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Texas Aging and Disability Provider Network. Project coordination provided by:. Texas Aging and Disability Provider Network (TADPN) Partnering to better meet the needs. o f United’s high-risk Medicaid and Medicare beneficiaries. Who we are.

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texas aging and disability provider network

Texas Aging and Disability Provider Network

Project coordination provided by:

texas aging and disability provider network tadpn partnering to better meet the needs

Texas Aging and Disability Provider Network (TADPN) Partnering to better meet the needs

of United’s high-risk Medicaid and Medicare beneficiaries

who we are
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
provider agencies 1
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
provider agencies 2
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
provider agencies 3
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
provider agencies 4
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
provider strengths 1
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
p rovider s trengths 2
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
core services nutrition transportation
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
core services benefits options c ounseling
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
core services care c oordination
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
core services caregiver support
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
core services long term care ombudsman
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
services to support strategic priorities
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
1 services to r educe risk of hospitalization 1
1. Services to reduce risk of hospitalization (1)
  • Nutrition
    • Congregate meals
    • Home-delivered meals
    • Available statewide
1 services to reduce risk of hospitalization 2
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
1 services to reduce risk of hospitalization 3
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
1 local services to reduce risk of hospitalization 4
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)
spotlight on d allas aaa s diabetes self management
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
2 strategies to reduce preventable re hospitalizations 1
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
1 spotlight on harris county s care transitions programs 2
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%
3 services to increase medication adherence
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
4 services to avoid nursing home placement 1
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
4 services to avoid nursing home placement 2
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
4 services to help nursing home residents return to community
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
5 services to promote patient activation
5. Services to promote patient activation
  • Chronic Disease Self-Management Program
  • Diabetes Self-Management Program
  • Care Transitions Program
selected challenges opportunities 1
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
selected challenges opportunities 2
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
selected challenges opportunities 3
Selected challenges/opportunities (3)
  • Capitated payments for Medicaid-only inpatient care
    • Care Transitions
    • Chronic Disease Self-Management
why pay for services that are already funded
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
p rovider contacts
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