Reframing CVNA’s Strategic Plan

It’s time to think differently about aging.

As Colorado VNA’s CEO, I think about aging and the perception of aging a lot given that over 75% of patients we serve are 65 and older. In fact, in partnership with our Board of Directors, our organization has begun to update its strategic plan beginning with our mission, vision, and values. This was encouraged largely by the realization that our patient demographics are changing and that the over-65 population will grow dramatically in Colorado over the next several decades (it is estimated that one in four Coloradans will be 60+ by 2040).

I’ve been doing a lot of research on the subject of aging, too, and recently I was introduced to The FrameWorks Institute” Aging Toolkit which is the result of a strategic analysis into the “communications aspects of aging issues.” This toolkit provides a set of tools and “guidelines that help [organizations and people] work more intentionally and strategically to advance the conversation about older people in the United States.”

Further, the Aging Toolkit challenges all of us to re-frame how we think about and communicate aging in America. The developers assert that the:

“public must come to appreciate that well being is influenced by a range of social policies (e.g., health care policies, tax policies) and social structures (e.g., the way American communities typically arrange housing and transportation) and, crucially, that these aspects of society can be changed with respect to aging.”

The Aging Toolkit provides excellent guidance for policy makers and healthcare decision makers – and I would argue that the Toolkit also provides inspiration and guidance for service providers like CVNA, particularly now as we examine our programs as part of our strategic plan overhaul and think about how we will communicate our updated focus in the coming months and years.

The most significant correlation between the Aging Toolkit and CVNA’s updated mission comes from the Toolkit’s Eight Themes for a New Frame on Aging. The themes provide guidance on useful ways to boost the general public’s knowledge of and focus on aging issues and to build support for future policies and practices that encourage an “age-integrated” society.  The theme that most resonates with CVNA is Ingenuity:

Ingenuity: Americans are problem-solvers. When we see an opportunity, we figure out how to seize it—and when we see that something isn’t working, we rethink our approach. Replacing outdated practices with new, smarter ways of doing things is the key to our nation’s ingenuity.

CVNA has identified a new core purpose – our most fundamental reason for being, why we exist and the guiding statement that underlies everything CVNA does – as part of our strategic planning process, and ingenuity is woven into its foundation:

CVNA provides the most appropriate range of health care solutions to allow people to maximize independence and to heal and age at home.

By developing and utilizing diverse tools, competencies, and capabilities to offer a “range of health care solutions” that help a person remain in the home while they heal and age – and knowing said tools, competencies, and capabilities will differ for each and every person we serve – exemplifies an ingenious spirit and approach to older adult health care.

As an example, CVNA is one of Kaiser Permanente’s primary home health partners in Colorado, and we work continuously with them to develop new and creative ways to transition people home from hospitals, skilled nursing facilities, and rehabilitation facilities all within the intricacies of the Kaiser system, the Medicare regulations by which we are governed, and the requirements of being a licensed provider of home health. The work we do to help Kaiser patients heal in the home is vastly different than what we do to support our Area Agency on Aging clients that need in-home support services to remain independent. Simply put, helping older adults remain in the home is complex and requires ingenuity.

In addition to this purpose, CVNA has defined four core values that reflect our deeply held convictions and priorities.

  1. Provide health solutions that enable people to function as independently as possible in their homes and communities.
  2. Deliver high quality care that is cost effective with high patient, employee, provider and insurer satisfaction.
  3. Provide high-acuity and individualized healthcare in the home.
  4. Maintain a culture of opportunity and meaningful work.

In these core values we also see the strong connections to the Aging Toolkit’s ingenuity theme.

The final part of CVNA’s new strategic plan is our two key goals for the next ten years. The first is our aspiration to become a nationally recognized leader in the provision of home and community-based care that maximizes independence. We will achieve this goal by continuing to improve the quality of the care we provide as measured by our patients and Medicare Home Health Compare. We will also do this by developing innovative care and support models that help people remain independent like our CAPABLE program and our new telehealth program.

CVNA’s second and just-as-important goal is to become and stay financially stable for the coming years and decades. As I wrote about here, financial stability is difficult in this time of limited reimbursement. Fortunately, our organization has been blessed with excellent leaders in the past who made decisions to purchase buildings at 390 Grant Street in Denver and 2400 Clubhouse Drive in Greeley. Recently, we decided to sell our Denver-based headquarters and move to a new building in Arvada in December 2017. This sale and move allows us to put some reserves in the bank as well as build out a custom interior that will make more efficient and creative use of space, allow for best-in-class clinician training rooms, and overall provide a healthier workplace for our employees and visitors. Stay tuned for more updates on the new building in the coming months.

CVNA is preparing for an uncertain health care future, as well as a major demographic shift, by utilizing tools such as the Aging Toolkit and seeking guidance from organizations like the FrameWorks Institute. Individually and collectively we need to tap into our ingenuity to create adaptable health solutions that help adults remain in the home.

The Dentists of Feet: How Colorado VNA is Keeping Feet Healthy

Wanda Wofford, RN at the Glenarm Foot Care Clinic

Wanda Wofford, RN at the Glenarm Foot Care Clinic

Over the last two decades, we’ve come to understand that oral health means much more than healthy teeth. As the American Dental Association states “Your mouth is a window into the health of your body” and regular visits to a dentist allow for a view into general health and wellness. Similarly, foot care is about so much more than simply clipping toe nails, especially for older adults and those with diabetes. Our feet often reveal signs of disease such as nerve disorders, gout, arthritis, melanoma, and heart disease. Feet can tell us about the state of our circulation and the condition of our thyroid. Our feet falter when our shoes are too tight, our toenails too long, we don’t moisturize our skin, and problems such as ulcerations and infections go unnoticed and untreated.

This is why for over 30 years Colorado VNA registered nurses have been providing foot care, and why we believe foot care should be an integral part of preventive care for older adults and those with diabetes.

The highest risk group of patients for foot maladies is diabetic patients. The CDC has reported that over 29.1 million people, or 9.3% of the US population, have diabetes. In Colorado, more than 19,000 adults were diagnosed with diabetes in 2012 and there is belief that as many as 100,000 or more Coloradans could be unaware that they have diabetes. Further, nearly 33% of adults age 65+ have diabetes. According to the Indian Health Service ~40% of people with diabetes will develop nerve damage in their feet, ~20% will have an acute foot problem, ~15% will develop a serious wound (costing about $13,000-$30,000 to treat), and 5-10% of people with diabetes will progress to amputation (at a cost of about $50,000). Indeed, the most common cause of hospitalizations among persons with diabetes is diabetic foot problems, including ulcerations, infections, and gangrene.

Almost all of the above conditions can be prevented or diagnosed early with primary care and the care that Colorado VNA provides at its 150+ foot care clinics across the Front Range. While clients attend clinics for various reasons – difficulty bending over for self-care, trouble finding a family member or friend to assist, limited hand strength due to arthritis, etc. – all receive the same high-quality and comprehensive RN visit that entails:

  • medication reconciliation;
  • blood pressure monitoring;
  • a foot exam for inspection for any discoloration, swelling, corns, calluses, or other changes of the foot, ankle, and leg below the knee including identifying cancers of the nails and skin;
  • trimming, cutting, clipping, and debridement of nails;
  • minor buffing of corns or calluses (if applicable); and
  • hygienic and preventive maintenance care such as cleaning the feet and testing for neuropathy (nerve damage).

Further, our nurses have repeated contact with their clients over long periods of time, sometimes years, and are in a good position to note health changes that may go unnoticed during routine medical visits, such as darkened nail beds that could be early signs of melanoma.

To continue the dental care analogy, Colorado VNA’s nurses provide both the routine care AND assessment for the need for more specialized care provided by podiatrists, surgeons, cardiologists, and other medical specialists. Colorado VNA’s nurses are also an extension of these specialists as they assist with administering care plans in an effort to keep patients healthy and on their feet. Colorado VNA has also started offering more complex foot care services, such as the use of dremels, which are provided by nurses certified by the Wound, Ostomy and Continence Nursing Certification Board. And, just in the last year, Colorado VNA has begun providing foot care in the home when patients are home bound and meet appropriate Medicare guidelines.

Routine foot care is a little understood and often undervalued part of the healthcare system.  Too many older adults turn to nail salons where they run the risk of being exposed to improperly cleaned tools and technicians that are not trained to look for ingrown, overgrown, and thickened toenails as well as fungal infections. Over the next year Colorado VNA will be gathering more clinical data in an effort to demonstrate improved health outcomes such as decreased falls, fewer serious wounds, decreased hospitalizations and/or surgeries resulting in amputations, and better compliance with care plans, as well as higher patient satisfaction. Each month, Colorado VNA cares for more than 1,000 clients, which allows us to generate an incredible wealth of data to share. We are confident that our foot care service is keeping individuals healthier and independent longer. Stay tuned for further updates on our foot care services in the coming months!

For more information about our foot care clinics or to schedule a visit, please call 303-698-6496 or visit https://vnacolorado.org/medical-foot-care-program/.

Why non-profits need to partner

As I described in this post there is massive growth in the elderly population in Colorado with projections of more than 1.4 million people over the age of 65 in Colorado by 2030. This surge is taxing our health care system and there is no one solution to this challenge. In fact, clinicians, community health workers, and senior advocates alike all agree that it is best serve older adults with a constellation of health and wellness services that address both acute and long-term needs. I strongly believe that, too. I also believe that by creating more and better partnerships within the nonprofit health sector, where organizations focused on different aspects of care and services collaborate together, we can better respond to the diverse and growing needs of older adults. This post details several of Colorado VNA’s burgeoning partnerships as well as information on other community-based nonprofit organizations that are delivering low-cost, high-quality service solutions through partnerships.

CVNA is over 128 years old, has grown to more than 460 employees, and serves over 30,000 patients a year across the Front Range. We certainly want to continue to grow and evolve our core services, yet we know that we cannot provide all the services necessary to help older adults age in place. In fact, our organization is evaluating the services we currently provide, and services that are not well-positioned to both provide excellent care AND also remain sustainable are being decreased. This recent introspection was in large part inspired by CVNA’s participation in the Colorado Health Foundation’s Linkage Lab Program. Through this 19-month program, CVNA along with other excellent community-based organizations such as Easterseals Colorado, DRCOG, and Senior Resource Center, learned or reinforced critical skills like strategic planning, monitoring and evaluation, marketing, and program design. Most importantly, the participating organizations learned the value of collaboration and partnership as a way to accelerate impact while limiting the duplication of services and resources. CVNA has created two formal partnerships as a result of our participation in the Linkage Lab, one with Easterseals of Colorado and another with DRCOG. We have also created a partnership with Habitat of Metro Denver which I described in my last post.  Here is a brief overview of these partnerships.

  1. Through a partnership with Easterseals of Colorado, CVNA has created a home transition program for stable stroke patients that bypasses a stay in a rehabilitation facility. Currently, stroke patients often spend needless time in a hospital while discharge planners determine an appropriate discharge location. Some of these patients could go home aided by appropriate home health and rehabilitation services. CVNA and Easterseals have developed a program that combines CVNA’s home health nursing and rehabilitation expertise along with Easterseals’ day stroke rehabilitation services to allow patients to quickly return home. We are now working to find funding and hospital partners to pilot this program.
  2. Our second partnership is with DRCOG as part of its Medicare Accountable Health Communities Grant. Through this partnership, CVNA is one of several community-based organizations that assists DRCOG in collecting data to help in improve communication and collaboration between medical and community-based organizations. Additionally, the grant will study how addressing social needs like housing instability, food insecurity, domestic violence, and transportation can decrease unnecessary healthcare spending.

In addition to the above partnerships, I have been impressed with several other local nonprofits that are working creatively to help keep people independent with minimal cost. These organizations are ones I definitely see CVNA creating partnerships with the in the future!

  1. Project Angel Heat in Denver has created an excellent Meals for Care Transitions program that provides patients leaving a care setting with medically-tailored meals three times a day for up to 30 days. The purpose of the program is to ensure that patients returning home have the food and nutrition they need to reduce their risk of readmission and/or prevent further health complications. Project Angel Heart is offering this program in partnership with a hospital in the Denver metro area and is also partnering with other organizations to provide this service.
  2. A Little Help is an organization leveraging the power of community volunteers and its partnerships with other community-based organizations to help the elderly remain in their homes. A Little Help operates like a virtual PACE program without the medical providers and community centers. The program works by charging “members” a yearly fee to become part of the network. The cost of membership is a small fraction of the benefits each member receives through A Little Help’s programs and services.

There are many more examples of Colorado organizations doing tremendous work in the aging space. Unfortunately, not one of these organizations alone has the resources necessary to address all the challenges of the rapid pace at which our older adult population is growing. By putting our hearts and heads together, we can develop collaborative programs and shape a more responsive system for older adults and their families.

Do you know of any/have you used any older adult collaboration-based programs or services to meet your health and wellness needs? Tell us about your experience!

CAPABLE, a low-cost program to improve senior independence?

The population in Colorado is aging quickly, more quickly than most other states. Related to our aging population, is the rising cost in healthcare, much of it fueled by chronic disease management which affects about 80% of older adults in our country.

And yet, despite the additional medical oversight required when living with chronic disease, the vast majority of older adults want to remain in their homes. According to a study by AARP (Page 2, Housing Preferences) “73 percent [of older adults] strongly agreed that they would like to stay in their current residences as long as possible, while 67 percent strongly agreed that they would like to remain in their communities as long as possible”.

The challenge of aging in place is complicated. Medicare is not intended to provide support for long-term care.   Medicaid does support long-term care but only for those people who qualify per Medicaid income guidelines. Yet, it is unclear what the future of Medicaid is, including programs like Medicaid HCBS which I recently wrote about here. As a result, there is a pressing need for cost-effective programs support aging in place. One such program is CAPABLE, an acronym for Community Aging in Place—Advancing Better Living for Elders. Colorado VNA is pleased to be partnered with CAPABLE’s founder Dr. Sarah Szanton and Habitat for Humanity of Metro Denver to bring CAPABLE to Colorado.

Launched as a research project in Baltimore by Sarah L. Szanton, PhD, ANP, FAAN, of the Johns Hopkins School of Nursing, and expanded to 12 cities in five states, CAPABLE is a five month, home-based intervention for low-income older adults with functional limitations. It entails ten, 60- to 90-minute home visits with an occupational therapist, a registered nurse, and a handyman who work together with elderly individuals to identify mobility and self-care issues in their homes and fix or modify them.

Preliminary data from the Centers for Medicare and Medicaid Services (CMS) Innovation Center, which has funded CAPABLE, is promising:

  • 79% improved their self-care over the course of five months.
  • The average participant improved by cutting disability in half (i.e., the number of self-care tasks that are difficult for the participant were halved).
  • Participants experienced a decrease in depressive symptoms similar to that of taking an antidepressant medicine.

Further, CAPABLE is beginning to yield evidence of cost-savings via delaying nursing home admittance and proper utilization of primary care rather than emergency care. The leading health policy journal, Health Affairsrecently published results showing that the program, which costs less than $3,000, saves more than $10,000 to Medicare in decreased outpatient and hospital costs, including observation stays and hospital readmissions. Additionally, CAPABLE builds on model intervention strategies such as patient-centered care and motivational interviewing.

Colorado VNA clinicians know from their own patient experiences that a safe home environment is critical to the ability to function, yet the home setting is often overlooked by care models because they take place in a clinical setting. Thus, Colorado VNA was awarded a major grant from the Colorado Health Foundation, along with additional support from the Comprecare Fund at the Denver Foundation and an anonymous donor, to implement CAPABLE in Colorado with its  own clinicians and with home alteration support from Habitat for Humanity of Metro Denver. The grant will allow us to provide CAPABLE to 60 patients over 18 months split into three groups of 20 patients. After we care for these 60 patients we will work with Dr. Szanton to study the results and to assess whether our version of CAPABLE yielded similar or better results compared to the original study.

Colorado VNA is thrilled that CAPABLE is now underway and that we are seeing our first patients. We are closely monitoring clients’ progress against our goals of improved health outcomes and decreased healthcare costs, and actively looking for additional philanthropic investments to support the ongoing implementation, monitoring, and evaluation costs.

If you know of an older adult who

  • is having trouble remaining independent (difficulty with eating, bathing, housekeeping) or feels unsafe (at risk of fall) in their home,
  • owns their own home,
  • is on Medicaid or eligible for Medicaid, and
  • lives in the Denver Metro area,

please call me at 303-698-6306 so that we can evaluate the person for our CAPABLE program.

 

HCBS is at risk, will this affect senior independence?

care

Colorado VNA (CVNA) in Northern Colorado has been providing Medicaid Home and Community-Based Services (HCBS) services for over thirty years. Like many organizations that care for HCBS patients, our organization is struggling to care for these patients because the reimbursement is too low, well below our costs. In recent years, with the increase in home health care regulations; the cost to provide homemaking and personal care services has risen significantly. It is because of the gap between reimbursement and costs that CVNA is working to find other agencies to take on some of our patients. Additionally, CVNA will be kicking off a fundraising campaign to seek support from caring donors passionate about helping Colorado residents remain in their homes. The following is an overview of how CVNA came to this decision to decrease our HCBS census as well as a description of what other states are doing with HCBS.

A large challenge that CVNA and other HCBS providers struggle with is the low HCBS reimbursement rates. The rates have simply not kept pace with the increasing cost of living in Colorado. There was an increase from $15 per hour to $17 per hour in 2015 and then a 50 cent proposed increase for 2018. This increase is simply not enough and I fear that a growing number of agencies serving HCBS patients will decide to stop taking new HCBS patients and/or get out of HCBS altogether.

This is unfortunate because increased spending on attendant and homemaking care like HCBS has been shown to decrease institution costs, i.e. the more states increase and support HCBS services, the less funds are spent on skilled nursing. In fact Colorado has been a leader in supporting HCBS and as a result has had very limited to no growth in skilled nursing days for patients over 65 in the past ten years, however I fear that this trend may reverse in the near future if more money is not allocated for HCBS or other financial sources of support are not found.There is data that show systematic support for HCBS results in decreasing spending growth on institutional long-term care services. According to an article in Health Affairs “expansion of HCBS appears to entail a short-term increase in spending, followed by a reduction in institutional spending and long-term cost savings.” In fact “Nursing home spending grew by 3.4 percent in the low-HCBS states over the period, after adjusting for inflation, but declined by 15.3 percent in the high-HCBS states;” like Colorado. These findings match what CVNA hears from its own patients in Denver and Northern Colorado. Through our own patient surveys, over 93% of our patients report that the personal care and homemaking services provided by CVNA are critical to that patient’s ability to remain independent in the home. After the progress Colorado has made, I fear that there may be a decrease in patients remaining in the home and a move towards more patients returning to nursing homes. Not only that, recent success in transitioning patients from skilled nursing to the home will slow down or stall altogether. In a 2005 survey by the Centers for Medicare and Medicaid Services (CMS), 165,276 nursing home residents indicated that they would like to return to their communities; if they received HCBS waivers to do so, the public could see annual savings of $2.6 billion.

It does not have to be this way. In fact Arizona has a more expansive program called Arizona Long Term Care System (ALTCS) which emphasizes HCBS and rewards providers to keep people out of facility-based care. In addition to the higher level of incentive, Arizona also pays their HCBS providers dramatically more at $22 per hour vs. Colorado’s current $17. What is particularly telling is that Arizona has a significantly lower cost of living than Colorado; a salary of $36,000 in Phoenix needs to be $46,000 in Denver according to this cost of living calculator. Arizona is not the only state that pays more and has done more to coordinate HCBS services. Missouri pays $18.40 per hour for homemaking even though the cost of living in Missouri is much lower than Colorado and even lower than Arizona. Additionally, Missouri has rolled out its own program to keep people in their home called Aging-in-place which has seen improved outcomes by connecting HCBS services with nurse care management and traditional home health services like nursing and physical therapy services.

Colorado’s Department of Health Care Policy and Financing (HCPF), i.e. Colorado’s Medicaid organization now known as Health First Colorado;  is working to evaluate the current rates and is going through a detailed rate setting process with the help of various stakeholders. The process does allow for HCPF recommending a higher rate, but any recommended increase would be limited by the current allocated budget by the Colorado State Legislature. In other words, Colorado could remain at a near $17 an hour if there are not additional funds allocated.

As you can see, HCBS is an extremely important part of the care continuum that helps people remain in their homes. Colorado has been an extremely progressive state in its implementation and support for more HCBS services than many other states and as a result, Colorado’s skilled nursing admissions and overall census has either decreased or remained stable over the past decade. However, I believe these gains may be lost if Colorado does not invest more in its HCBS providers in the coming months and years. And, the problem is only going to get worse as Colorado’s minimum wage inches towards $12 an hour. In the meantime, CVNA will reduce our own HCBS patients in order to remain sustainable unless of course we find other funding sources to support our patients as it is our mission to help people remain independent in their homes.

Christopher J. Lee
President & CEO
Colorado Visiting Nurse Association