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Live Well At Home Project: Targeting At-Risk Older Adults August 18, 2009 Age Odyssey Conference MN Board on Aging/ MN PowerPoint Presentation
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Live Well At Home Project: Targeting At-Risk Older Adults August 18, 2009 Age Odyssey Conference MN Board on Aging/ MN Dept. Human Services Presenters Catherine Sampson, Arrowhead AAA Lori Vrolson, Central MN Council on Aging,

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Live Well At HomeProject: Targeting At-Risk Older AdultsAugust 18, 2009Age Odyssey ConferenceMN Board on Aging/ MN Dept. Human Services

  • Catherine Sampson, Arrowhead AAA
  • Lori Vrolson, Central MN Council on Aging,
  • Elaine Spain, MN River AAA,
aoa funded nursing home diversion project nhdp 2007 2009 goals
AOA-Funded Nursing Home Diversion Project (NHDP) 2007-2009 - GOALS
  • Develop consistent, evidence-informed process to identify and triage persons at-risk of NH use and/or spend down to Medicaid.
  • Further develop flexible service options for older adults and family caregivers who are private pay.
project approach
Project Approach
  • Collaborate with 3 AAAs partners and their local partners for development and service delivery
  • Coordinate with existing strategies and MBA programs including caregiver support, MNHelp (ADRC), memory care, and health promotion strategies
  • Validate screening tool and process through formalized evaluation study
target population
Target Population

Primary: At-risk private pay older adults with incomes at 200-250% FPGs and their family caregivers

Secondary: At-risk private pay older adults with incomes >250% FPG and their family caregivers; others reluctant to use public programs



Reduce Medical Assistance spending by helping the target group stabilize and/or mitigate risk through risk management, evidence-based, and self-directed strategies.

the live well at home lwah model
The Live Well At Home (LWAH) Model
  • Focus on risk factors
  • Design for the private pay market – lighter, softer, self-directed approach
  • Build on success of caregiver coaching, risk management, and self-directed support models
  • Empower and support vs. case manage and control to reach consumer and system outcomes
1 rapid screen services
1. Rapid Screen Services
  • Rapid Screen
    • 7-question tool and income question
    • Identify personal risks most often associated with permanent nursing home entry and/or spend down to Medical Assistance.
    • Scores: high-moderate-low-no risk
    • Easily administered (3-5 minutes)
  • Post-Screen Counseling
    • 10-15 minute session following Rapid Screen
    • Offers basic risk factor and initial tips information
    • Offers information and assisted referral to direct diversion support options
how risk is targeted
How Risk Is Targeted

Rapid Screen risk factors:

Assistance with > 2 ADLS

Injurious fall

No family caregiver

Stressed family caregiver

Lives alone

Planned housing move

Memory concern

Additional Question About Income

2 diversion support services
2. Diversion Support Services
  • Intense, on-going professional consultation/coaching and planning services directly tied to help person stabilize/mitigate identified risk factors
  • Grounded in risk management, caregiver support/coaching, memory care, consumer direction, health promotion themes, principles, and evidence-based practice
  • Initial (2 hours) and Extended (12 hours/year) Services
  • 3 Modes of Service Delivery
      • Web
      • Group Session
      • 1:1
  • Providers (group/individual): Specially trained providers who demonstrate competence in risk factor management and outcome monitoring, and adherence to protocols; coaching; self-direction
  • Funded under Title III, grants, and/or private pay sliding fee
consumer impact to date 12 months
Consumer Impact To Date (12 months)

Sustained community living for:

243 persons screened

114 high-risk persons receiving diversion support

12 targeted persons using grant-funded self-directed services with a Fiscal Support Entity

components tools for consumer empowerment
Components & Tools for Consumer Empowerment
  • On-going screening, education, counseling, planning, outcome measurement, and follow-up
    • Rapid Screen tool
    • Standardized risk messaging, information, and tip sheets, up-to-date risk information
    • Risk Action Plan
    • Cost-calculator tool
    • Link to Senior LinkAge Line® and
    • Link to MNHealthyAging website (enrollment in classes)
    • Link to consumer-directed support infrastructure
    • Professional tools
  • Direct access to start-up funds
phase ii goal leveraging system capacity to support lwah model
Phase II Goal: Leveraging System Capacity to Support LWAH Model

On-Line Education (print education on risk factors)

Multi-media Education (pod casts, video clips, recorded messages)

Direct Service Providers

Evidenced Based Community Programs, Aging Services, & Self Directed Supports


Minnesota Department of Human Services

what needs to happen a paradigm shift
What Needs to Happen: A Paradigm Shift

Highly Focused Impact

Aggressive identification

& screening for those

at highest risk

Focused assessment for

specific risk factors

Evidenced based

Interventions by risk factor

Proactive Prevention

Risk Management Model

Topic Related Impact

More Focused


Coaching on topics where

content is built and in use

Usually Crisis Reaction

Coaching Model

Diffused Impact

Generalized Assessment

Less ability to prioritize

Crisis Reaction

Social Work Model


Now -- Future


Minnesota Department of Human Services

social work vs risk management
Definition- social work

Organized work intended to advance the social

conditions of a community, and especially of the

disadvantaged, by providing psychological

counseling, guidance, and assistance

Definition- Risk Management

Proactively assessing, prioritizing, mitigating (to an acceptable level), and monitoring

specific risk factors.

Why risk management makes sense in LWAH

Social Work Vs. Risk Management


Minnesota Department of Human Services

expected system impact
Expected System Impact
  • Medical Assistance savings
  • Less use of emergency/urgent care
  • Face-to-face services and Title III funds become directed to the target population
  • MN’s ADRC strategy, MBA programs, and local networks working to support LWAH model
what s ahead
What’s Ahead?
  • Broadly disseminate the Rapid Screen Tool
  • Integrate diversion support services and risk management protocols into the MinnesotaHelp Network™ and HCBS system
  • Build capacity and sustainability for high quality diversion support services
  • Implement Veterans-Directed HCBS option
  • Community Living Grant Proposal (AoA)
    • Implement 7 AAA regions 10.01.09 – 09.30.11
  • Community Services/Service Development Grants (CSSD)
catherine sampson director csampson@ardc org arrowhead area agency on aging
Catherine Sampson, Director


Arrowhead Area Agency on Aging

LWAH Project: AAAA Experience
project partners
Project Partners
  • Senior LinkAge Line® (Arrowhead AAA staff)
  • Parish Nurses (Duluth area)
  • Hands in Service
  • Consumer Directions, Inc. – FSE
  • Benedictine Health Center*
regional approach
Regional Approach
  • Rapid Screen:
    • Partners conduct rapid screen (in person, telephone) and provide post-screen assistance
    • Parish Nurses obtain informed consent and AAA Care Consultant obtains informed consent from persons screened by other partners
    • Partners refer to AAA Care Consultant for Diversion Support

(86 rapids screens completed to date)

direct diversion support services
Direct Diversion Support Services
  • Specialized consultation and follow-up provided by AAA Care Consultant to help person manage risk factors
  • Consumer-Directed funds – provided to consumer via FSE to purchase self-directed community supports

(currently 25 individuals/families using diversion support services; 12 persons using CDC funds)

alice 82 year old
Alice – 82 year old
  • She was failing to thrive living alone in a malodorous apartment and with an apparent need for personal care. Meals on Wheels were her only community support.
  • She was found to be “high” risk for nursing home diversion entry and spend down to Medical Assistance
    • Her income is between 200-250% FPG
    • She lives alone
    • Does not have an available family caregiver to help her with personal care and housekeeping needs
    • Is actively considering a move to assisted living
    • Has concerns about memory.
alice continued
Alice – continued
  • Under LWAH she employed a friend in the building to help her with personal care and housekeeping needs.
  • With her private dollars she matched the $1,500 flexible service grant dollars at 100% and has continued to buy this help once the grant funds were fully spent.
  • A fiscal support entity helps her employ the worker. Alice and her worker were educated in ways to manage her risks.
  • Risk factors were stabilized and a crisis was avoided. She is now thriving and living in a clean apartment where she is happy and content.
lori vrolson executive director central mn council on aging experience
Lori Vrolson, Executive Director

Central MN Council on Aging Experience

project partners27
Project Partners

Title III Caregiver Coaches

1. East Central Senior Resource Center

-Rapid Screen/Support Planning

2. Great River Faith in Action

-Rapid Screen/Support Planning

3. Memory Care Clinic

-Rapid Screen Services

Senior LinkAge Line®

-Rapid Screen Services


cmcoa rapid screens
CMCOA: Rapid Screens
  • 166 Rapids Screens Completed

42% High Risk

12% Moderate Risk

20% Low/No Risk

  • 27 high-risk persons using support planning (i.e., diversion support) services


lessons learned
Lessons Learned
  • Rapid Screen is quick and easy to use
  • Relationships between the older adults and the provider are key to assisting the individual in developing and implementing their risk action plans


Elaine Spain, ElderCare Development Partnership Consultant[]Minnesota River Area Agency on Aging®, Inc.


Aging Services for Communities –

Le Sueur Co.

Mankato Area Living at Home/Block Nurse Program – Mankato

VINE Faith in Action – Blue Earth & Nicollet counties

regional approach32
Regional Approach
  • Rapid Screen: given at time of request for services
  • Each partner provides rapid screen services
  • 70 rapids screens completed to date