Positioning a Community Collaboration for Outcomes and Managed Care - PowerPoint PPT Presentation

Positioning a Community Collaboration for Outcomes and Managed Care AJAS: Association of Jewish Aging Services 2016 Annual Conference Presenters: Deborah Winn-Horvitz, President & CEO , Jewish Association on Aging Mary Anne Foley, Vice President Home & Community Based Services, Jewish Association on Aging

Program Objectives Participants will: • Gain knowledge of how 3 community agencies have combined discrete competencies to develop a seamless delivery system of services to improve the quality of life for seniors residing within their geographic territory • Learn how participant outcomes can be improved through structured collaboration • Understand the impact of continuous client assessment and evaluation through evidence-based tools and services and the correlated positive outcomes dispersed throughout the community • Learn how these partnerships can led to successful funding and alternative sources of revenue 2

AgeWell Pittsburgh  A coordinated effort between  Jewish Community Center of Greater Pittsburgh  Jewish Family & Children’s Service  Jewish Association on Aging  Provides a broad range of community-based services to older adults living in the Pittsburgh community  Helps older adults continue to live independently in their own homes by identifying those at risk of losing their independence and helping them link them to services that will allow them to remain safely at home 3

Collaborating Agencies 4

Jewish Association on Aging Home & Residential Community-based Services Services Personal Skilled AgeWell Meals on Outpatient Adult Day Home Hospice Care Nursing Wheels Rehab Program Health Facilities & Rehab 5

Jewish Association on Aging FY 2015 • $31.0 million operating budget • $2.8 million charity care • 53,974 Skilled nursing days of care • 319,693+ meals prepared (served or delivered) • 23,837+ Outpatient Therapy Visits • 28,983+ Home Health Visits • 3,377+ Hospice Visits • 4,900+ days of Adult Day Services provided 6

Jewish Family & Children’s Service • Multi-faceted non-profit organization – Assists over 10,000 individuals annually • Service Areas – Elder Care – Employment – Refugees and Immigrants – Mental Health – Food Pantry – Adoption, Foster Care and Guardianship 7

Jewish Community Center of Greater Pittsburgh • One of the largest social service, recreational and educational organizations in the Pittsburgh region – Comprehensive programming includes • Child Care and Preschool • After- school and School’s -out Programs • Day and Overnight Camping • Senior Adult Activities • Fitness and Wellness Programs • Special Needs Services • Arts and Cultural Activities – Nationally-Accredited Jewish Museum 8

What Does AgeWell Do? Sample Case S. is an independent 89 year old woman. She has been relatively stable, living in a senior high-rise, but tended to isolate herself. Her mental health issues had recently escalated, which resulted in her reaching out for help for the first time in many years. S. contacted AgeWell Pittsburgh’s Information and Referral (I&R) Specialist who was able to refer her to a number of services. The Jewish Association on Aging’s AgeWell at Home program seemed especially well suited for S. The Care Navigator from AgeWell at Home met with S., and together they created a plan to address her various issues. She was referred to the Squirrel Hill Health Center for medical and mental health care. S. also began attending the UCLA Memory Training Program for cognitive enhancement and socialization through Jewish Family & Children’s Service. To further decrease isolation, she agreed to receive calls from AgeWell at the JCC’s Checkmates program, a peer led telephone reassurance program. S. feels more secure in her independence knowing that these supports and services are available to her to help maintain her independence. 9

What is AgeWell Pittsburgh? • Outcomes based collaboration of three non- profit, community agencies • Goal of the collaborative: – “to provide an integrated, seamless delivery system of services to Pittsburgh’s older adults, supporting a sustainable quality of life and helping seniors to live independently in the community ” • Mission of the collaboration: – “to provide a client -centered, one-stop-approach to service delivery issues” 10

AgeWell Pittsburgh History • Developed in the 1990’s as a response to – Overlapping or duplication of services in the community – Community provider/organization silos – Lack of coordination • First MOU developed in 2007 • MOU revised in 2015 11

AgeWell Pittsburgh MOU 2007 MOU components 2015 MOU components • • Partner agencies agree to collaborate Partner agencies agree to on: continue to collaborate on goals – Developing a seamless service delivery system for the elderly established in 2007 – A client-centered approach to service • MOU expanded to include the delivery – A system of care open to all elderly following components: individuals – A cost-effective service system that – More formalized hierarchy eliminates duplication of services – Marketing: inclusive of website – Collaborative marketing of aging services offered by participating organizations maintenance and community – Joint efforts to secure sufficient funding to outreach support the core of services of AgeWell – (outreach, assessment, linkages, Program Funding and Grant evaluation) Development – Joint efforts to raise sustainable funds to support the ongoing collaboration 12

Before AgeWell Pittsburgh 13

AgeWell Pittsburgh Now: Integrated Model of Services Food Pantry Inner Core • Outreach • Assessment Mental Health Services Home Delivered Meals • Linkages • Evaluation Vocational Services 14

AgeWell Pittsburgh Discrete Services • • Anathan Club/Adult Day Services Home Health Services (Medicare certified) • • AgeWell Community Nursing Services Home Modification • • AgeWell at Home Information and Referral Line • • Caregiver Connection (private duty registry) Mollie’s Meals (Kosher Meal Delivery) • • Care Coordination Night Time Memory Program • • Check Mates Outpatient Rehabilitation Services • • Cognitive Enhancement/Brain Builders Residence at Weinberg Village and Weinberg Terrace • Congregate Meals • Silver Sneakers and Silver Fit • Counseling/Support groups • Sivitz Jewish Hospice • Elder Alert • Squirrel Hill community Food Pantry • Elder Express • Volunteer Services • Focal Point Senior Community Center (AgeWell at the JCC) 15

Client Profile AgeWell Impact Number of clients served 7,248 Maintained or Improved 96% Protective Factors Score Nursing home eligible clients 16% ER Visits Estimated 24 ER visits per 100 clients per Living alone 40% year(based on self report) Hospital Admissions Estimated 26 hospital admissions per 100 Medicaid Assistance 30% clients per year(based Male 34% on self report) Female 66% Skilled Nursing Facility Estimated 9 SNF Age 60 - 64 2% Admissions admissions per 100 Age 65 - 74 30% clients per year Age 75 - 84 32% (based on self report) Age 85+ 35% 16

AgeWell Pittsburgh: Outcomes Impact Translates to Financial Impact • $1,500 per ER visit - AVOIDED • $9,800 per hospital admission - AVOIDED • $77,000 per nursing home stay per year - AVOIDED 17

AgeWell Pittsburgh: Volunteers Add Value • Over 1,800 AgeWell Pittsburgh Volunteers • AgeWell Pittsburgh Volunteers provided over 9,700 hours of volunteerism • All AgeWell Pittsburgh Volunteer programs are co-branded and affiliated with “Open Your Heart to a Senior” • Examples of AgeWell Pittsburgh Volunteer Programs • Check Mates (reassurance calls) • J Café ( congregate meal program) • AgeWell Rides (volunteer transportation) • AgeWell Visits (friendly visitor program) • Mollie’s Meals (home delivered meals) • Squirrel Hill Community Food Pantry 18

AgeWell Pittsburgh: Evidence-Based Programs Evidence-Based programs offer an ideal model for linking older adults to pertinent information and support. These value- added programs have the ability to: – Significantly improve the health and well-being of older adults in the community – Attract new participants and funders through innovative programming – Create powerful partnerships with other organizations, including health care providers 19

AgeWell Endorsed Evidence-Based and Evidence-Informed Programs • HomeMeds Medication Assurance • Building Better Caregivers • Walk with Ease • Memory Training • Aging Mastery Program (AMP) 20

HomeMeds Medication Assurance Program • Developed by Partners in Care Foundation – Evidenced-based program with recognition from Administration on Aging (AOA); the ACL Aging and Disability Evidenced-based programs and Practices; the US Agency for Healthcare Research and Quality (AHRQ) Innovation Exchange and the Leading Age National Innovation & Research Center • A comprehensive, individual screening, assessment and alert process to identify medication issues in the senior population • Alerts included: • Therapeutic Duplication • Drug/Drug Interaction • Psychotropic Drug Use • Non-steroidal anti-inflammatory (NSAID) Drug Use • Cardiovascular Medication Problems 21