Community-BasedCollaborationModels:PromotingClinicto

CommunityLinkagesLindaNetterville,RD,LD(Moderator/Speaker),NationalResourceCenteronNutritionandAgingJeromieBallreich,PhDcandidate,JohnsHopkinsUniversityTriciaJefferson,RD,LDN,YMCAofDelaware

Community-BasedCollaborationModels:PromotingClinictoCommunityLinkages

PCPCC2015ANNUALFALLCONFERENCE

NOVEMBER12,2015

Panelists:•LindaNetterville,RD,LD,MealsonWheelsAmerica

•JeromieBallreich,PhDStudent,HealthEconomics,JohnsHopkinsUniversity

•TriciaJefferson,RD,LDN,Director,HealthyLivingandStrategicPartnerships,YMCAofDelaware

•UcheomaAkobundu,PhD,RD,MealsonWheelsAmerica

CommunityServicesfromaPatient’sPerspective

JeromieBallreichNovember12,2015

Aboutme…

• Sufferedaspinalcordinjury(C4/C5)andneardrowningMarch13,2005.• Spentnearly6monthshospitalized• DischargedAugust2005• Myaccidentwasacute,butmyquadriplegiaischronic

Beingapersonwithachroniccondition• Quadriplegiaaffectsmultipleorgansystems• Requirecarefrommultipleproviders• RequireassistanceforADLsandIADLs• 3-4hourseverymorning(ADLs)• 1-3hoursinevening(ADLs)• 4hoursIADLsdaily

• Economistperspective:• $2millioninhealthcareexpendituresincemyaccident

Whyisstayinginthecommunityimportant?

• Iwanttocontribute…• FeelthatIaddsomethingmeaningfultosociety• Beemployed

• Iwanttobeindependent…• Bein-chargeofmycare• Bein-chargeofmylife(where,when,andwhat)

• Iwanttobepartofthecommunity…• Personalrelationships• Socialrelationships

• ALTERNATIVEisinstitutionalliving

Myearlyexperiences(1/2)

• DischargedtomyhomeinCentralPennsylvania• Concernsaboutrurallocation• Concernsaboutaccessibility• Mymotherwasprimarycaregiver

• SocialworkeratMageeHospitalestablished• ContactwithVocationalRehabilitation• ContactwithPennsylvania’sPublicWelfare

• Personalconnectionwithlocaldoctors• Neededmedicalstabilitybeforepursuinglifegoals

Myearlyexperiences(2/2)

• Transportation• Used“CART”-localsharedrideprograminPennsylvania• OfficeofVocationalRehabassistedwithVehiclemodifications

• Homehealthcare• HomenursingagencyweeklyacutecareincludingPT• IndependenceWaiver-Medicaidwaivertoliveathome

• Allocates“X”numberofhours• Mostlyconsumer-employed

• SystemNavigation• NonprofitsincludingCentersforIndependentLiving(CILs)andAHEDD• Independencewaiverservicecoordinator

Myrecentexperiences(1/2)

• In2009,IlefthomeandattendedLafayetteCollegeformysenioryear• 3hoursaway• CoordinationbetweenCollege,OVR,andMedicaidServicecoordinator• FIRSTTIMElivingbymyself(on-campusapartment)

• LafayetteCollegeHealthServices• Alwaysopen• Tookcareofmychronicneeds

• SetbacksatLafayetteCollege• Didnothave24hourcare• Wheelchairtechnicalissues• Agencycare

Myrecentexperiences(2/2)

• EnrolledinMastersandlaterPhDatJohnsHopkinsUniversity• LiveindependentlyinanapartmentinBaltimorewithmygirlfriendandcat• RelyonJohnsHopkinsandGeisingerhealthsystemsformedicalsupport• Homehealthcare(caregiving)providedbyIndependenceWaiver

Caregiving(1/2)

• Integraltomyneeds• ADLs(activitiesofdailyliving)• IADLs(instrumentalactivitiesofdailyliving)• Day-to-daymedicalcare

• Typically,caregiversare• Limitededucation• Mayormaynotbecertified• Minimallycompensated• Largelaborpoolbutverytransitory

Caregiving(2/2)

• Coordinatingcareisajob• Scheduling,hiring,firing,training• Micromanagement• Reluctantboss

• Caregivingnightmares• LPN• Providedroom,board,andhourstowork• First4monthswentfine!• Awfulsituationturnedworse…

• Refusedtoleave• Fewwarningsigns• Vulnerable,anxious,disruptive

Barrierstocommunityliving(1/2)

• Medicaidisprimarypayerforhomehealthcare• Statebystatebasis• Complexsystem• Means-tested• Waitlists

• Accessibilityisnotuniversal• Fewroll-inshowerapartmentsavailableinBaltimore• Doorsandflooringoptionslimited

• Findingtherightcaregiversiscritical!

Barrierstocommunityliving(2/2)

• Homehealthcareisnotfullyintegratedwithtraditionalmedicalcare• Caregivers,healthaidesarerarelyincorporatedintoadoctorsvisit• Day-to-dayjudgementcallsonmedicalcareareonmewithlittlesupport• Traditionalmedicalcareisveryacutefocused• Barrierstoaccesstraditionalmedicalcare

• Appointmentavailability?• Waittimes?• Appointmenttimes?

• Goodhealthisnecessarytopursuelifegoals!

Opportunities

• De-centralizeservices• Integratetechnology• HealthIT• Technologyfornon-healthservices

• Considerbroaderhomehealthcaresolutions• Otherpayersresponsibility• 529(b)plans?• Workforcedevelopment

Success

• Myconditionisomnipresent• Livingindependentlyallowsmetopursuemylifegoals• Myconditionrequires:• Moretime• Moreplanning• Moreresources• Confrontingoccasionalsetback

• HEALTHisthefoundationofallaspectsofmylife(i.e.Maslow’shierarchy)

THANKYOU!

HealthcareBeyondtheClinicSetting:Community-BasedServicesLINDANETTERVILLE,RD,LD

Community-BasedServices

ThereisNoPlaceLikeHome!

TheAgingandDisabilityNetwork:PartnersintheHealthcareSpace

AdministrationforCommunityLiving(ACL)

StateAgingandDisabilityAgencies

Community-BasedAgingandDisabilityOrganizations

TheAgingandDisabilityNetwork:PartnersinHealthcareSpace

HowcanCBOsimpactdeliverysystemreform?

Managingchronicconditions

Activatingbeneficiaries

Diversion/Avoidinglong-termresidential

stays

Preventinghospital

(re)admissions

• Evidence-basedcaretransitions• Carecoordination• Information,referral&assistance/systemnavigation• Medicaltransportation• Evidence-basedmedicationmanagement• Evidence-basedfallpreventionprograms/homeriskassessments• NutritionServices• Caregiversupport• Environmentalmodifications

• Chronicdiseaseself-management• Diabetesself-management• Nutritionprograms(counseling&mealprovision)• EducationaboutMedicarepreventivebenefits

• Evidence-basedcaretransitions• Person-centeredplanning• Chronicdiseaseself-management• Information,referral&assistance/systemnavigation• Benefitsoutreachandenrollment• Employmentrelatedsupports• Community/beneficiary/caregiverengagement

• Transitionsfromnursingfacilitytohome/community• Person-centeredplanning• Assessment/pre-admissionreview• Information,referral&assistance/systemnavigation• Environmentalmodifications• Caregiversupport• LTSSinnovations

TargetedPatientPopulationManagementwithIncreasingDisease/Disability

End of Life

Complex Chronic Illnesses w/ major

impairment

Chronic Condition(s) with Mild Functional &/or Cognitive

Impairment

Chronic Condition with Mild Symptoms

Well – No Chronic Conditions or Diagnosis without Symptoms

Hot Spotters!

EvidenceBasedSelf-Management,HomeAssessmentandHomeMeds

HomePalliativeCare

PostAcuteandLongTermSupportsandServices

25

MoreonthevalueofCBOs“Fortheseindividuals[withbothchronicconditionsandfunctionallimitations

requiringlong-termservicesandsupports]toachievebetterhealth,providersmustbeabletoconnecttheirpatientstosocialsupportsandhumanserviceswhilefocusingonpreventionandwellnessinwaysthatemphasizebehaviorchange.Bypartneringwithcommunity-basedorganizations(CBOs),suchasAreaAgenciesonAging(AAAs),providerscanhelpindividualsmanagetheirchronicdiseasesandmeettheiroften

overlookedsocialneeds.”Dr.AnandParekh&Dr.RobSchreiber

“HowCommunity-BasedOrganizationsCanSupportValue-DrivenHealthCare”HealthAffairs,July10,2015

http://healthaffairs.org/blog/2015/07/10/how-community-based-organizations-can-support-value-driven-health-care/

BuildingtheBridge

HealthcareCommunity-BasedServices

Wehavetogetitright!

Formoreinformation:

MarisaScala-FoleyMarisa.scala-foley@acl.hhs.gov202-357-3516http://acl.gov/Programs/CIP/OICI/BusinessAcumen/index.aspx

Questions:

DiscussionQuestion:Whodoyoualreadypartnerandhow?Whatcommunitypartnersorcommunityresourcesdoyouhaveinyourareathatcanbeusedtoimprovepatientcare?

YMCA’s Diabetes Prevention Program

TRICIA JEFFERSON, RD, LDN DIRECTOR OF HEALTHY LIVING AND STRATEGIC PARTNERSHIPS YMCA OF DELAWARE

BenefitsofClinictoCommunityPartnershipsCollaborative Missions Growth in Operations ◦ Approx. 15% growth in practice operations

Lower Healthcare Costs Engaging patients across continuum of care ◦ Primary, Secondary and Tertiary

Better health outcomes Increased healthcare reimbursement Greater Integration and Population Health Aligns with Healthcare objectives: ◦ Accountable Care Act ◦ ACO’s ◦ PCMH ◦ Community needs assessment

| YMCA’S DIABETES PREVENTION PROGRAM | ©YMCA OF THE USA

YMCA’S DIABETES PREVENTION PROGRAMTHE PROGRAM IS: •Led by a trained Lifestyle Coach

•A one-year program: 16 weekly sessions, then 8 monthly sessions

•Open to all community members; YMCA membership is not required

•A Centers for Disease Control and Prevention (CDC)-approved curriculum

PROGRAM QUALIFICATIONS: •At least 18 years old,

•Overweight (BMI ≥25), and

•Prediabetes confirmed via one of 3 blood tests or previous diagnosis of gestational diabetes

•If no blood test, 9+ score on risk assessment

PROGRAM GOALS: •Reduce body weight by 7%

•Increase physical activity to 150 minutes per week

33

Nancy R. from Wilmington, DE - lost nearly 10% of her starting body weight! I feel healthier–-terrific even-–and friends tell me I look great. I’ve changed the way I cook for myself and my daughter, and now [she] is checking the packaging on foods, taking smaller portions for dessert and making wiser food decisions. I’m now doing something that is positive for both of us, and I want to tell everyone about it.

DPP Locations StatewideYMCAsites Medical

BuildingSeniorCenters Community

Centers/OtherLibraries/Churches/Stores

BrandywineYMCA SilversideMedical WilmingtonSeniorCenter

BrandywineTownCenter

CalvaryAssemblyofGod

DowntownYMCA GlasgowMedical MiddletownSeniorCenter

ClaymontCommunity WoodlawnLibrary

WesternYMCA PikeCreekSportsMedicineBldg.

NewarkSeniorCenter

HockessinActivityCenter

LewesLibrary

BearYMCA UDStarCampus ModernMaturityCenter

GarfieldParkActivityCenter

ShopRite

DoverYMCA HenriettaJohnsonMedicalCenter

MilfordSeniorCenter DelawareStateUniversity

TerryApartments

SussexYMCA GreenhillFamilyMedicine

LewesSeniorCenter LutherTowers(Wilmington)

IngelsideRetirementApts

YMCAAssociationOffice

MiddletownFamilyCareAssociates

ClaymoreSeniorCenter

BloodBankofDelmarva

HeritageatDover

| DIABETES PREVENTION PROGRAM OVERVIEW | ©2015 35

LocalDataParticipantsattendingatleastonesession(through2014)inDelaware

~1,500

Averageweightlossatendofweeklysessions

4.9%

Averageweightlossatendofyearlongprogram

5.8%

Average#ofweeklysessionsattended 14.1/16

Retentionfromsession1tosession4 92.9%

Retentionfromsession4tosession9 89.6%

Percentofparticipantswithavalidbloodtest

91%

PercentofLowIncomeparticipants 7%

YMCAReach ByTheNumbers

0

10

20

30

40

DPPLocauons

YMCAsitesOther

ParMcipantReferralSources(n=383)InsuranceCompany1%

Other5%YMCAStaff

5%Screening/TesungEvent

6%

Family/Friend12%

Media/Markeung20%

HealthcareProvider51%

HealthcareProviderMedia/MarkeungFamily/FriendScreening/TesungEventYMCAStaffOtherInsuranceCompany

ReferralMechanisms

RetrospectiveLetters 20%EnrollmentRate• 1.Pulldataof

patientswhohaveIFG/IGT(thatdonothaveDM)

• 2.Sendlettersoutwithpracticeletterhead,inviting/referringtotheDPP

• 3.Interested

FlagPatientsintheEHR• 1.Configureaauto-

runmonthlyreportofhighriskpatients

• 2.CreateanalertnotificationinEHRforpatientswithprediabetes

• 3.AlertwilladvisephysicianandotherhealthcareproviderstodiscussandrefertoYMCA’sDPP

PointofCareReferrals78%EnrollmentRate• 1.Patientscome

intotheofficeforannualorf/uvisits.

• 2.Discusslabswithpatient(elevatedBSorA1c)

• 3.SendelectronicreferralorefaxtoYMCA’sDPP

• 4.YMCAwillcallpatientwithin

POCEnrollment

EnrolledNotEnrolled

RetrospectiveLetters384ParMcipantEnrolledasParMcipants

QualityPhysicans

DoverFamilyPhysicians

StoneyBaxerFamilyMedicine

SouthernMedicalAssociates

Mid-AtlanucFamilyMedicine

0 150 300 450 600

2052LexersGenerated

Healthcare/YMCAPartnershipOpportunitiesinDelaware

SharedFacilities-throughexpansionorCapitalprojects

FitnessCentermanagement

CollaborativeLeaseagreementswithancillaryandMedicalServices

Co-Branding/Marketing

IntegratedClinic-to-CommunityreferralsintheEHR

MembershipReimbursementthroughhealthsystem

DirectPayorPartnershipsforevidenced-basedprograms

Underwriting/Supportingevidenced-basedprograms

TriciaJefferson,RD,LDNDirectorofHealthyLivingandStrategicPartnerships

tjefferson@ymcade.org302-571-6998

CONTACT:

MealsonWheels:MorethanMealstoSupportHealthandIndependenceUCHEOMAAKOBUNDU,PHD,RD

WHAT ARE MEALS ON WHEELS PROGRAMS?

• Part of the established Home and Community Based System

• Non-profit or government organizations

• Variety of funding including the federal Older Americans Act

• Trusted entity with long history of success

• Delivering both home-delivered and senior center meals and nutrition services

43

REFERRAL SOURCES FOR MEALS ON WHEELS PROGRAMS

Referrals for Meals

0%

25%

50%

75%

100%

Hospital, Health Care Facility, or

Discharge Planner

Self Family and Friends

93%

64%64%59%

86%

44

*NationalEvaluationofNutritionPrograms-2015

CLIENT PROFILE

– 64% Women

– 37% At or below poverty

– 51% Live alone

– 27% Minority

– 37% Live in rural communities

– 67% Over age 75

HEALTH CONDITIONS

– 51% Take 6+ medications

– 63% 6+ Health Conditions

– 38% Stayed Overnight in the Hospital Last Year

– 57% 3+ IADLs

– 49% 3+ADLs

WHO GET THE MEALS?

45

SERVICE OPTIONS ARE DETERMINED BY THE LOCAL PROGRAM

• Types of Meal Delivered

• Hot

• Cold

• Frozen

• Shelf-stable

• Special Diets: Renal, Pureed, Low Sodium

• Ethnically or Culturally Appropriate: Kosher, etc

46

OTHER NUTRITION AND NON-NUTRITION SERVICES• Nutrition services provided by Meals on Wheels Programs

– Nutrition education (77 percent)

– Nutrition screening and assessment (52 percent)

– Nutrition counseling (28 percent)

• Non-nutrition services provided by Meals on Wheels Programs

– Safety checks and socialization (the More than a Meal Service)

– Transportation to and from meal sites (76 percent)

– Health promotion and disease prevention activities (63 percent)

– Social activities at congregate meal sites (62 percent)

– Case management (53 percent)

– Assistance with chores or housekeeping (34 percent)

– Grocery assistance (28 percent)

*National Evaluation of Nutrition Programs-2015

47

More Than a Meal: Results from a Pilot Randomized Control Trial of a Home-Delivered Meals Program

Conductedby:Fundedby:Commissionedby:

In-person Interviews of all 626 study participants

Participants randomly assigned to daily-delivered meals (n=214), frozen, once-weekly delivered meals (n=202), or to remain on the waiting list (n=210)

Meal delivery began and continued 15 weeks

Conducted follow-up interview over telephone (n=459; 154 in control group, 174 in daily-delivery group, and 131 in frozen, once-weekly

delivery group)

Baseline and outcomes analyses

Study Design

Improvement in Isolation

0%

10%

20%

30%

40%

ImprovementinIsolauon LivingAlone

29%

22%

36%

25%

14%17%

Control DailyDelivered WeeklyDelievered

Improvements in Loneliness

0%

12%

23%

35%

46%

ImprovementsinLoneliness LivingAlone

45%

31%

46%

37%

28%28%

Control Daily Weekly

0%

13%

25%

38%

50%

ImprovementsinLoneliness LivingAlone

26%

18%

42%

32%

18%21%

Control Daily Weekly

Lower Rate of Hospitalizations

• Hospitalized during study period– 14% of individuals who received meals – 20% of individuals in the control group

Falls Among Population of Fallers

0%

20%

40%

60%

80%

Didnotimprove Improved

59%

41%

79%

21%

46%54%

Control DailyDelivered WeeklyDelivered

Feel Safer in the Home

0%

25%

50%

75%

100%

DailyDelivered WeeklyDelivered

70%

80%

Reasons for Feeling Safer

0%

13%

25%

38%

50%

Delivery Meals OutofKitchen StayHome Other

6%

29%33%

31%

24%

6%

11%15%

25%

49%

DailyDelivered WeeklyDelivered

Improvementinfeelingsofanxiety,self-ratedhealth,isolationandloneliness

Decrease in hospitalizations and falls

Improvementinfeelingsofanxiety,self-ratedhealth,isolationandloneliness

Decrease in falls and worry about staying in the home

Daily Home-delivered Living Alone Clients

Improvementsinfeelingsofisolationandloneliness

Decreaseworryaboutbeingabletoremaininthehome

Feelsafer,helpedthemtoeathealthier,moresocialcontacts

Loneliness

Summary• MealsonWheels:APartnerintheHealthcareSpace– Challengefaced• QuantifyingtheimpactofMealsonWheelsservices

– Steps/processcreated• Establishmentofoutcomesresearchprogram

– Keyplayersinvolved• Healthinsurancecompanies,academicresearchers,localMealsonWheelsprograms

– Outcomesachieved• Datasupportiveofpractice-based/anecdotalindicatorsofimpact

– Successfactors/pre-requisites• Goalalignment,willingnesstopartner,&innovativeapproaches

UcheomaAkobundu,PhD,RDRDMealsonWheelsAmerica

Uche@mealsonwheelsamerica.org

Questions:

DiscussionQuestion:Whatistheprocessusedtocoordinatepatientserviceswithcommunitypartners?Whatarethechallengeswhenreferringpatients?Whatstaffcanstreamlineareferralprocess?

WrapUp:

Community-BasedCollaborationModels:PromotingClinicto

CommunityLinkagesLindaNetterville,RD,LD(Moderator/Speaker),NationalResourceCenteronNutritionandAgingJeromieBallreich,PhDcandidate,JohnsHopkinsUniversityTriciaJefferson,RD,LDN,YMCAofDelaware