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Challenges in HC Minutes 12-16-13
Healthy Aging Task Force  
Healthcare Challenges Work Group

Summary of Meeting on Dec. 16, 2013

Present:   Trudy Carter, Julie Fay, Joy Ganapol, Charles Hodge, Paddy Moore, Kathleen Samways.

Absent:  Cindy Doyle, Susan Mercier, Sheila Shapiro, Grace Sullivan

  • 1. Approval of December 2nd meeting minutes
  • 2. Review the Charter of Workgroup and how group relates with Coordinating Committee.
  • 3. Try to set short and long term priorities.
  • 4. Discuss how to interface with health care leader agencies (MVH, MVCS) concerning service gaps, and their plans and priorities
  • 5. Discuss how to prepare a work plan for next year that will be reviewed by the Coordinating Committee and needs to be completed by Feb 15, 2014.
  • 6. Set future meeting schedule.~

I.   December 2nd Meeting Minutes were approved.

II.   Review the Workgroup Charter:

Trudy raised the question of how “Aging” would be defined by the HATF. There was a vigorous discussion of the various age-related definitions currently in use, such as Medicare (eligibility set at 65 and over); some disabled people are covered through the Supplemental Security Income (SSI) program. Island COAs use age 60 and over. The MVCS CORE program uses 55 and over. Other programs refer to the “functionally disabled,” while still others refer to those “at risk,” or the “frail elderly.”
Decision:  The group decided in favor of a broad definition that is inclusive, does not refer to any specific age, but includes the frail elderly and the functionally limited/disabled.

The group clearly understands that the Coordinating Committee role is to review and approve Workgroup work plans and activities, to develop funding for different workgroup activities, and to coordinate across workgroups to minimize duplication, enhance effectiveness, and support workgroup efforts.

Workforce: The charter asks the Workgroup to “encourage workforce development and training for the professional and caregiver workforce, especially on an inter-agency shared basis.” Last meeting we focused on the assignment to "work with existing organizations to address identified service gaps” (including specialists.) This discussion focused on questions of  Workforce Shortages.  
Kathleen reported that the new Medicare regulations affecting the homebound, though extremely restrictive in that they require that a physician attest that a patient is homebound and cannot leave the home, has expanded to permit certain types of behavioral health diagnoses ñ a step forward mandated by the Affordable Care Actís call for parity between mental and physical health services.  However, Joy noted that most Medicare services still require that a physician be present in the building where services are delivered, and that eligible service providers are LICSWs, psychologists and psychiatrists; Bachelor level social workers, or mental health counselors are not eligible for reimbursement.

Charlie asked about the sources of shortages, and what areas are short? What numbers are needed for the population now; could we use that to extrapolate into future needs? Which professional titles?

Collecting data re Workforce Shortages: We should include in our workplan our intention to see if we can collect such data.  First step would be to ask the different agencies to identify the jobs/positions which they have most difficulty filling ñ and be sure we understand the roles needed. Agencies should include MVCS (for ICC, Daybreak, etc.), VNA, Elder Services, Hospice, Hope Hospice, Rural Health Clinic. (Paddy suggests also such smaller organizations as Vineyard Houses, Family Planning, and possibly include the COAs.

Discussion suggested agencies have difficulties recruiting LICSW, SWs, Psych, NPs, PAs, MSWs, PTs, OTs, Speech Therapists., and at VNA this includes RNs, LPN, HHAs, CNAs. The two Hospice agencies may also be experiencing similar shortages, and should be polled. We know the island also needs Geriatric competency in all these positions, and could certainly use (and possibly share) a Geriatrician or Gerontologist.

Goals: Talk with hospital re possible additional role for Dr. Ellen McMahon who is a geriatrician, and might be able to share her specialty knowledge in ways with other professionals through Grand Rounds, and/or other teaching/training opportunities.  
Note:  Since Dedie is retiring end of January, Paddy will invite Jay Ferriter to join this group representing the hospital, to facilitate conversations and planning.

Group also identified medical specialties which will be needed by an older population, and for which we should do appropriate needs assessment:  Urology, Dentistry, Dermatology, Podiatry, Ophthalmology, Neurology, Rheumatology, Endocrinology.
        ï  There is supply of retired physician specialists: what would be possibilities for utilizing them? Group identified certain concerns: cost of malpractice coverage; would only want to work part time; concern for continuity of coverage for patients (Kevin Carey); need for back-up plan.
        ï  Also supply of retired nurse practitioners and RNs; would there be interest in registering with hospital for per diem work when needed?
        ï  Agreement that further exploration both with hospital and with individuals in community is necessary. Paddy suggested again that the group use the format used by the MH/SA network to ID existing services and services needed in order to clarify.  (Format attached to this document.)

Discussion re need for new models of health care delivery on island, more integrated, more patient-focussed for clinical team.  Need to develop an integrated health model long term.  What is the current business plan for MVH/Partners?  Could MV become demonstration program for rural areas, small populations?
        ï  Joy described the community team model MVCS uses for children/adolescents, with goal of wrap-around care. Could it be duplicated for use with elders?

Other  areas identified in discussion:
        1.  Concern re under-utilization of EMTs scope of practice:  Some EMTs are trained to identify strokes or heart attacks of patients while in ambulance. If permitted to call for off-island transfer, they might save precious time, but hospital (???) regulations require that MVH doctor attest need to transfer. Does this delay result in adverse outcomes? Would need to look at mortality data for strokes and heart attacks and compare outcomes with other sites. Should this concern be referred to the Patient/Family Advisory Committee for further exploration?

        2.  January 1st implementation of MOLST (Medical Orders for Life-Sustaining Treatment) when this new legislation and revised form takes effect.  Should the HATF play a role in community education effort re this new opportunity for patients to declare their intentions and desires concerned life-sustaining treatment?  It appears that the MOLST form is being supported by the Mass. Medical Society and other health care groups, and may be helpful even if patients already have a similar directive in the form of Five Wishes, etc.  What plans does the MVH have for training physicians, EMTs, and other medical staff to recognize and abide by these patient directives?

The group agreed that the principle of cross-training for providers could be a useful principle as we develop proposed plans for meeting workforce shortages.
        3.  Alzheimers Dementia: The Alzheimers  Association estimates that 45% of those 85 years or older will be diagnosed with AD.  What preparation are island healthcare and support services providers making to prepare for this avalanche? What is the current number of AD patients?  Should the workforce and program issues associated with this issue be part of our workgroup planning, particularly projected shortage of Caregivers?
Note that there are a number of  Support Groups for those suffering from different diseases, such as Prostate, Cancer, Cardiac, Diabetes, Stroke, and possibly others.  Also, there is NAMI (National Association for the Mentally Ill) which provides family support and education in this field; these may also be considered as a caregiver group.  These existing groups may be a source of further information.  

        4.  Volunteers were discussed as a necessary component of any plan to address workforce shortages.  Group discussed possible methods to identify current number of island volunteers and where they are focused.  We will begin by contacting COAs and provider agencies, making sure they understand we are looking for numbers, not trying to recruit./poach their volunteers.
            In future, will need to address issues of recruitment, training, support, and possible role in clinical models.  

        5.  Other issues:
                ï  Question was raised about causes of death on Vineyard. Possible sources of information would be MVH, town Boards of Health, island Coroner.
                ï Can we determine where and why do island residents go for care off-island? Probably not possible to determine who goes where, because of HIPPA.  Paddy suggested that group members might want to review the 2003 Island Health Report produced by the now-defunct Foundation for Island Health, as that is best/only real baseline data available. It was a self-reported survey, with a very high rate of return, and can be very useful.  Can be found at ___________________________.
III.  Work on Short and Long-Term Priorities
IV.  Interfacing with Health Care Agencies

V.  Work Plan

VI. Future Meeting Schedule
Next meetings: January 6th 8:30 ñ 10:00am; January 29th 8:30 ñ 10:00am; February 3rd 8:30 ñ 10:00am. To be held at MVCS Board Room.

Respectfully submitted,
Paddy Moore, Co-Chair Workgroup

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