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

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

May 02, 2023 144 likes •503 views

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

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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

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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

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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
  • lder adults living in the Pittsburgh community
  • Helps older adults continue to live independently in their
  • wn 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

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Collaborating Agencies

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Jewish Association on Aging

Home & Community-based Services Residential Services

Meals on Wheels Outpatient Rehab Adult Day Program Home Health Hospice Personal Care Facilities Skilled Nursing & Rehab AgeWell

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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

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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

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Jewish Community Center of Greater Pittsburgh

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  • 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

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What Does AgeWell Do? Sample Case

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  • 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.

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What is AgeWell Pittsburgh?

  • Outcomes based collaboration of three non-

profit, community agencies

  • Goal of the collaborative:

– “to provide an integrated, seamless delivery system

  • f 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”

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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

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AgeWell Pittsburgh MOU

2007 MOU components

  • Partner agencies agree to collaborate
  • n:

– Developing a seamless service delivery system for the elderly – A client-centered approach to service delivery – A system of care open to all elderly individuals – A cost-effective service system that eliminates duplication of services – Collaborative marketing of aging services

  • ffered by participating organizations

– Joint efforts to secure sufficient funding to support the core of services of AgeWell (outreach, assessment, linkages, evaluation) – Joint efforts to raise sustainable funds to support the ongoing collaboration

2015 MOU components

  • Partner agencies agree to

continue to collaborate on goals established in 2007

  • MOU expanded to include the

following components:

– More formalized hierarchy – Marketing: inclusive of website maintenance and community

  • utreach

– Program Funding and Grant Development

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Before AgeWell Pittsburgh

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Inner Core

  • Outreach
  • Assessment
  • Linkages
  • Evaluation

Food Pantry Home Delivered Meals Mental Health Services Vocational Services

AgeWell Pittsburgh Now: Integrated Model of Services

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AgeWell Pittsburgh Discrete Services

  • Anathan Club/Adult Day Services
  • AgeWell Community Nursing Services
  • AgeWell at Home
  • Caregiver Connection (private duty registry)
  • Care Coordination
  • Check Mates
  • Cognitive Enhancement/Brain Builders
  • Congregate Meals
  • Counseling/Support groups
  • Elder Alert
  • Elder Express
  • Focal Point Senior Community Center

(AgeWell at the JCC)

  • Home Health Services (Medicare certified)
  • Home Modification
  • Information and Referral Line
  • Mollie’s Meals (Kosher Meal Delivery)
  • Night Time Memory Program
  • Outpatient Rehabilitation Services
  • Residence at Weinberg Village and

Weinberg Terrace

  • Silver Sneakers and Silver Fit
  • Sivitz Jewish Hospice
  • Squirrel Hill community Food Pantry
  • Volunteer Services

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

  • n self report)

Skilled Nursing Facility Admissions Estimated 9 SNF admissions per 100 clients per year (based on self report)

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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

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AgeWell Pittsburgh: Volunteers Add Value

  • Over 1,800 AgeWell Pittsburgh Volunteers
  • AgeWell Pittsburgh Volunteers provided over 9,700 hours
  • f 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

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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

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AgeWell Endorsed Evidence-Based and Evidence-Informed Programs

  • HomeMeds Medication Assurance
  • Building Better Caregivers
  • Walk with Ease
  • Memory Training
  • Aging Mastery Program (AMP)

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HomeMeds Medication Assurance Program

  • Developed by Partners in Care Foundation

– Evidenced-based program with recognition from Administration

  • n 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

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JAA HomeMeds Average Client Profile

Average Age 82.3 Average # Chronic Conditions 3.9 Average # Medications Taken Daily 12

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HomeMeds Medication Assurance Program Outcomes

  • Initial Phase

– Implemented in HUD housing program; senior high-rise (primarily non-English speaking population); Independent Senior Condos; JAA Adult Day Services – Completed 200 assessments

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HomeMeds Medication Assurance Program Outcomes: Phase 1

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HomeMeds Medication Assurance Program Outcomes

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HomeMeds 6-Month Pilot Data

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Memory Training

  • Program developed by the UCLA Longevity

Center

  • Four week program combines trainer

presentations with group discussions, memory checks and skill building exercises

  • Target population: individuals with mild

memory deficiencies

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Aging Mastery (AMP)

  • Program developed through the National

Council on Aging

  • Behavior change incentive model for aging

well-helps older adults take key steps to improve their well-being, add stability to their lives, and strengthen their ties to their community

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AgeWell Satisfaction: Participant Survey

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  • Participants are queried annually
  • Questions include

– Demographic information – Living arrangements – AgeWell involvement

  • Programs currently utilized or utilized in the past
  • Length of time involved with AgeWell

– 10 quality of life questions – 2 general satisfaction questions

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AgeWell Satisfaction: Survey Results

Quality of Life Survey Question % Agree or Strongly Agree

I talk to more people than I used to 81% I leave my home more than I used to 76% I participate in social activities more than I used to 78% I take better care of my health than I used to 89% I know where to ask for assistance when I need it 94% I volunteer in the community more than I used to 44% I eat meals that are healthier for me 85% I am more physically active 84% I feel happier or more satisfied with my life 79% I have more energy than I used to 64%

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AgeWell Satisfaction: Survey Results

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31% 55% 1% 2% 11%

General Satisfaction: I feel satisfied with AgeWell Pittsburgh

Strongly Agree Agree Disagree Strongly Disagree Not Applicable

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AgeWell Satisfaction: Survey Results

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43% 48% 0% 0% 9%

General Satisfaction: I would recommend AgeWell Pittsburgh to a friend or family member

Strongly Agree Agree Disagree Strongly Disagree Not Applicable

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AgeWell Sustainability: Next Steps

  • Taking HomeMeds to scale
  • Develop and Implement a Virtual Senior

Center

  • Electronic Medical Record integration
  • Establishing partnerships with MCO’s for

MLTSS implementation in Southwestern, PA

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MCO’s-the AgeWell Advantage

  • Unique model of service delivery

– Opportunity to reach over 10,000 community dwelling participants in the geographic area – Expansive/Inclusive support and healthcare services through one integrated “hub” – Access to the RIGHT services at the RIGHT time – Demonstrated success in decreasing utilization of the most costly healthcare services

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AgeWell Pittsburgh

  • Questions?

THANK YOU FOR YOUR TIME!

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