Aging in Place

1. Aging in Place • Craig Jones, MD • Molly Dugan • Kevin Loso • Nancy Eldridge

2. We All Want to Stay Home • Home centric • Consumer driven • Unlicensed

3. WE BUILT AN EDUCATION SYSTEM NOW THEY NEED A LONG TERM CARE SYSTEM! FOR THE BABY BOOMERS IN 1953

4. A Network of Care Management HUBS • 150 + HUBS • All Incomes, • Ages and • Settings • Medicare • Dual Eligibles • Others??

5. Housers at Health Reform Table with the State

6. The Technology Embedded Home • Central Clinical Registry • iPads • Tele-Tai Chi • Broadband for all! • Cyber Seniors

7. THE SAVI!! THANK YOU ENTERPRISE COMMUNITY PARTNERS!!

8. How Will Our Residents Benefit? HEALTHY HOMES CARING COMMUNITIES POSITIVE AGING!

9. Housers Working Together Non-Profit Housers Land Trusts CCRC’s Public Housing Authorities Assisted Living Residential Care Facilities

10. Department of Vermont Health Access Vermont Blueprint for Health Community Systems of Health Housing Assistance Council June 5, 2012

11. Department of Vermont Health Access • Building A Foundation For The Future • Advanced Primary Care Practices (PCMHs) • Community Health Teams (core) • Community Health Teams extended(MCAID CCs, SASH Teams) • Multi-insurer payment reforms • Health Information Infrastructure • Evaluation & Reporting Systems • Learning Health System Activities

12. Department of Vermont Health Access Hospitals Advanced Primary Care Specialty Care & Disease Management Programs Community Health Team Nurse Coordinator Social Workers Nutrition Specialists Community Health Workers Public Health Specialist Extended Community Health Team Medicaid Care Coordinators SASH Teams Advanced Primary Care Social, Economic, & Community Services Advanced Primary Care Mental Health & Substance Abuse Programs Advanced Primary Care Healthier Living Workshops Public Health Programs & Services Health IT Framework Evaluation Framework Multi-Insurer Payment Reform Framework 11/20/2014 12 12

13. Department of Vermont Health Access Financing Payment Reform Delivery System Reform • Advanced Primary Care • NCQA Standards • Patient Centered Care • Access • Communication • Guideline Based Care • Use of Health IT Fee for Service - Volume $ PPPM (NCQA) - Quality Medicaid Medicare BlueCross MVP Cigna Self Insured • Community Support • Community Health Teams • MCAID CCs • SASH Teams Shared Costs - Utility • Specialized Services • Hospitals • Specialty Care • Mental Health Services • Substance Use Services • Family Services • Social Services • Economic Services • Long Term Care • Nursing Homes

14. Blueprint Information Technology Architecture Hospital-owned Primary Care Practices • Central Registry • Visit planners • Care coordination • Reporting Hospital - hosted EMR Data warehouse Core data elements FQHC-owned Primary Care Practices Vermont Health Information Exchange (VHIE) Core data elements Central Clinical Registry (Covisint-DocSite) Core data elements FQHC - hosted EMR Unique Patient identification information Core data elements Independent Primary Care Practices Community Health Team EMR Web Access Core data elements Primary Care Practice No EMR Web Access

15. Blueprint Expansion January 2012

16. Department of Vermont Health Access 16

17. 11/20/2014 Gifford CME 3-2-2012 17

18. Department of Vermont Health Access

19. Care Management Begins at Home

20. Multi-payer Advanced Primary Care Practices (MAPCP) Medicare Demonstration States • Maine • Michigan • Minnesota • New York • North Carolina • Pennsylvania • Rhode Island • Vermont

21. Integrated Care for the Dually Eligible • California • Connecticut • Colorado • Massachusetts • Michigan • Minnesota • New York • North Carolina • Oklahoma • Oregon • South Carolina • Tennessee • Vermont • Washington • Wisconsin

22. Department of Vermont Health Access • Data Sources & Evaluation • Central Clinical Registry • Multi-payer Claims Database • Chart Reviews • NCQA Scoring • Public Health Registries • Patient Provider Qualitative Assessment • Patient Experience

23. Department of Vermont Health Access Early Trends – Inpatient Discharges

24. Department of Vermont Health Access Early Trends – Inpatient Discharges (Rate / 1000)

25. Department of Vermont Health Access Blueprint Team Craig Jones, MD Lisa Dulsky Watkins, MD Jenney Samuelson Terri Price Diane Hawkins Beth Tanzman Pat Jones Julie Trottier (Milbank Fellow)

26. SASH is a System, Not a Type of Housing • All settings – all ages – all incomes • Access to information for housing based staff • Population based – plus targeting • SASH as an extender to the Blueprint for Health- • VT’s Medical Home Model.

27. What are the Essential Elements? • Person-centered – Population based • SASH Staff • Team Based Care Management • Information Sharing through Technology • Prevention and Wellness through Healthy Living Planning • Volunteers

28. SASH Keeps “Katie” in the Driver’s Seat

29. SASH Staff = Trusted Guides

30. Multi-Agency Team Based Care Management Nonprofit Housing PACE Comm. Mental Health Agency Visiting Nurse Assoc. Area Agency on Aging

31. The SASH Teams • Care Manager • Wellness Nurse • Acute Care Nurse • Case Manager • Mental Health Expert • PACE Intake • Assessments • Person Centered Plans • Individualized Supports • Transitions Support • Self-Management of Chronic Conditions • Care Coordination

32. Prevention and Wellness

33. Volunteers!

34. Where are we now? • Started rolling out in October 2011 • Currently have 19.5 panels up and running! • 1,950 people have access to SASH supports. • 57 affordable housing sites are SASH sites • DocSite- Statewide Repository of Data is on-line.

35. Vermont’s SASH Goes Statewide

36. SASH and the Blueprint for Health • An Extension of the Community Health Team • Support for Goals of the Medical Homes • CHT Case Manager Representation on Functional Team • SASH Representation on CHT Planning Committee • SASH Representation on CHT Referral Committee

37. Rutland County SASH Community Partners • Rutland Regional Medical Center (RRMC): Social Work Department • RRMC: Case Management Department (Discharge Planners) • RRMC: Community Wellness Programs • Rutland Area VNA & Hospice – Nursing and Wellness Services • Southwestern VT COA– Case Management and Programming • PACE Vermont – Intake Coordination • Rutland Mental Health Services – Elder Care Clinician & Case Management • Southern VT Area Health Education Center – Interns • Vermont Department of Health – Programming • Castleton State College, School of Nursing – Interns

38. SASH and the Blueprint for Health • The Pines of Rutland (SNF) – Discharge Planning • Vermont Division of Disability & Aging Services – Choices For Care • Community Health Center of the Rutland Region (FQHC) – Medical Homes • Albany School of Pharmacology – Interns • The BUS – Transportation • Local Farmers – Nutrition Programs • Castleton Community Center – Programming • Retired Senior Volunteer Program – Volunteers • Lions Club – Vision Program • LensCrafters – Vision Program

39. SASH Local Table • Engages key community leaders in SASH • Provides support, guidance and general oversight • Represents interests of the SASH population • Members include leaders representing community partners, other providers, and other community stakeholders

40. SASH Local Table Roles & Responsibilities • General promotion of SASH to the community • Reviews strategic direction and priorities • Reviews protocols and services • Support in seeking funding sources • Reviews reports • Provides specialized experience • Reviews processes, data and outcomes • Supports overall development and sustainability

41. Profile of Residents SASH Local Table Roles & Responsibilities Templewood Court Sheldon Towers 40 residents enrolled 17 female 23 male Average age: 58 years old Average # of prescription medications taken: 6 Have 3 or more medical conditions: 80% Have 5 or more medical conditions: 55% • 49 residents enrolled • 39 females • 10 males • Average age: 72 years old • Average # of prescription medications taken: 7 • Have 3 or more medical conditions: 90% • Have 5 or more medical conditions: 55%

42. Profile of Residents Templewood Court Sheldon Towers Failed cognitive screening: 12% Used ER: 48% Have self-reported mental health concern: 45% Have moderate to high nutritional risk: 75% • Failed cognitive screening: 39% • Used ER: 43% • Have self-reported mental health concern: 33% • Have moderate to high nutritional risk: 83%

43. Profile of Residents Templewood Court Sheldon Towers Top 5 Medical Conditions Vision High Blood Pressure Arthritis Depression Chronic Pain 33% have fallen in last year • Top 5 Medical Conditions • Vision • Arthritis • High Blood Pressure • Heart or Circulatory Problems • Chronic Pain • 33% have fallen in last year

44. Community Program Support • Castleton State College Nursing Programs - Internship Program • Vermont Center for Independent Living - Hunger Free Vermont Nutritional Program • Council on Aging; AmeriCorps Members – Tai Chi, Walking Program • Beauchamp & O’Rourke Pharmacy – Brown Bag Medication Review, Diabetes Education • Castleton Community Center – A Matter of Balance • RRMC – Eat Well Feel Great

45. Information Sharing Housing Staff Nursing Homes/Rehab Facilities Community Providers (VNA, AAA, Mental Health) Primary Care Provider Community Health Team Family Support Persons Hospital

46. Benefits to Residents • Enhanced quality of life • Decreased isolation • Increased physical activity • Improved nutritional status • Increase in primary care • Vision issues addressed • Reduction in ER and SNF utilization • Earlier treatment of health issues • Enhanced aging in place

47. SASH Benefits To Housers • Added supports for a changing resident population • Liability exposure reduced • Increase in on-site support staff • Operate without a blindfold • Application of evidence-based practices • Integral part of home & community-based services aging network • Part of linking non-profit assets • Sustainable funding for services • Place at the health care table • Benefit from a collaborative network