all right.now we will turn to the san fran sisqo strategy excellence in dementia care.i think george and i will be stepping away here so we don't interrupt things and catchan airplane. so turning the meeting over to jen to runthe rest of it and get us back on time, as i'm sure she will do.because i clearly have failed to do that. [ laughs ]>> can i use this? can you hear me in the back?all right. so thank you for having me.this is an honor to be here and a lot of hard acts to follow, i have to say.so, matthew started out his presentation talking
about why a state plan?why is that important? and maybe you'll ask, why a city plan?why in san francisco would we do a city plan? first let me say that san francisco is a cityand a county in california. and i want to also point out that californiahas a unique distinction in that they pushed a lot of autonomy down to the counties.the counties have a lot of power and a lot of independent funding.the stateblocked grant then you figure out how to spread your money around between agingservices and mental health and whatever those programs are.i asked our mental health directors at a meeting that i was at this last summer issues about,if the state passed some of the mental health
standards that we were looking forward throughthe alzheimer's association, would it automatically then play down that the counties would followsome of those priority recommendations in and he said, we could do that.he says but no, there would be no guarantee the counties would follow those recommendations.so you almost have to work county by county in a lot of ways in california.so, san francisco had a special distinction of being both a city and a county and in about2007, i was there when the discussion took place around longterm care.we had just come out with new facts figures and the coordinating council was hearing fromlots of people about this problem. when i was there, i can tell you it was arobust, heated, difficult conversation and
the people at the table are penal that runadult protective services. they run the managed care programs and allthese different agencies and have a vested interest and were having difficulties.so we went to the then mayor, who provided us with money.i want you to look at the year here. this was just before the economy tanked sothankfully we got $100,000 to start this and after that the economy started on a freefall.but we put together an expert panel and at the end of 2009, we developed a strategy forexpense dementia care. this wasâ excellence and dementia care.a 10 year plan with the idea that we could improve quality of care acrosstheboard forpeople with alzheimer's disease and it was
really about systems change.how do we really look at this community? that the time, we were estimating in california,state of california,ia between 500 and 600,000 people with alzheimer's and dementia.san francisco had 35,000 people, depending on how you counted it.alzheimer's or dementia and alzheimer's members. so the idea behind this effort was to treatalzheimer's disease in the same concentrated, tactical way that they had with aids in the1980s. they wanted it to be a comprehensive communitybasedresponse to really look at how we deliver care and what it should look like.we ended with 35 recommendations, two documents. what san francisco likes to do is to reallylook at, what do we have and what are we doing?
so the document is in two parts.part of it is the historic context. where did we gather our information?what is the national research? what are people doing around the world?and literally that is what this piece was. and what are the current resources in sanfrancisco we can bring to bear, bring to the table and participate in this work?then the second part was the 35 recommendations that came out of this and were distributedand we were to implement. as part of that, the department of aging andadult services were invested. they were invested from the beginning.this very definitely was a governmentdriven plan.we were at the table, which was a wonderful
piece of it.but per then and currently still now, we made a commitment to staffing the oversight committeeas well as the work groups that went forward so there was coordinated effort from the countyalways to support what was going on and you can see that we were looking at guidelines.the oversight committee was really to draw together the information that the work groupsworked on and developed. each of the work groups was assigned certainnumbers of the recommendations with the idea that they would work on these and report backand we would move forward. i think the key here for us, was that thisagain was expected to be and was a coordinated effort.when we developed the experts panel in san
francisco, it was leadership from all themajor organizations in the city. ucs was at the table.managed careplanners at the table. all the large organizations in the city wereparticipating in that. and we also looked at how will we know ifwe make a difference? how will we know if change curse?and so what what we really tried to do is say, these are the things that would be happeningif we were successful in our efforts. and you can say delayed need for more intensiveservices. shared client information.education and training. i have to tell you that in the strategic planningeffort, the one thing that crossed over every
work group, every aspect of our work, wasthe need for training and education. training for caregivers.training for professionals. training for physicians.training for health care providers. training for facility operators.it just crossed over every aspect and i know you all have heard this and know this butpart of what we wanted to do was start early and focus on training as a key component ofwhat we needed to do in our work. in march of that next year, in march of 2010,daas received an award from the roz listened and arthur gilbert foundation of 20,000 dollarsand this was primetime because it allowed us to focus on training and education.we started out by looking at training all
areas of our service community in terms ofcaregivers and the general public as a key component and then started to work throughdifferent professional groups. now let me say something to you.one of the things that we learned in this, is that people did not beat our doors downasking for training. surprisingly, right?what we did was, we proactively began to work on asking different groups accept trainingfrom us. some were surprisingly delighted to receivetraining. some were surprisingly resistant to training.i can tell you, we worked staff in many ways doing things like paramedics and emts andfirst responders.
they were delighted to get training.it was very difficult to get training to police officers.we'll give you 10 minutes between shifts and you can come out and do a training.that isn't what we wanted to do. we didn't feel like that was worth the timewe needed. so there was a lot of challenges in that.i think the surprising one for us was tsa agents.i don't know how many of you have been through security with somebody with dementia.but i have to tell you i went through with a couple that after the forum, a couple ofyears ago, i went through first and the husband and wife were going through.the husband went through next and she had
everything she needed until she got to tsaand they asked herself for her id and she couldn't find it.and when the husband turned around to go back through and help her, you can manage whati know that debacle looked like. i was afraid they weren't going to make theplane. they did but just barely.so in san francisco, there were surprising outcomes that were exciting and opportunistic.and again, it really took proactive energy to get that going.over the course of those two years, we provided training for about in all, 5000 people, inthe san francisco area. at the end of 2010, we were awarded an aoagrant to look at improving quality of care.
and this was part of our medical resourceswork group, to look at care for people that would keep them out of emergency rooms.and this grant was over a 3year time period and the goals were to improve medical systemsto diagnose alzheimer's disease, to connect highrisk caregivers to the appropriate resourcesand to look at if we can keep people out of hospitals, on a proactive basis.the intervention for this was that we worked with keiser hospital in san francisco, ucsf,the alzheimer's association, and our goal was to have a clinical care specialist, socialworker, who was at keiser, who collaborated with families and helped educate, train andwork with them as they were identified as highrisk individuals.dementia care plan was developed.
they were automatically referred through afax referral progress to the alzheimer's association so as soon as they were identified, they gotconnected up with services. we could call them.by using a fax referral process, we could satisfy hippa requirements around that andtherefore a doctor could say, if are willing, if you sign this document, they fax todaydirectly to us and we could call that family and work with them directly.and then there were preand postsurveys as part of this study.in all, over the course of the time period, there were 105 diads.for every person with dementia because it was part of a study, we had to have a caregiveridentified.
in all, the results were remarkable.40% reduction in hospitalizations in this population.i think the social worker, the people working directly with families to help train, educate,support, get them in support groups, whatever those things were, were really the linchpinin that process. our behaviors pilot projects groupâ our waiversâ looked at systems. how do we begin to anticipate.what systems are coming down the pikes? what can we do to intervene or make sure thatwill san francisco takes advantage of those opportunities?so we wereâ this group was the one looking at some of the grant opportunities.we looked at the medicare wellness check.
how do we make sure our docs are aware ofthis? we looked at this waiver and how that willaffect california. we looked at twice remove barriers for peoplewith alzheimer's disease. we were starting to learn about folks whowere younger onset who were being denied services in certain sectors, not all the time, butin certain sectors. how do we address that?how do we get information out to these programs or can we do things legislatively to removethose barriers? we started looking specifically at hospicecare. one of the things we were hearing from familiesis that their people didn't qualify for hospice
until they were very, very late in the process.and maybe they would get two or three days of hospice care.some of that has been changing and there were some efforts at that time to really changethe way hospice identified people with dementia. it didn't change.i don't want know that whole system, there are some things still difficult and challengingbut this continued to be an area we worked on and looked at.our additional services and settings work group really looked at a couple of thingsthat are difficult in san francisco. san francisco notoriously has no skilled nursingbeds. when somebody is being discharged, there isno place to send them, especially if they
are medicaid eligible.so what are we doing about these folks? where do they go?and i'm going share with you something about a survey that we did with hospitals here injust a minute. but, one of the things that they started tolook at is, can we develop temporary shortterm housing situations that are more akin to residentialcare but could provide people with shortterm level of care stay within home support andtell theirâ until they are okay to go home? could we did that through some of the currentmechanisms for funding reimbursement? for instance, they are looking at assistedliving waiver. could we grab that and look at doing thatin san francisco in a way that would help
us do that?they are also looking at ways to look at best practices.how do we best serve people with mild cognitive impairment?there is a major research center in san francisco and many people are a part of research studies.they get identified as nc i and never hook up with services because they are like, idon't have alzheimer's so i don't have to worry about that.and what about things like driving? and what is the role with that?in california if you're identified and diagnosed with alzheimer's disease, it triggers a reportto the dmv. if you are not identified and diagnosed withalzheimer's disease, it does not trigger a
report to the dmv.so how or what do we do about things like this that the medical rear resources workgroup, and the hospital list conference. another area that our medical researcherswork, i heard something about that earlier today is, how do we develop some sort of amobile medical record so that no matter where somebody goes, they have their medical recordswith them, especially identifies them as having dementias and alzheimer's disease?people are getting into the hospitals and people don't know they have alzheimer's disease.so there are several areas of success i'll run through rather quickly because i knowthat we are out of time. wrong of the things that happened as a resultis a single donor in san francisco, inspired
by this work, funded a brain health centeredthat is now in operation at california pacific medical center that is operational.there is a team of neurologists, a conan works specifically with dementiaspecific care anda social worker that works for the alzheimer's associations and provides support and carefor all the person that are diagnosed with alzheimer's disease and hooks them up withservices. always always alzheimer's always always alzheimer'si will talk about emergency room care. we were approached by one of the people whoprovides emergency department care in san francisco and he talked about the challengesthey have with people with dementia who get into the hospitals and they are dilearuousor they are having episodes of agitation,
anxiety.sometimes they are alone, sometimes they are with a family member.but the physicians take on this was that this is really not a medical problem.these people need more services and supports at the community level.they are not appropriate in the hospital. we can't admit them.so we asked how many of these folks areâ how often do you think this is occurring?what do you think is happening here? what we did was worked with the physicianto survey all of the hospitals in san francisco and surveyed the eds of each of those emergencydepartments and asked them some of the specific questions that we didn't know.and this is really raw data.
it is based on your best guess, as a physician,as the head of the department, how many people with dementia do you see in your emergencydepartment a week? are they there because of the alzheimer'sdisease or are they there because of something else and the alzheimer's disease is complicatingit? what shift do they show up on?what percentage of your folks overall? what ended up happening is, we got resultsfrom 16 of the hospitals in san francisco. as high as 60% of the people arriving at theers they estimated, again this is raw data, they estimated had some form of dementia.as many as 70% in their estimation, had no true medical reason for being in the hospital.they did not want to admit them.
what they did to assess them, we don't know.but they didn't necessarily identify them as alzheimer's.they didn't dike diagnose but they discharged them at some point.in san francisco, of the people with dementia arriving in the ers, the estimate ranged fromalmost 50% to almost 95% who live alone. san francisco has the distinction of having40% of their senior population is single living alone in that community which is high formost cities. i did bring a copy of the survey questionswith me. and they were remarkable.but i'll tell you that we learned a lot from that.and one of the things that we did as a result
of some of this work is, these physicianswere coming to us and asking us, we'd like to have like a, some kind of a mobile dementiateam that comes and helps us assess and helps us work with these people because we don'tknow what happens to them when they leave the hospital.we don't know where they are going. so, in february 2013, we did a conferencethat was geared specifically for hospitallists and emergency room physicians and social workers,geriatricians and it was on the need to identify cognitivative impairment and dementia.how to address the needs of the patients, especially those admitted with dilear yum?one of the interesting things that we talked about was the reduction in antipsychotic meds.we had a speaker there that day who was a
physician who was doing research on this andthe whole focus of this was on earlier detection. we want these people identified.we want them diagnosed. we want best practices.we want them to go out knowing that their families will get connected to services.and he said to us, be careful what you ask for.be careful what you ask for. what we find is that if people are identifiedin the hospital, as having dementia or alzheimer's, what you drive is the use of antipsychotics.they are much more likely to leave with these drugs and they are not necessarily likelyto leave with things like resources in the community or prescriptions for arasapt, thatyou would think would be part ofâ it would
seem logical but apparently it's not.so, this is the first of several conferences and we hope to have several more on thesetopics as we go forward. in process right now, there is a new partnershipbetween ucsf, the alzheimer's association and keiser, to provide a collaboration onphysician education. and these groups will go out and do trainingson cognitive impairment to any physician groups or other partners in the san francisco bayarea. not just san francisco.we are now working specifically with a group that wants to address transportation.you all may know that san francisco has a pretty viable transportation system, busesand all that but people with dementia lose
the capacity to navigate that pretty quickly.and why do have paratransit but one of the things we are learning is that paratransitfor the people with disabilities, does doortodoor service which is great, especially if theyare going to adult day care, but there is no mandate, no rerequirement the bus driverensure that person go into their home when they are dropped off at the bus station.so they are looking at developing a senior peer program that may allow seniors to getpaid for riding the bus and actually accompanying people to the right door or from the dooron to the bus to make sure that that piece of it is finalized.san francisco is also developing right now an aging and disability friendly city.and that work is underway and we are looking
at how to weave dementia, specifically intothat whole process as we go forward. i think that the continued keys to successis going to be continued leadership. the shared responsibility and sustaining thateffort. and one of the things that we have been tryingto do is to keep that sustained effort going, is to look at ways to bring our people backtogether and say, what are the new opportunities that we are being provided now based on whatis happening with our economy? we have health care reform coming down thepike. california has a community collaborative comingdown where many integrations are going forward county by county and how do we include thosethings.
so we have just started on the series of meetings.eliâ lilly fund today and daas and alzheimer's association brought back the groups to lookwhat the our recommendations should be now and how do we weave new recommendations intothe ones that are underway? i talked about the long term paraintegration.that would provide supportive health for all of our communitybased services through medicareand medical for the most lowincome folks. let me just end by saying, we are hoping toimplement some services in san francisco around this.san francisco is a littleâ is second air netheir rollout of this.there are 7 or 8 counties in california that are starting this roll out and it's a littlemessy on the ground, i will say.
but the alzheimer's association and the statehave a grant to look at, can we train care managers in these programs?can we develop care specialist to provide dementiaspecific care as each of these countiesrollout the managedcare plan for the medymedy population?can we provide training for caregivers who are in those plans?and can we participate in the stakeholder work group so we can influence the assessmentsand tools and that kind of thing? let me tell you where we are seeing a coupleof gaps and then i'm going to stop right there. a couple of the gap that is we are seeingis that numberâ 1, the health plans and these are health plans like blue shield and healthnetdifferent health plans, cannot identify people
in their system who have alzheimer's and dementia.we talked about having them use the dc9, dc10 codes but that only works if alzheimer's istheir primary diagnosis. now we know that about half of the folks neverget diagnosed anyway and then you say, how many of those folks that are diagnosed actuallyhave a diagnosis that is their primary diagnosis of alzheimers disease?and we suspect that those numbers are not very high.so getting at who has alzheimer's is hard. the other thing is, each of the plans developedtheir own assessment tools. they have to be approved by the state.some are better than others. we found in l.a. county that the assessmenttool that they were using to ask people about
whether mental health was a problem, theywere using interchangeably with dementia and weren't distinguishing between the two.we also found that some of them were pretty knowledgeable about dementia but these aretelephone assessments as to what services people are going to need and it was askingthings like, do you have a diagnosis of alzheimer's or dementia?if you do, are you experiencing agitation? are you experiencing symptoms of sun downing?are you taking any antipsychotic medications? which ones?and now i don't know how you all think people with alzheimer's disease, if they took thatcall would be able to answer that, but we know that there are gaps in the service deliverysystem that we are hoping to influence in
some important ways and once we work out someof those glitches, we hope to use those learnings as san francisco begins to role that out.there are challenges. so, i'm going to just stop right here andsay, are there any otherâ i don't even know if there is time for questions.>> there is. thank you very much.that was great. [ applause ]i think you really did continue the high quality of the talks in this session.so thank you. are there any questions for ruth?i have one. so, this plan, the san francisco plan, andwe just learned that california, because it
was blue on the map, has its own californiastate plan. what is the interaction between the city planand the state plan? >> and that is a good question.i should have said something about nat beginning. so, the san francisco plan predazed the californiastate plan. so the san francisco plan in some ways, sincei was on that work group, informed the state plan.but in terms of interactions between them, they are both kind of different.the state plan is much more state focused and is looking at some of the state integrationefforts. but no mandates around what counties or howcounties will implement.
which is what is happening as san franciscois implementing at the county level what the state is talking about in the bigger pictureat the state level. >> thank you.soâ yes? news.>> any movement in other counties for for similars plans.>> i think it is spotty but i think one of the things that started to happen to us isas we have begun working with this california integration plan for the medy medies, thereis a lot of interest in dementia. i think there is a recognition that peopledon't know they don't knowâ they know what they don't know or they don't know what theydon't know.
however you want to say that.we started to have request to have some metings specifically around dementia care.whether they go forward with a fullblown plan like san francisco did, but i think thereis lots of pieces of what san francisco is doing that are transportable to another citywhether you took the physician piece and transported that or the work on housing or transportation.so i think pieces of it are transportallable and that is what we are hoping, maybe pieceseven if a city doesn't go forward with a fullblown plan.>> [ off mic ] >> actually, i thought about trying to getsome discussions going. i'll use nevada as an example because northernnevada is very rural.
and there is interest in rural communitiesaround that. we have had some alzheimer awareness daysin places like winna mucka and the whole town will turn out and the kids will turn out andwe are thinking about having them write up essays of why my brain matters.that kind of thing. so, there is interest.the thing that i think would happen is that in rural communities, whether california ornorthern nevada, you probably have to look at counties collaborating together, becauseoften people have to crossover county lines even to go to a doctor or to go to a day careor whatever. so, i think there would be interest in itand it would have to be tweaked to meet the
needs of that particular community and i thinkthat is what is ideal sometimes about a city similar county.sometimes rural communities feel like the state doesn't get them anyway.they are like, we are out here and you forget about us all the time.and we need to talk about transportation and you don't.so these are issues that come up and if they had their own, they would tweak it to meettheir individual needs, i think. >> thank you, ruth.[ applause ]
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