Cp2 brochure

Kissito Healthcare’s Collaborative Patient Care Pathway TM

Adding Chronic Disease Self-Management Competency to the Post-Acute Agenda Written by Taj Bhaloo, PhD, MHA

Message from the CEO One of Kissito’s most unique programs is the Collaborative Patient Care PathwayTM, referred to as the Collaborative Pathway. Recognizing how difficult care transitions are for patients, especially older adults, we partnered with Steven Hahn, MD, FACP Clinical Professor of Medicine at the Albert Einstein College of Medicine to create an innovative, evidencebased self-management program that coaches our patients to understand their disease, recognize and manage their symptoms, and communicate better with their health care providers. As their health stabilizes during their stay at a Kissito facility, we work in partnership with patients and their families to empower them to be actively engaged in the patient’s well being while improving the patient’s functional abilities. Essentially, we prepare our patients to be in the “driver’s seat” and give them the information and tools to support their return to home.

Kissito Healthcare’s values of integrity and passion provided the impetus to develop this program that has become a benchmark for quality care. Our values of excellence and respect for patients and families lead us to work with national experts to create an exceptional program that is driven by patient and family needs. Acknowledging that our post acute care environment is an opportunity to educate, prepare and inform patients, Kissito’s experts have designed the four-component program which is founded on principles of interdisciplinary care, sound clinical tools, and wireless and information technology that supports care coordination.

I n t e g r i t y, P a s s i o n , E x c e l l e n c e ,

Ultimately, when a patient leaves our organization our goal is to improve their health literacy, develop important life-long selfmanagement skills and improve their ability to interact with their care providers to achieve better health.

Having refined the model for our post acute settings, we are pleased to work in collaboration with our partners who have a similar need to increase the self-management competence of their patients and to achieve a reduction in hospital readmissions. In anticipation of future changes to health care payment systems we are excited about adapting and applying our program across the continuum of other healthcare settings, starting with acute care and managed care organizations.

I am proud to share our Collaborative Patient Care PathwayTM with you.

Sincerely, Tom Clarke President & CEO, Kissito Healthcare

Respect

The Facts: Why Focus on Chronic Disease Self Management Eighty percent (80%) of elders have at least one chronic condition and 50% have more than one illness.

Chronic diseases such as heart disease, diabetes and cancer are the number one cause of death and disability in the United States.1 Eighty percent (80%) of elders have at least one chronic condition and 50% have more than one illness.2 According to the Medicare Payment Advisory Commission 75% of all national health expenditures are related to the treatment of chronic diseases3 which cost over $277 billion in treatment costs alone or over $1 trillion including loss of productivity and work days.4 In confronting the gravity of this problem there is reason for concern regarding the technical quality of chronic disease care and the effectiveness of the systems designed to provide it. For example, despite the availability of treatment guidelines for most chronic diseases, only 55% of patients with chronic disease receive guideline compliant care.5 More than 50% of older adults experience more than one chronic condition. In the current healthcare system patients often receive fragmented, uncoordinated care from multiple providers. As a result they often are subject to redundant tests and redundant or even conflicting treatments. Fragmented and uncoordinated care puts an even greater burden on elderly patients who may be least able to coordinate and self-manage their healthcare needs.6

Fragmented care and substandard care are two of the factors that have contributed to high hospital readmission rates. Heart failure (HF) is the number one reason for hospital admissions in the Medicare population (age 65+) costing $32.3 billion annually in (direct/indirect) costs in the U.S.7 Half of patients admitted for congestive heart failure are readmitted within six months. An estimated 20% of these readmissions are due to substandard care.8 In fact a prospective, randomized study concluded that 12-75% of readmissions are preventable9 and readmissions can be reduced with pre-discharge assessments, patient education or follow up home health.9 For example, patients with heart failure participating in one disease management program were found to be more vigilant about their symptoms and had almost 30% fewer readmissions.10 Current trends in health care reform include powerful incentives such as penalties for high readmission rates that put providers at risk if patients are re-hospitalized within 30 days. The goals of recent incentives and reforms are to promote increased attention to patients’ chronic disease self- management competencies, increase accountability among delivery systems and enhance quality care while using resources wisely.

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The Focus on Post Acute Rehabilitation Kissito Healthcare’s Collaborative Patient Care PathwayTM has transformed the post acute care experience by taking advantage of its potential as an ideal setting for patient and family caregiver self-management education. Traditionally, post acute rehabilitation in skilled nursing facilities have only focused on disease treatment, recuperation and short-term rehabilitation. However, the post acute environment may be the ideal venue for addressing an equally, if not more important, dimension of health and wellness: chronic disease selfmanagement.11 The post acute rehabilitation environment is ideal for self-management education because: • Patients stay for an average of three to four weeks, a time frame that permits gradual acquisition, practice and consolidation of self-management skills and knowledge.

• Patients are in a receptive frame of mind as they have been made attentive to their medical problems by their recent hospitalization. However, they have typically recovered from the crisis of acute hospitalization which virtually precludes learning, and not yet slipped into the complacency that often sets in after return to home.

• Patients’ families are often more present and more attentive to the patient’s medical problems than they are under any other circumstances.

• The post acute rehabilitation environment already provides interdisciplinary teams of skilled and caring health professionals.

Three Element Model for Enhancing Self-Management Competence In continuous pursuit of excellence, Kissito, in collaboration with Professor of Clinical Medicine at Albert Einstein College of Medicine Dr. Steven Hahn, has developed a comprehensive program which employs a unique Three-Element Model for Enhancing Self-Management Competence, implemented through a Collaborative Patient Care PathwayTM in which patients, family caregivers, physicians and our facilities’ interdisciplinary teams collaborate to provide care guided by “pathways” that structure the process of selfmanagement assessment, care planning and educational intervention across all chronic disease. Pathways also provide therapeutic area-specific guidance in self-management education for the illnesses of greatest interest in post acute rehabilitation.

1. The Four Domains of Self-Management Competence • Disease Awareness • Adherence Attitudes • Treatment and Medication Competence • Healthcare Communication 2. Patient-Centered Communication • Most healthcare communication is clinician-centered • Kissito staff are trained in patient-centered communication • Ask-Tell-Ask; the foundation of patient-centered communication 3. Family-Centered Care • The family is the context in which patients manage their chronic diseases • Kissito clinicians understand the role that the family will likely play in self-management

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1. The Four- Domains of Self-Management Competence The first element of the Collaborative Patient Care Pathway’s Model for Enhancing SelfManagement Competence is a model for understanding the components of selfmanagement competence. The Pathway’s unique clinical system defines four domains of self-management competence: • Disease Awareness • Adherence Attitudes • Treatment and Medication Competence • Healthcare Communication

Patients are not only taught about their disease (or diseases), but they are made aware of ‘red flags’ and learn to recognize when to call the doctor to prevent further deterioration.

Disease Awareness A basic understanding of the nature of their illnesses is fundamental to patients’ selfmanagement competence. In addition to understanding the names of their illnesses and meaning of their symptoms, patients need to understand asymptomatic disease progression and measures of disease status to motivate adherence to treatment, conduct selfmonitoring and recognize the “red flag” signs and symptoms that should prompt immediate action.

Adherence Attitudes Nonadherence to medication, diet and selfmonitoring is one of the most important remediable causes of poor chronic disease outcomes. We now understand that in addition to cost and the skills required to follow a regimen, patients’ perception that they need their medication competing with their concerns about taking medication (and other treatments) are the most important

determinants of adherence. Contrary to expectations, perceived need for medication and concerns about taking them are only loosely related to knowledge about the disease and treatment.12-15 There are patients who know the bare minimum about their medications yet have strong beliefs in their necessity because their doctor prescribed them. Others are very knowledgeable but their knowledge seems only to exacerbate concerns and undermine perceived need. Our understanding of adherence attitudes has resulted in the incorporation of structured, evidenced-based assessments of patients’ perceived needs and concerns about medications and other aspects of their treatment.16-18

“Often patients are knowledgeable about what they need to do, however, after some probing, I find that they are not putting their knowledge into practice.“ - Lori Stockton Director of Self-Management Education Palm View, Arizona

Treatment & Medication Competence Knowing what to take and when to take it has always been the foundation of the treatment competence domain of self-management.

However, effective self-management of chronic disease requires this and more. Patients also need to know how to self-monitor their chronic diseases, interpret the results and take appropriate action. These competencies require both skills and knowledge and the post acute rehabilitation hospitalization is the perfect environment to acquire them. Day by day, using post acute as a “Self-Management University”, patients and their families learn how to manage and even self-administer medications, and interpret their symptoms and self-monitoring results. For example, patients with CHF are introduced to monitoring their daily weight, recording and interpreting the results; they discuss the salt and nutritional content of the meals they are eating with nurses, nursing assistants and dietary staff; they learn to assess their legs for swelling, monitor their exercise tolerance and measure and understand their blood pressure and heart rate; they learn to recognize “red flags” that signal the need to take action or call their physicians;

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and they prepare questions for their physician and are supported in talking with them during visits in the rehabilitation facility. In effect, the Kissito Collaborative Patient Care PathwayTM turns the patient’s room into a classroom and the processes of care into a collaborative “Self-Management University”, incorporating every act of care and daily living into the selfmanagement learning experience.

Kissito staff works with patients and families and give them the opportunity to ‘practice’ taking their medications as they would in their own setting.

Nonadherence to medication, drug interactions, adverse events and inappropriate prescribing practices account for a substantial proportion of hospitalizations19-23 and anywhere from 15 to 28% of hospital visits for older adults.24 Because medication self-management (including adherence to medication schedules and reconciliation of medications across transitions in care from hospital to post acute, to home and after outpatient encounters) is so important, the Pathway incorporates Med Action PlanTM, a web-based and user friendly software program that supports medication adherence and includes powerful information to support the continued health literacy of patients and families. This web-based tool facilitates medication reconciliations across healthcare settings and enrolled physicians are also

able to view all prescribed drugs and make modifications as necessary. In keeping with the Self-Management University philosophy, once a medication regimen is stable, Kissito staff works with patients and families and gives them the opportunity to ‘practice’ taking their medications as they would in their own setting.

Patients assume increasing responsibility as per their comfort level.

Healthcare Communication The essence of collaborative care and selfmanagement is communication between patient, family caregivers and healthcare providers. Patients and their families need to be trained and empowered to communicate effectively with each other and with medical providers even when those professional caregivers’ communication skills and practices are not optimal. The Kissito Collaborative Patient Care Pathway includes structured assessment of health literacy, satisfaction and confidence in communication with family, informal caregivers and health professionals, and employs structured self-management education curriculum and tools to enhance communication. For example, patients and families are introduced to a “Questions for my Doctor” tear sheet that staff uses to help patients prepare for visits with their physician while in post acute care and which patients can use to empower and support their discussion during those encounters and after they go home.

Kissito staff probes to understand patient-specific issues in communicating with their doctor, nurse or other care provider and coach patients to get the most out of each interaction.

2. Patient-Centered Communication Enhancing patients’ and families’ selfmanagement competence requires understanding their individual experiences of illness and treatment. Patient-centered communication brings the patient’s experience, perspective and concerns into the dialog and promotes true shared decision making between provider and patient.

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Most healthcare communication is clinician-centered.

Although the evidence is strong that patientcentered communication has dramatic impact on healthcare processes and outcomes2529,30-35 the evidence is equally strong that patient-centered communication is the exception rather than the rule. Numerous

studies,30, 31, 36-42 including three conducted

by Dr. Hahn that used sociolinguistic analysis of actual videotaped doctor-patient visits, have demonstrated a striking homogeneity of clinician-centered communication patterns in areas as disparate as migraine management,26, 43 adherence to glaucoma drops44, 45 and women’s sexual health.46, 47 In these studies, deficits in patient-centered communication were associated with a variety of poor healthcare that were improved after interventions designed to enhance patientcentered communication.26, 45 Kissito staff are trained in patient-centered communication.

All members of our healthcare team at Kissito post acute sites have been trained in the use of patient-centered communication including the use of open-ended questions focusing on patient and family understanding and concerns about their illnesses, medications and self-monitoring skills. Staff probes to understand specific issues patients may have when communicating with their doctor, nurse or other care provider and coaches them to get the most out of each interaction. The range of communication skills varies from assessing patients’ confidence in asking their

doctor questions to how well they are able to understand medication labels. Based on these assessments, Kissito staff teach and coach the patient and family to improve their healthcare communication.

Ask-Tell-Ask; the foundation of patientcentered communication.

As an example, and one of the most important patient-centered communication techniques, “ask-tell-ask”, serves as the foundation for all clinician-patient dialog. Based on adult learning theory, ask-tell-ask begins with an open-ended question that allows the patient to reveal what s/he knows about his/her illness, treatment or symptoms.25, 26, 48 The patient’s answer allows the care provider to reinforce correct information or to correct mistaken beliefs.

The next step, “tell”, allows the clinician to add incrementally to the patient’s understanding.

The second “ask” allows the provider to ensure that the patient has understood and/or to assess the patient’s motivation or attitude.

Although empirical study demonstrates that ask-tell-ask is not employed in typical current communication,43, 49 it also demonstrates that clinicians will employ the technique when taught and that communication becomes more effective when they do.25, 26

“Often we find that residents are hesitant to ask their own families for help. We involve the family and ensure that they are aware of the resident’s needs. We also play a role in making sure that support systems are in place prior to discharge.”

- Lori Stockton, Director of Self-Education Management Kissito Healthcare Palm View in Yuma, Arizona.

3. Family-Centered Care The family is the context in which patients manage their chronic diseases. Families can be life-saving assets in self-management or a hindrance to a patient’s already complicated chronic disease challenges. Either way, success or failure in self-management is largely determined by the role they play.

The Collaborative Patient Care PathwayTM incorporates structured assessment tools to

evaluate the strengths, weaknesses, availability and willingness of family members to play a role in the patient’s self-management team. It also ensures early discovery of family problems that will require attention. Kissito clinicians understand the role that the family will likely play in self-management and begin scheduling and structuring opportunities to work with the family from day one.

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Kissito’s unique Three Element Model for Enhancing Self-Management Competence is provided in an environment that is anchored in interdisciplinary teamwork, guided by pathways and informed by disease-specific protocols and supported by information technology and documentation. Kissito healthcare is guided by two principles: 1. A Pathway Approach that Provides Direction The program is founded on the concept that a pathway guides the overall provision of care.

The pathway approach: • Provides direction and enables the patient to make progress in a structured manner • Allows for disease-specific pathways and protocols to be incorporated in care provision • Promotes continuity of care for the patient among shift and staffing changes In the arena of post acute rehabilitation, Kissito has committed to focusing on the following chronic illnesses given the current needs of their patient population: congestive heart failure (CHF), pneumonia, acute myocardial infarct (AMI), diabetes, orthopedic conditions, depression and COPD/asthma.

2. Interdisciplinary Teamwork and Communication A critical success factor in caring for older adults with chronic diseases is interdisciplinary care; good communication is one of the root causes that enables interdisciplinary teams to be successful and effective.50 Kissito has made efforts to enhance communication between: • Certified Nursing Aides and Registered Nurses • Physicians and the Interdisciplinary Care Team • Registered Nurses and Physicians

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The Collaborative Patient Care Pathway Experience TM

The term ‘Collaborative Patient Care PathwayTM’ describes the fact that self-management is an outcome that requires the cooperation and joint efforts of caregivers, patients and families. The Pathway component was specifically designed

by Kissito experts for the long term care setting.

While each patient is unique in diagnosis, functional abilities and co-morbidities, the Pathway approach ensures that care delivery balances unique circumstances with an ordered approach.

the healthcare team and is also responsible for helping the patient settle into our post acute care facility. The DSME’s initial objective is to get to know the patient, understand his/her goals and concerns, the issues leading up to hospitalization, and what each patient and family needs to safely return home. The DSME is responsible for all self-management assessments which are conducted in addition to discipline-specific assessments performed by other members of the care team.

The pathway consists of five phases that occur sequentially: 1. Pre-admission 2. Orientation & Assessment 3. Treatment 4. Preparing for Home 5. Discharge & Post-discharge Follow Up

Phase 3

Phase 1 Phase I, Pre-admission, includes Kissito staff working with the referring hospital to receive important patient information prior to the patient’s arrival.

“We use the term ‘pathway’ intentionally because while we recognize that each patient is unique, managing our patients’ complex chronic illnesses needs direction and should be goal-oriented.”

- Angela Mattocks Chief Nursing Officer

Phase 2 Upon admission, the patient is introduced to the Director of Self-Management Education (DSME), a senior and experienced nurse who has been trained in the Collaborative Patient Care PathwayTM and who plays a critical role in Phase 2, Orientation and Assessment. The DSME provides leadership to all members of

During Phase 3, Treatment, the DSME leads the Interdisciplinary Collaborative Care Rounds, a forum where the team integrates their findings and then develops a Self-Management Care Plan that incorporates: all functional and clinical assessments, the patient’s and family’s feedback, and plans that address all domains of self-management competency and rehabilitation goals. All information is shared with the patient and family so everyone knows what to expect. During each day of the patient’s stay at Kissito health facilities, staff diligently follows the care plan and the patient’s progress is reviewed every week by the care team.

Phase 4 Preparing for Home, Phase 4, is a time when the patient’s health has stabilized and s/he is encouraged to gradually take on more aspects of their self-care in the post acute environment envisioned as a Self-Management University.

For example, when the patient’s medication regimen is stable, staff teaches individual patients (and their family caregivers) how to take each medication as they would in their own home. Also, patients are encouraged to perform a range of routine duties that they hope to perform in their own home

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such as meal preparation or laundry. This gives patients and families an opportunity to understand any new concerns or challenges they may face in their own homes and ask staff for guidance.

Patients are asked to bring in all old medications from home so that they can be reviewed and “reconciled” with the current and planned discharge medications using MedAction PlanTM. Medication reconciliations, treatment competency assessments and education help prevent medication errors (particularly once the patient returns to their own environment).

Kissito’s rehabilitation team will also train family members to conduct safety assessments to ensure that the home environment is as safe as possible for patients and all precautions for fall prevention have been put into place.

Phase 5 As part of the Discharge phase, Phase 5, the same assessments conducted upon admission are repeated to assess progress and identify areas for continued attention. The DSME supports the patients’ return by calling patients during the first 24 hours post discharge and ensuring that the patient will be successful in following his/her self-management care plan at home. The DSME will follow up with the patient in two to three weeks, after 30 days, and as often as needed in-between to ensure adherence to medication, diet, self-monitoring and visits with physicians. Kissito has established a care line, available to discharged patients and families 24 hours per day and seven days per week to provide advice and comfort.

“The key is developing a rapport with patients and families; as they begin to trust me, I am able to help them realize that they can make better decisions for themselves.”

- Crista Ferguson Director of Self-Management Education Cane Island Post Acute Care in Katy, Texas

Interdisciplinary Team Care & Communication Not only is interdisciplinary team work associated with higher levels of health professional satisfaction,51 but it is also related to improved patient outcomes and better care coordination . In addition to the Interdisciplinary Collaborative Care Rounds, Kissito recognized that it needed to facilitate more opportunities for crossdiscipline communication and to empower the direct care staff that have the most patient interaction. For example, Kissito has introduced systems that enable direct care

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staff such as Certified Nursing Aides to share important information to supervisory staff like nurses or rehabilitation therapists.

Improving communication between nurses and physicians is equally important to care coordination. Therefore, Kissito supports using SBAR (Situation-Background-AssessmentRecommendation) which is considered an efficient way to articulate pertinent patient information, especially when immediate action is necessary.52

Enablers: Documentation, Tools and Structured Assessments Kissito has invested considerable resources, researching tools and techniques that are well tested as well as developing its own set of tools tailor-made for the self-management education agenda. In addition, Kissito experts have developed disease-specific documentation templates that are useful in guiding staff and also ensuring that care provision follows established disease-specific protocols.

We have invested considerable resources into evidencebased tools that are considered best practice in the industry; we have even developed new tools catered to our selfmanagement program.

An example of a tool that is considered best practice in the industry is the Beliefs about Medicine Questionnaire (BMQ), an assessment that helps predict adherence to treatment for a number of chronic diseases18 and the Patient Activation Measure, a quantitative assessment of the patient’s global selfmanagement attitudes and competence.53, 54 Additional tools that have been developed include structured assessments of all four domains of self-management competency and interventions to guide coaching and behavior change.

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The Kissito Collaborative Patient Care Pathway Curriculum TM

Kissito has developed an extensive staff training and program development curriculum designed to implement the Collaborative Patient Care PathwayTM in post acute rehabilitation facilities and sustain quality practice over time. The curriculum is designed to transform the culture of post acute rehabilitation by adding the agenda of self-management education to the traditional agendas of acute disease treatment and short term rehabilitation. The curriculum equips all staff - managers, nurses, nursing assistants, rehabilitation therapists, life

enrichment therapists and social workers - with patient-centered communication skills and imbues the philosophy of the Self-Management University. Staff become proficient in the use of the structured self-management assessment tools, documentation templates and decision support tools. The curriculum helps structure workflow around the selfmanagement education agenda, the role of the Director of Self-Management Education and the integration of Interdisciplinary SelfManagement Collaborative Care Rounds.

Expected Outcomes With the program implementation phase complete, as part of a collaborative effort with other organizations, we will be enlisting a select group of organizations to partner in our future outcome research endeavors to assess patient and program outcomes at an individual level, but also in the context of the larger healthcare system.

At the patient and family (individual level), we are tracking a variety of outcomes, some of which include: • Increased awareness/knowledge of their disease • Change in motivation (adherence) • Increased competency to recognize red flags and respond with appropriate action • Increased confidence in communicating with healthcare provider • Other short term changes in self-management behaviors • Longer term changes such as improvements in functional health and independence or quality of life

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At a program and systems level we are interested in the following indicators: • Change (reduction) in readmissions • Patient, family and provider satisfaction with care • Overall change (reduction) in hospital admissions • Appropriate use of primary and community-based care options

An Exciting Future Ahead . . .

“Given today’s uncertain climate, now is the time to form strong integrated strategies with our acute care partners. Sharing and studying data is just not good enough. When our care partners see real movement, real evidence, they get equally excited and passionate about working towards a solution. They are looking for answers and I feel Kissito is delivering just that.”

- Josh McGilliard Vice President Kissito Healthcare, Roanoke, VA

Having implemented the Collaborative Pathway at three of our post acute sites, we are refining our program processes. The implementation process has served as a learning opportunity to fine-tune program delivery details, improve our interdisciplinary communication processes and maintain the momentum and excitement among our staff as the program continues to mature.

We are embarking on a number of interrelated and exciting initiatives. First of all, Kissito has made an investment in a myriad of wireless technologies that continuously monitors patients at a low cost, supports learned selfmanagement behaviors and enables care to be provided in a more efficient manner. Wireless technologies have already been demonstrated to have numerous benefits ranging from more accurate diagnoses to long term monitoring of patients in their own home, to improving health literacy and supporting earlier discharge from institutionalized settings.55 Consequently, embracing wireless technology and related innovations are a key part of Kissito’s future.

Secondly, our future includes joining forces with other health care partners; managing care transitions for our patients and families means working in collaboration with hospitals, home health organizations, (community) physician practices and other stakeholders. We are cognizant that sustaining the enhanced self-management that patients and families acquire during their stay at Kissito means working with our partners to ensure continued self-management support.

Lastly, recognizing that our acute care partners share our goals of increasing the selfmanagement competencies of patients and reducing preventable hospital readmissions, we are excited about collaborating with interested stakeholders to adapt our model and make it equally successful across a variety of health care settings, starting with acute care and managed care organizations. Given impending healthcare reforms, we are confident that our Collaborative Patient Care PathwayTM will be a valuable asset to all organizations and will be an integral component of Accountable Care Organizations.

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Abstracts Selected in 2011 1. ACPEL 2011 Conference, June 22-24, 2011, Queen Elizabeth II Conference Centre, London. Accepted abstract: Collaborative Patient Care Model for Geriatric population: Poster Presentation.

2. 11th Australian Palliative Care Conference 2011: August 30-September 2, 2011, Cairns, Australia: An Evidence-Based Patient-Centered, Comprehensive, Collaborative and Coordinated Care Model for At Risk Elderly Population”: Poster Presentation.

3. ISQUA 28th International Conference 2011: Hong Kong, China; September 14-17, 2011: Abstract titled “Program of All inclusive Care for the Elderly: An Evidence-Based Patient Centered Comprehensive, Collaborative and Coordinated Care Model”: Poster Display.

4. 2011 International Conference on Communication in Healthcare; October 16-18, 2011, Chicago: Program of All inclusive Care for the Elderly: “An EvidenceBased Patient-Centered, Comprehensive, Collaborative and Coordinated Care Model “: Poster Presentation.

5. ASEM 2011: 40th Annual Scientific and Educational Meeting of the CAG & 4th Pan American Congress of the IAGG: ”Program of All inclusive Care for the Elderly: An EvidenceBased Patient-Centered, Comprehensive, Collaborative and Coordinated Care Model for At Risk Elderly Population”: October 22-24, 2011, Ottawa, Ontario, Canada: Oral Presentation.

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6. ASEM 2011: 40th Annual Scientific and Educational Meeting of the CAG & 4th Pan American Congress of the AGG; “Collaborative Patient Care Model: Comprehensive Care Coordination for Geriatric Population”: October 22-24, 2011, Ottawa, Ontario, Canada: Poster Presentation.

7. 139th APHA Annual Convention October 29-November 2, 2011: Washington DC: Program of All inclusive Care for the Elderly: An Evidence-Based Patient-Centered, Comprehensive, Collaborative and Coordinated Care Model for At Risk Elderly Population”: Poster Presentation.

8. Ageing and Society Conference 2011; the University of California, Berkeley, CA, November 8-9, 2011. Abstract Titled: A Collaborative Patient Care Model: Comprehensive Care Coordination for Geriatric Populations: 30 minutes Oral Presentation.

9. 1st NUS-NUH International Nursing Conference; PROGRAM OF ALL INCLUSIVE CARE FOR THE ELDERLY: AN EVIDENCE-BASED PATIENT CENTERED COMPREHENSIVE, COLLABORATIVE AND COORDINATED CARE MODEL: November 17-19, 2011; Singapore; Oral Presentation.

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