Texas Aging and Disability Provider Network

1. Texas Aging and Disability Provider Network Project coordination provided by:

2. Texas Aging and Disability Provider Network (TADPN) Partnering to better meet the needs of United’s high-risk Medicaid and Medicare beneficiaries

3. Who we are Members of Texas Aging and Disability Provider Network (TADPN), a voluntary, interagency collaboration representing: • 10 Aging and Disability Resource Centers • 24 Area Agencies on Aging • 12 Local Authorities • Texas Department of Aging and Disability Services

4. Provider agencies (1) • Area Agencies on Aging (AAAs): network of 28 agencies, serving persons age 60 and over, their family caregivers, nursing home residents of all ages, and Medicare beneficiaries of all ages • Bexar market: Bexar and Alamo AAAs • Central market: Alamo, Brazos Valley, Central, Heart of Texas, North Central, and West Central AAAs • Dallas market: Dallasand North Central AAAs • El Paso market: Rio Grande AAA • Harris market: Harris and Houston-Galveston AAAs

5. Provider agencies (2) Area Agencies on Aging (cont.) • Hidalgo market: Lower Rio, Middle Rio, and South Texas AAAs • Jefferson market: Deep East, Houston-Galveston, and South East AAAs • Northeast market: Ark-Tex, Deep East, and East Texas AAAs • Nueces market: Alamo, Coastal Bend, and Golden Crescent AAAs • Tarrant market: Tarrant and North Central AAAs • Travis market: Capital AAA

6. Provider agencies (3) • Aging and Disability Resource Centers (ADRCs): 14 community-based interagency collaboratives serving people of all ages, with all types of disabilities, with all income levels • Bexar market: Alamo Connection • Central market: Central Texas ADRC • Dallas market: Connect to Care (Dallas) and North Central Texas ADRC • El Paso market: El Paso and Far West Texas ADRC

7. Provider agencies (4) • ADRCs (cont.) • Harris market: Care Connection, the Gulf Coast ADRC • Hidalgo market: Rio-NET • Northeast market: East Texas ADRC • Nueces market: Brazos Valley ADRC, Coastal Bend ADRC, and Alamo Service Connection • Tarrant market: Tarrant County ADRC and North Central ADRC • Other United markets: will be served by ADRCs in 2014

8. Provider strengths (1) • Local visibility • Expertise working with high-risk individuals • Ability to navigate complex systems of care • Knowledge of federal, state and local services, including non-Medicaid services • Ability to serve consumers and caregivers, regardless of payer source

9. Provider strengths (2) • Knowledge of nursing home regulations and resident advocacy • Well-developed network of down-stream providers • Experience administering evidence-based programs • Ability to provide intensive health education/peer support

10. Core services: Nutrition/Transportation • Congregate Meals: 3,633,468 during FY 12 • Home-Delivered Meals: 4,886,825 during FY 12 • Transportation: 772,515 one-way trips during FY 12

11. Core services: Benefits/Options Counseling • Helps consumers understand and access public and private benefits (e.g., veterans’ programs), protect consumer rights, plan for future needs • Staff Benefits Counselors have completedextensive training and are certified by state agencies • 21,062 persons received legal assistance during FY 12 • Expertise in Medicare Part D, Medicare Savings Programs, nursing home Medicaid, and alternatives to nursing home care

12. Core services: Care Coordination • Targets persons at greatest risk of premature institutionalization • Consists of: • Assessment: functional, psychosocial, financial • Planning: development/implementation of person-centered plan • Implementation: service authorization and at least monthly contact to monitor delivery • 18,111 received care coordination during FY12

13. Core services: Caregiver support • Targets caregivers who are experiencing adverse effects relative to their caregiving responsibilities • Services include: • Caregiver support coordination • Caregiver support groups • Caregiver education • Caregiver respite • Evidence-based programs including Stress Busting for Family Caregivers and REACH II

14. Core services: Long-Term Care Ombudsman • Helps prospective residents and families make informed choice of facilities, understand financing, resolve complaints, and have access to relocation services • Provides training to staff on resident-centered care and residents’ rights • Supported by statewide network of 996 certified ombudsmen

15. Services to support strategic priorities • Reduce risk of hospitalization • Reduce incidence of potentially preventable re-hospitalizations • Promote medication adherence • Avoid nursing home placement/ assist nursing home residents in returning to community • Educate and empower consumers to take charge of their health

16. 1. Services to reduce risk of hospitalization (1) • Nutrition • Congregate meals • Home-delivered meals • Available statewide

17. 1. Services to reduce risk of hospitalization (2) • Fall Prevention: A Matter of Balance • Series of eight peer-led, small group sessions that counteract fears, improve balance, and mitigate environmental risks • Outcomes: increased activity levels, mobility, social function • Available in United’s Bexar, Capital, Central, Dallas, Harris, Jefferson, Nueces, Tarrant markets

18. 1. Services to reduce risk of hospitalization (3) • Stanford Chronic Disease Self-Management Program (CDSMP) • Series of six peer-led small group sessions that focus on managing symptoms, dealing with stress, talking to health care providers, evaluating treatments • Outcomes include reduced hospital lengths of stay, outpatient visits, and hospitalizations • Services available in United’s Central, Dallas, Bexar, Harris, Jefferson, Nueces, and Tarrant markets

19. 1. Local services to reduce risk of hospitalization (4) • Tai Chi (Harris County) • Prevention and Management of Alcohol Problems (Harris County) • Exerstart (Harris County) • Diabetes Screening and Management (Tarrant County)

20. Spotlight on Dallas AAA’s Diabetes Self-Management • 300 participants completed series of six workshops • More than 80% of participants reported: • Greater ability to care for diabetes • Greater ability to rely on informal support for dz. mgmt. • Greater ability to make healthy choices • Lesser disease-related impact on daily activities

21. 2. Strategies to reduce preventable re-hospitalizations (1) • Dr. Eric Coleman’s Care Transitions Program (CTP) • Transitions coach conducts follow-up in home and by phone at least three times during first month post-discharge, focusing on medication compliance, follow-up with primary care provider and understanding of “red flags” • Outcomes include reduction of all cause readmissions • Available in United’s Bexar, Central, Dallas, El Paso, Harris, Hidalgo, Jefferson, and Tarrant markets

22. 1. Spotlight on Harris County’sCare Transitions Programs(2) • Partnership with CHRISTUS St. Catherine Hospital and Memorial Hermann Katy Hospital • Reduction in participants’ 30-day all-cause readmission rates from 20% to 10%

23. 3. Services to increase medication adherence • HomeMeds • In-home medication reconciliation, including all prescription and over-the-counter meds, with intervention by pharmacist as needed • Outcomes: reduced incidence of drug-drug interactions, greater compliance with medication regimen • Available in United’s Central, Dallas, Jefferson, Tarrant, and Travis markets

24. 4. Services to avoid nursing home placement (1) • Stress-Busting for Family Caregivers: Provides education and support to small groups of family members who care for loved ones with Alzheimer’s • Outcomes include decreased caregiver stress, depression, and anxiety, in addition to decreased rates of nursing home placement • Available in United’s Bexar, Hidalgo, Jefferson, Nueces, Tarrant, and Travis markets

25. 4. Services to avoid nursing home placement (2 ) • ADRC Options Counseling: helps identify and access community-based services that serve as alternatives to institutionalization • Available in United’s Bexar, Central, Dallas, El Paso, Hidalgo, Northeast, Nueces, and Tarrant markets • Will be available statewide in 2014

26. 4. Services to help nursing home residents return to community • Home by Choice: intense case management for Medicaid residents to remove barriers to relocation such as lack of housing, need for assistance with 5+ ADLs, severe mental illness, lack of family support • Options Counseling: information, referral and assistance for non-Medicaid residents

27. 5. Services to promote patient activation • Chronic Disease Self-Management Program • Diabetes Self-Management Program • Care Transitions Program

28. Selected Challenges/Opportunities (1) • Carve-in of nursing home care in September 2014 • Pre-placement counseling regarding community-based alternatives, paying for care, and quality considerations • Resident advocacy • Relocation counseling and assistance

29. Selected Challenges/Opportunities (2) • Members with multiple, complex psychosocial needs that jeopardize disease management/independent living • Benefits/Options Counseling • Care Coordination • Members with caregivers on verge of burnout • Caregiver consultation, case management, evidence-based programs

30. Selected challenges/opportunities (3) • Capitated payments for Medicaid-only inpatient care • Care Transitions • Chronic Disease Self-Management

31. Why pay for services that are already funded? • Make proven interventions available to United members who don’t qualify on the basis of providers’ age-eligibility or screening criteria • Provide priority access to United members

32. Provider contacts Aging and Disability Resource Centers • Doni Green: dgreen@nctcog.org Area Agencies on Aging • Millie DeAnda: mdeanda@ccgd.org • Jennifer Scott: jscott@capcog.org • Curtis Cooper: curtis.cooper@h-gac.com • Deborah Moore: deboraha.moore@houstontx.gov General Questions • Doni Green: dgreen@nctcog.org