.  The Care Advocate program is modeled on both the Wisconsin Partnership Program and the Evercare case management approach. The distinguishing feature of the care advocate compared to a case manager is the emphasis on transitions, patient preferences and systems interventions.

In the simplest terms, the case manager often views the world through the eyes of a payer or provider and is often most focused on a particular service setting. The care advocate views the world through the eyes of the patient and views the world in terms of choices and systems.

The care advocate understands that helping assess and fulfill the client’s preferences and helping them manage transitions are the primary challenges to achieving a successful outcome from the client’s perspective. Therefore, the care advocate must have the skills and knowledge of a case manager, along with an ability to assess client preferences, engage the client in the care planning and negotiation process, and be able to intervene to alleviate systemic barriers to access and quality. 

The first Care Advocate is a social worker who has been working closely with the Village Nursing Home, acute care and ER providers, as well as with Village Care’s home care and day care programs on diversion, transition and “rightsizing” initiatives.  Since the summer of ’06 the Care Advocate has served 62 individuals.

          Initially the Care Advocate focused on the voluntary transition of select individuals in the nursing home to the community. In these initial cases,  the outstanding barriers to voluntary outplacement were limited housing options, behavioral instability and trepidation on the part of caregivers regarding the availability of comprehensive community supports. 

4.   Transforming the LTC Workforce

The SeniorChoices team implemented several retention/educational initiatives for the staff at VNH and Chelsea ADHC to bolster skill sets in person-centered care.  Consultants were retained to provide these multi-session trainings for CNAs, nursing and recreational therapy staff.  Separate sessions were held on coaching and reinforcement techniques for managers and supervisors, and communication skills for direct care staff. 

The staff participating in the training worked closely with management to develop operational practices that allow them to be more empowered to make decisions on behalf of the residents they serve.  For example, CNAs who work on the dementia units have begun to plan and run activities themselves, and created their own scheduling system.  This is a shift from previous strategies, where these elements were developed largely without their input and passed on as a fait accompli.  As many long-term dementia residents have issues with food consumption because of increasing dysphasia, specific activities have been developed around feeding in the ongoing effort to prevent/delay the need to place a feeding tube.  Bathing, another typically challenging area of dementia care, now takes place at times in the whirlpool, turning the care regimen into more of an “activity.”   Lastly, the staff involved have begun to approach the delivery of care from a “safety-orientation” rather than a pure “task-orientation.”  As such, the residents are showing less agitation, staff are more embracing of these changes and show more dedication to their “floor,” and family members are similarly pleased.

A comprehensive training program was also offered to VNH and ADHC staff by the Rusk Institute for Rehabilitation on subacute services for orthopedics, cardiac and stroke. Rusk nursing and physical medicine professionals instructed clinical staff through didactic lectures, workshops and in-services that examined the etiology, clinical and behavioral manifestations, after-care best practice techniques, specialty care (i.e., telemetry) and educational approaches and exercise physiology. 

4.a.      Transforming the LTC Workforce—The Role of 1199SEIU

We have made strides in planning for the new roles all staff must adopt in the new nursing center. We have also made progress on the “human factors.”    Most of the changes for staff need to take place well before the opening of the new nursing home.  Recognizing this, and the role the that our Union, 1199SEIU, can play in making this transition a  success, Village Care undertook a formal process of incorporating the Union into  transition planning and implementation.  

A committee called the “Building for the Future Committee” was created, composed of union and management to research and accomplish the following goals:

Village Care undertook this effort in recognition that these extremely critical issues are best negotiated, studied and resolved by seeking common cause and obtaining the best ideas among those on the staff and management team of our current nursing home.  Both SEIU1199 and Village Care understand that a valuable template for this type of transition can be created if we are successful in our efforts.

6.b.      The Role of Risk in a LTC IDS

            Unless or until Medicare and Medicaid eligibility is contingent on enrollment in a managed care organization (MCO), most seniors will receive their benefits through fee for service (FFS). For this reason and others, there is a strong need for a method to promote the appropriate development of provider services, the appropriate use of those services and effective cross provider coordination and care management.  The IDS LTC could be that method. It can achieve the goals often attributed to MCO’s… without capitation.  The focus of a LTC IDS will be on creating the necessary conditions for comprehensive LTC continuums and coordinated care.  The State will assure the achievement of those goals through oversight and paying for performance.

Specifically, a LTC IDS would be certified after initial and periodic reviews that all structures and processes are in place, and be rewarded for meeting designated outcomes.  This oversight would also be a backstop for over- or underutilization of services.

            This is not to say that the LTC IDS cannot accept sub- or partial capitation. It should be authorized to do so for services directly provided but that should not be the raison d’etre of the system or a necessary feature. 

Government and commercial payers have goals for their purchase of health care that go beyond merely meeting cost-containment strategies measured against historical budgets—they also have population health goals for the individuals they cover. To achieve those larger goals, the actual conduct of providers must be observed and compared to benchmarks. With the right tracking of processes and outcomes, a better approach than capitation for purchasing care is to pay a fair cost plus minimal margin on a fee-for-service basis and reward excellent performance through a P4P methodology.

            This would mean a fundamental shift in thinking about IDS.  Originally, the IDS emerged as one more capitation method, with the purpose of keeping dollars and margins within a system/network.  Care coordination was less important than utilization management and there were almost no mechanisms for the State, and few for the customer, to right this imbalance. A better way is to change the IDS focus and change the incentive, by placing it firmly on structures and processes designed to deliver the best long-term care in a community setting by making sure that all options are available, well coordinated and responsive to consumer preferences.

6.c.      Expected Outcomes of a LTC IDS

Although there are many flavors of IDS in the United States, research indicates that many beneficial outcomes could be expected, including:

6.d.      Key Challenges for a LTC IDS

Managing  a complex system and “forcing” integration is more difficult than operating in silos.  There are legal and organizational management techniques to overcome these barriers but the challenges in this area are still immense.  The most compelling force for integration is the nature of the clinical and social needs faced by frail elders and the overriding desire of almost every professional who serves them to see that those needs are met, within their program or without.

The history of acute care-centered capitated IDSs is not always positive, especially in New York.  A legitimate question is why a LTC IDS would work when so many large hospital/physician organizations have failed?  A major problem with those systems has been an inability to overcome institutional inertia and nimbly shift resources to the service or geographic area where needs were paramount.

In simple terms, beds had to be filled and that became the driving force, not “rightsizing” and the reorganization of the delivery and coordination of care by the providers. Any LTC IDS that starts with a SNF that must have its beds filled will face similar inertia and must work diligently to rightsize those beds in the context of the larger IDS. 

6.e       Proposed Special Authority to be Granted to the LTC IDS

            The certified LTC IDS  meeting the above criteria for structure and performance should be granted the following authority:

• To function as an official POE entry point and to receive FFS or capitated/budgeted payment for that function;

• To function as an official protective services agent given additional appropriate  standards and staffing requirements are met and to receive payment for that function;

 

• To function as an official authorizing agent for Medicaid home care and personal care services in NYC and to receive payment for that function;

• To be eligible for Medicaid/Medicare Pay for Performance grants or other forms of enhanced FFS or capitation reimbursement for exceeding system benchmarks.

• To be eligible for Medicaid and Medicare reimbursement for care advocacy across the LTC IDS.

• To be eligible to receive sub capitated payments from licensed MCO’s for services directly provided

Because of working relationships throughout the system and the core competency in care coordination, the IDS will uniquely positioned to more effectively marshal the resources needed to carry out these functions. The last function, care advocacy would be a new Medicare and Medicaid benefit, but it is a vital part of the new LTC world.

Care advocacy and/or case management across time place and discipline is only possible in IDS or managed care settings.  Even in managed care, the case management is “one off” from the system and the providers and can not be as effective as a case manager embedded in an IDS. Furthermore, the typical HMO case manager is focused on managing (restricting!) the utilization of a particular service, whereas the advocate will be helping with choices and transitions throughout a system.  Medicaid and Medicare have long resisted paying separately for case management as a distinct service but this would a clear case of where it would make sense to do so.

The SeniorChoices demonstration will continue working on these ideas and putting in place the elements of a working LTC IDS while pursuing opportunities with the State to create a formal recognition of this promising approach to better long term care.

7.  Next Steps for Senior Choices

In 2007, the SeniorChoices team will expand the scope of its initiatives to integrate residential and community care in several distinct areas.

As previously noted, Village Care received in July 2006, official designation from the Assembly to pursue the development of a MLTCP/PACE application.  The developmental work, including creation of a separate corporate entity to operate the managed care program, business plan and network development, financial planning/rate negotiations with the State and preparation of the required applications, is anticipated to take approximately 24 months.

Village Care is also awaiting final approval on its application to offer 80 ALP beds at its 46th and Ten residence, which will provide much needed housing to VNH residents desiring to return to community dwellings.  In addition, the 125 LTHHCP slots recently opened will be operating at full capacity within the next year. The other efforts toward specialization throughout our system will continue, most notably the new short-stay day rehab program and the new ALP dementia residence.

The Care Advocate team will continue to refine practices and processes with VNH, CHHA and sub-acute settings, and across clinical care and support service partners in the community.  Special attention will be paid in all settings to identifying at-risk individuals and moving discharge planning further upstream than it customarily occurs.  This different approach provides additional time needed for all parties involved -- care providers, patients and caregivers -- to make more-informed decisions that are proactive, embrace consumer choice and empowerment, improve quality of life and quite possibly reduce the financial burden to both consumers and the State over the long-term.

The construction of the Center will commence this summer, culminating in a new building in early 2009. Transition work with staff, patients and business partners will be in full operational mode in 2007.  This includes new EMR module development and implementation.  There will also be continued development efforts in making the EMR available and useful across community settings throughout Village Care , and finding ways to share information beyond those boundaries as legally and where technically feasible.

Moving forward, it is clear that there will be significant financial strains on the existing nursing home as it moves through this period of transition from 200 beds with a variety of residents to105 beds for specialized rehabilitation and complex care needs.  The transition must be orderly and safe and therefore will take some time during which there is a risk of financial loss to the facility.  The reimbursement system is not designed to accommodate this kind of change.  

The State is looking to lessons learned from SeniorChoices to help inform other statewide policy initiatives for long-term care reform.  Those initiatives will have little hope of success if there is not consideration and methods created for transitional funding.  Village Care will be working in the coming months with decision makers to achieve an appropriate resolution to this challenge.

Finally, SeniorChoices will collaborate with interested parties to pursue the promising idea of a formal Long Term Care Integrated Delivery System.

Appendix A: SeniorChoices Legislative Authority S. 6058--B A. 9558-B § 6. The public health law is amended by adding a new section 2807-x 52 to read as follows: 53 § 2807-x. Grants for long term care demonstration projects. 1. The 54 commissioner shall establish two demonstration projects to develop, 55 evaluate and implement programs to test new models for the organization 56 and delivery of long-term care services to encourage community based 1 programs and smaller residential health care models in order to promote 2 consumer choice, improve the efficiency and appropriateness of the use 3 of state and federal resources and ensure the recruitment, retention and 4 training of health care staff to adequately meet the needs of a communi- 5 ty and residential long term care system. 6 (a) The following factors shall be considered in approving each demon- 7 stration project respectively: 8 (i) Residential health care demonstration project. (A) the extent to 9 which there is a reduction in the need for skilled nursing beds for a 10 facility that is eligible to replace its existing skilled nursing facil- 11 ity; (B) the potential to design and develop more appropriate smaller 12 residential health care facilities as an alternative to replacing an 13 existing skilled nursing facility; (C) the extent to which the quality, 14 efficiency and continuity of care will be promoted and provided for by 15 the development of integrated long-term care services in the community; 16 (D) the extent to which the project will provide training to health care 17 workers to appropriately staff new community based models of long term 18 care; (E) demonstrate the involvement and support of workforce in the 19 program redesign; (F) the development of a new long-term care reimburse- 20 ment methodology that encourages care in the least restrictive setting Appendix A: SeniorChoices Legislative Authority 21 and adequately reflects the resources needed to serve consumers in each 22 level of long term care (G) and the incorporation of a research compo- 23 nent designed to evaluate the project. 24 (ii) Community based care demonstration project. (A) the extent to 25 which there is a reduction in the need for skilled nursing facility beds 26 on a countywide basis; (B) the development of a new system to inform 27 recently admitted residents of skilled nursing facilities of the avail- 28 ability of community long-term care options; (C) the extent to which the 29 discharge planning program from skilled nursing facilities will inform, 30 assist and maximize freedom of choice to consumers who choose to move 31 back to the community; (D) the extent to which the project will develop 32 community based long term care services, including funding for the 33 recruitment and retention of direct care health care workers necessary 34 to increase community based services; (E) the extent to which the 35 project will provide training to health care staff; and (F)the incorpo- 36 ration of a research component designed to evaluate the projects. 37 2. The commissioner is authorized to waive, modify or suspend the 38 respective provisions of rules and regulations promulgated pursuant to 39 this chapter if the commissioner determines that such waiver is neces- 40 sary or appropriate for the successful implementation of a demonstration 41 project and when the health, safety, and general welfare of persons 42 receiving services under such demonstration project will not be impaired 43 as a result of such waiver, modification or suspension. 44 3. The commissioner is authorized to seek federal waivers pursuant to 45 titles XVIII and XIX of the federal social security act when such waiv- 46 ers are necessary to develop cost-effective long term care demonstration 47 projects. 48 § 7. This act shall take effect immediately. Appendix A: SeniorChoices Legislative Authority Ammendment 24 § 7. The opening paragraph of subdivision 1 of section 2807-x of the 25 public health law, as added by section 6 of part D of chapter 58 of the 26 laws of 2004, is amended to read as follows: 27 The commissioner shall establish two demonstration projects to devel- 28 op, evaluate and implement programs to test new models for the organiza- 29 tion and delivery of [*long-term*] *_long term_* care services to encourage 30 community based programs and smaller residential health care models in 31 order to promote consumer choice, improve the efficiency and appropri- 32 ateness of the use of state and federal resources and ensure the 33 recruitment, retention and training of health care staff to adequately 34 meet the needs of a community and residential long term care system. 35 *_Notwithstanding the provisions of section one hundred twelve of the_* 36 *_state finance law or any other inconsistent provision of the state_* 37 *_finance law or any other law, funds available for distribution pursuant_* 38 *_to this section may be allocated and distributed by the commissioner_* 39 *_without a competitive bid or request for proposal process._* As ammended § 2807-x. Grants for long term care demonstration projects. 1. The commissioner shall establish two demonstration projects to develop, evaluate and implement programs to test new models for the organization and delivery of long term care services to encourage community based programs and smaller residential health care models in order to promote consumer choice, improve the efficiency and appropriateness of the use of state and federal resources and ensure the recruitment, retention and training of health care staff to adequately meet the needs of a community and residential long term care system. Notwithstanding the provisions of section one hundred twelve of the state finance law or any other inconsistent provision of the state finance law or any other law, funds available for distribution pursuant to this section may be allocated and distributed by the commissioner without a competitive bid or request for proposal process. (a) The following factors shall be considered in approving each demonstration project respectively: (i) Residential health care demonstration project. (A) the extent to which there is a reduction in the need for skilled nursing beds for a facility that is eligible to replace its existing skilled nursing Appendix A: SeniorChoices Legislative Authority facility; (B) the potential to design and develop more appropriate smaller residential health care facilities as an alternative to replacing an existing skilled nursing facility; (C) the extent to which the quality, efficiency and continuity of care will be promoted and provided for by the development of integrated long-term care services in the community; (D) the extent to which the project will provide training to health care workers to appropriately staff new community based models of long term care; (E) demonstrate the involvement and support of workforce in the program redesign; (F) the development of a new long-term care reimbursement methodology that encourages care in the least restrictive setting and adequately reflects the resources needed to serve consumers in each level of long term care (G) and the incorporation of a research component designed to evaluate the project. (ii) Community based care demonstration project. (A) the extent to which there is a reduction in the need for skilled nursing facility beds on a countywide basis; (B) the development of a new system to inform recently admitted residents of skilled nursing facilities of the availability of community long-term care options; (C) the extent to which the discharge planning program from skilled nursing facilities will inform, assist and maximize freedom of choice to consumers who choose to move back to the community; (D) the extent to which the project will develop community based long term care services, including funding for the recruitment and retention of direct care health care workers necessary to increase community based services; (E) the extent to which the project will provide training to health care staff; and (F)the incorporation of a research component designed to evaluate the projects. 2. The commissioner is authorized to waive, modify or suspend the Appendix A: SeniorChoices Legislative Authority respective provisions of rules and regulations promulgated pursuant to this chapter if the commissioner determines that such waiver is necessary or appropriate for the successful implementation of a demonstration project and when the health, safety, and general welfare of persons receiving services under such demonstration project will not be impaired as a result of such waiver, modification or suspension. 3. The commissioner is authorized to seek federal waivers pursuant to titles XVIII and XIX of the federal social security act when such waivers are necessary to develop cost-effective long term care demonstration projects.

Appendix C -- Care Advocacy Case Studies

Home care services through Certified Home Health Agencies (CHHA) are typically arranged following an acute or subacute medical event, where a patient is homebound and in need of skilled care.  Home care is the number one community-based service thought of by hospital and nursing home discharge planners seeking to return the patient to the community.  Home care programs will typically discharge a patient when the skilled need ends, or the PPS episode of care concludes—sometimes continuing services to provide more long-term, in-home care for those patients who are financially and clinically eligible.  As CHHA becomes more ingrained in the home and lifestyle of a patient, it becomes more difficult for the patient to let these services go. The trick for the CA was in introducing these alternative community-based services to CHHA patients before they grow so accustomed to in-home services.

The initial CHHA-CA model sought to introduce the CA program to established CHHA patients thought to potentially benefit from ADHC programs.  The plan called for using case RNs to introduce the CA program, obtain signed consent for the CA, who would then schedule a joint visit with the RN to visit, educate and assess the client, after which she would formulate a community-based therapeutic plan of care with the client and family for implementation immediately upon CHHA discharge.  The CA was invited to participate in the weekly meetings to discuss current clients receiving CHHA services, identify potential candidates for community-based services and further build upon agency relationships, bridging gaps in interagency communication if/when they arose.  

As time passed, the CA has found that these “established” CHHA patients were less likely to reduce their home attendant hours, or alter their “routine” in exchange for ADHC services.  The CA also observed that most CHHA RNs focused on discharge planning only a few days before closing the case, which left little time for patient/family education and discussing options for post-skilled care.

As such, the CA shifted its point of entry with CHHA to commence during the Intake process.  This allows the CA to become a part of the client’s plan of care, either during their CHHA episode, or post-discharge.  This lengthens the amount of time the CA has to educate and prepare the client and family about post-skilled services. The CA is also now directly reaching out to the clients to discuss the program--rather than being dependent upon the case RNs--and this change is proving to be a more effective approach.  A total of 35 CHHA clients have been identified since the introduction, with approximately half of them poised to convert to supplemental community-based services. 

            Like the CHHA, the nursing home has a major role in providing long-term care to patients with active, chronic care needs.  The nursing home environment is a top choice of hospital discharge planners seeking subacute and chronic care services for patients awaiting discharge, particularly for those patients who have limited or no other caregiving support.  Yet, not all nursing home admissions need to be “nursing home

Appendix C -- Care Advocacy Case Studies

admissions,” – some are established only as a place of last resort.  The CA program sought to change the face of the nursing home patient – away from the domiciliary-type care patient and towards someone in need of rehabilitation and end-of-life care.  This is the point where the transition/diversion approach comes into play.

The transition/diversion model initially developed for the nursing home had a multifaceted focus:  identifying current long-term residents who could reside in a less restrictive setting with appropriate in-home and community-based supports; identifying short-term rehabilitation clients who would benefit from receiving continuing therapies in an outpatient, step-down subacute program, such as ADHC; and intercepting community PRIs to again, offer a community-based solution of care. 

Four pilot cases were initially identified for the CA to test the transition model--as these residents were classified as long-term, there was extensive planning and researching for their return to the community, including lengthy discussions with the residents and their family members.  Three of the four pilot cases were determined to have no community housing to which they could return.  The lack of housing (former, family) necessitated in-depth research on available housing in Manhattan—what was identified was limited in number and accessibility (waiting lists average 3 years, exclude residents using assistive devices, etc).  Because the stock was so limited in Manhattan, research was also conducted to investigate housing options in the outer boroughs.  The CA, however, worked with the residents/family/nursing home on completing housing applications for residences city-wide. 

As a result, three of the four individuals were approved for community housing and placed on waiting lists, with one of these individuals accepted and safely transferred into an Assisted Living facility.  The remaining individual became psychologically unstable and was no longer a candidate for transition.  To date, approximately 20 additional VNH cases were identified for transition to the community.  Yet challenges continue to emerge with placement.  To elaborate, families sometimes show apprehension or unwillingness to partake in the transition process—they do not wish for their loved ones to relocate away from their existing neighborhoods, even though visiting would become easier; the anticipated “burden” of responsibility becomes too overwhelming to face; they are estranged from their loved ones; or they do not have the spatial capacity to house them.   

In seeking alternative residential options, we’ve discovered that HRA does not view individuals who currently reside in a nursing home as a “priority.” Moreover, Manhattan’s market rate housing is unattainable for those individuals who are in receipt of Medicaid.  We are considering using waiver dollars to help resolve such barriers as a short-term solution to cover the first month’s rent and transition costs.  We also look toward our ALP which will assist those individuals who receive Medicaid in securing appropriate community housing. 

Appendix C -- Care Advocacy Case Studies

On the short-term rehabilitation side, the CA has begun to target those individuals who may be eligible for alternative and supplemental community-based services that further support compliance and preventive care, thus hopefully reducing recidivism rates.  To initiate this process, the CA and management conducted meetings with the VNH subacute staff to introduce the program and facilitate the integration of the CA into care and discharge planning activities.  The CA presently attends the weekly short-term discharge meetings and receives weekly updates from the Director of Rehabilitation identifying residents nearing discharge.  The CA combines this information with resident-specific financial and diagnostic information, and begins to craft a proposed plan of community-based care, which is initially shared with VNH staff, then with the resident, and if accepted, with the community-based program – such as ADHC or LTHHCP.  To date, the CA has identified 23 short term residents in need of transition assistance and is actively working with 5 residents on post-discharge service planning. 

Starting in Q1 2007, another important facet of the CA’s role at VNH will involve direct work with the Director of Admissions regarding diversion efforts.  The Admissions Department presently receives approximately 10 PRIs on a daily basis (the vast majority from hospitals), the majority of which are not focused on end of life.  The original diversion and transition approach called for the CA to review only those PRIs generated from the community, and to then reach out to the inquiring physicians / patients with an offer of a community-based alternative.    The CA reviews all rejected PRIs and then contacts the hospital discharge planner and CHHA intake staff offering a community-based alternative (i.e., ADHC and CHHA intake staff with wrap-around CHHA services; LTHHCP, etc.).  Education of the hospital discharge planners on alternative services will be required, and we have begun to pilot this approach on a small-scale basis with St. Vincent’s Medical Center.

To ensure the CA process “closes the loop,” the CA now collaborates with the VCNY Client Service Coordinator (CSC) in attempt to broaden the scope of program entry.  The CSC is a corporate marketing professional who fields consumer inquiries and triages them to the right person/program.  The CA educated the CSC about the CA program, created a workflow (Attachment C) that identified which types of inquiries should be forwarded, changed the recording on the toll-free VCNY “hotline” to identify SeniorChoices, and developed referral tracking tools.   This approach has proven effective, as the CA received three referrals from the CSC within the first few weeks of implementation.

We designed SeniorChoices to have many “doorways” for easy access by consumers. Recognizing, however, that many consumers are intimidated by any doorway that opens directly into a healthcare provider, we also created “storefronts” called Senior Information Centers, natural walk-in centers where seniors and their caregivers can receive information, support, and service recommendations in a relaxed environment.

Appendix C -- Care Advocacy Case Studies

The Samuels Foundation was instrumental in helping to establish these Centers as community resources through previous funding support

The storefronts work well for seniors whose needs are straightforward and who possess the motivation and mental/physical capacity to act directly. Some seniors, however, do not follow through on the advice and referrals they receive. They face barriers to navigating the health and social care system, including depression, low health literacy, and psychological fear. Without support, they do not act and remain isolated, growing more fearful and frail as time passes.

These complex cases cannot be adequately addressed at the storefronts. For instance, in most cases because of staffing limitations storefront staff cannot make a direct referral to a service provider (i.e. provide information on the client, arrange an appointment, ensure that the provider will accept the client for an assessment, and follow up to ensure the client’s needs are being met). Even when the recommendation process works smoothly, a provider may decline the client. Since most providers have limited time and resources to follow up, the client is left without help and without knowledge of alternative services.

Difficult-to-serve clients who walk into the storefronts are not the only seniors who need better help. Seniors who are isolated for social, behavioral, physical, or financial reasons would also benefit from more proactive assistance.  Seniors who are assessed as being high frailty and are at risk of transition and experiencing poor outcomes from transition, will be referred to the Care Advocate by the storefront.

Not everyone needs an advocate, nor should every person “coming off the street” be able to contact the Care Advocate, because this is a limited specialized resource. Thus, the storefronts will serve as a filter, handling straightforward cases themselves and funneling the more complex cases to the Care Advocate Program.