THE HEALTHCARE

NEIGHBORHOOD:

PHILANTHROPY'S ROLE

IN AGING WELL Grantmakers in Aging, October 2015

ROBYN GOLDEN, LCSW

DIRECTOR, HEALTH AND AGING

RUSH UNIVERSITY MEDICAL CENTER

Social Need

• Social factors influence health outcomes • Socioeconomic status

• Education

• Stress

• Early life

• Social exclusion

• Social support

• Addiction

• Food

• Transport

• Work/Unemployment

Health Care’s Blind Side

• 2011 Robert Wood Johnson Foundation survey of 1,000 primary care physicians

• 4 out of 5 not confident can meet social needs, hurting their ability to provide quality care

• Institute of Medicine recommendation: create “community links”

• Assessing psychosocial issues

• Delivering services in the community

• Communicating these issues with medical team

What’s Needed for Chronic Care

• Report from Georgetown Public Policy Institute

highlights opportunities for improving care for

people with chronic care needs:

• Comprehensive primary care

• Assessment of client and caregiver long-term services

and supports (LTSS) needs

• Coordination of LTSS and medical care

• Collaboration between care coordinators, PCPs,

patients, families

• Supportive care transitions

• Commitment to person- and family-centered care

Care Transitions

• Psychosocial issues are present all the time for

people

• needs during transition greater than simply medical

• Issues exacerbated post-hospitalization:

• Unanticipated needs emerge post-discharge

• Cognitive limitations after hospitalization

• Stress of hospitalization

• Differences in physical endurance and mobility

• Opportunity for intervention, community

engagement

But why are transitions so complicated?

• For these reasons, essential to involve medical care

as well as long-term services and supports (LTSS)

• Healthcare system to attend to medical needs

• LTSS system to provide continuous, coordinated services for

non-medical needs

• Psychosocial

• Environmental

• Emotional

• Financial

• Interpersonal

• Both systems sharing vital information

• Interprofessional collaboration key

Fundamental Change

• These efforts require interprofessional teams

• Physicians are critical - but others needed, too

• Nurse practitioners

• Physician’s assistants

• PT, OT

• Social workers

• Nutritionists

• Pharmacists

• Many more

• Also requires community

support systems, innovative

care models

Our History of Partnering Together

• Projects driven by Rush Health & Aging, Aging Care

Connections

• Care transitions: Bridge Model of transitional care

• Primary care: Ambulatory Integration of the Medical and the Social

(AIMS) Model

• Support of Community Memorial Foundation

A Health Neighborhood

• Flow of information between providers and patients

• Requires basic communication and coordination functions

• Each service provider needs… • to conceptualize itself as a team member

• a broad understanding of each patient’s medical and psychosocial needs

• Goals • Effectively coordinate all care

• Help the patient navigate the system

• Ensure that treatment plans from different providers work together as a whole

Older Adult Health Neighborhood Project

Designed to create a platform for a

comprehensive, well-integrated

“neighborhood” of health care resources

designed to foster preventative care,

further self management of chronic disease,

and create an intensive community

intervention for older adults who frequently

require healthcare

OAHN: Grant Agreement

Goal: To implement a network of for-profit and

non-profit organizations that will serve 1,000 older

adults in the Community Memorial Foundation

communities, across the continuum of aging –

from prevention to highly complex patients in

danger of unnecessary hospitalization and poor

health outcomes

LTSS in a Neighborhood

Other LTSS

CDSMP

DSMP

Exercise Program

Mental Health and Substance Abuse

Falls Management and Prevention

Alzheimer's Programs Medication Management

Home Injury/ Risk Screenings

Other Health Prevention Programs

Home-delivered meals

Nutrition services or nutrition counseling

Caregiver Support

Personal care/ homemaker/ choremaker

services

Transportation

Source: Medical Expenditures Panel Survey, 2009

Optimize timely access to resources from multiple sites

Risk Stratified Care Management

Acute Health Care

Comprehensive Primary Care

for:

Patient Centered

Care

Better Health / Better Care

/ Lower Cost

Source: Medical Expenditures Panel Survey, 2009

Change Concept

Continuum

• Aging as a process

• Health occurs throughout the life span and health benefits

are cumulative

• Three work groups based on this concept:

Prevention, Chronic Illness, and “Hot spotters”

Prevention Group

• Action Plan

• Target local for- profit and nonprofit businesses to

increase community awareness

• Educate businesses on aging and health related issues

• Further cultural competence

• Ask consumers for feedback through focus groups

Chronic Disease Group

• Statistically important group

• Traditional interventions focus on deficits

• Health system focused on acute episodes and

disease process

• Intervention needed at multiple sites; mental

health clinics, primary care offices, home of the

patient and throughout the community

• Access to tools for health behavioral change

Hot spotters – Who are They?

• Top 1% of high cost patients who consume 28%

of all health care costs

• Approximately 75% adults, 25% pediatrics

• Despite the high cost care they receive Hot

spotters are not getting well

• 5 year mortality rate = 26%

• Hot spotters say they need more help in

understanding complex follow up care

Hot spotters – Who are they?

• They describe their quality of life as fair to poor

• By a 2-1 margin they attributed their health problems to themselves

• 63% suffer from depression

• 77% have chronic conditions (cardiovascular, renal disease, cancer, stroke, arthritis, etc.)

Scott B Pingree, Harvard Business Review

Challenges and Opportunities

• Time limitations for neighborhood partners

• Careful selection of partners based on their assets and

role in the community

• Establishing a leadership format that reflects the

collaboration while providing a sense of direction

The Opportunities in the health care are now

Changes in the payments system, transformation from an

acute care model to a continuity of care model of care

OPPORTUNITIES FOR SOME, LOSS FOR OTHERS

GREG DIDOMENICO

PRESIDENT/CEO

COMMUNITY MEMORIAL FOUNDATION

Vision Statement for the Neighborhood

“To collaboratively transform the healthcare

of aging adults through the creation of a

health neighborhood that assists the whole

person, affirms the benefits of a life long

process of wellness and prevention.”

Community Memorial Foundation’s Vision

The Foundation,

together with the community,

will transform the western suburbs of Chicago

into the healthiest region in the country

Shared Vision

Vision Statement for the

Neighborhood

To collaboratively transform

the healthcare of aging

adults through the creation

of a health neighborhood

that assists the whole

person, affirms the benefits

of a life long process of

wellness and prevention

Community Memorial

Foundation’s Vision

The Foundation,

together with the

community,

will transform the western

suburbs of Chicago

into the healthiest region in

the country

Shared Vision

Healthy Cities

Healthy Regions

Healthy Neighborhoods

Achieving Our Vision for a Healthy Region

Three Strategic Priorities:

1. Develop coordinated, efficient and

effective health and human service

systems

2. Collaboratively establish a regional health

and human services agenda

3. Build healthy organizations

Foundation’s Role:

grantmaker

changemaker

catalyst

educator

convener

advocate

changemaker

grantmaker

Board’s

Role

Foundation’s Commitment

The Trifecta

Hospital Grantee Foundation

Health Neighborhood Outcomes Current readmission data provided by our partner hospital

shows a reduction in 30 day readmissions from 22% to 9%

for patients who receive the Bridge Intervention.

Successfully intervened with 287 older adults and/or their

caregivers onsite at Primary Care Physician’s sites in the

last year reports show high levels of physician satisfaction

and improved health literacy.

Developed a network of 15 separate community entities

committed to moving toward the goal of integrated

healthcare for all older adults residing in the Community

Memorial Foundation’s footprint called the Aging Well

Health Neighborhood

With Thanks to Our Partners

LOUISE STARMANN, LCSW

AGING CARE CONNECTIONS

Achievements by the Older Adult Health

Neighborhood • Prevention Group

• Conducted community focus (N=34)

• Piloted and created a business training integrating nursing, social

work, and public health expertise

• Reached out to 30 local businesses and slated to train 13 businesses

• Chronic Disease Group

• Coordinated 4 medication reviews and blood pressure screenings

• Coordinating and building capacity Chronic Disease Self-Management

Program (Lorig) and other evidence-based health promotion

• High Utilizers

• Partnerships secured with two PCP practices

• 10 referrals received

• Anticipating data coordination with health system

Next Steps • Submission for year 2 funding for the Older Adult Health

Neighborhood Project submitted by Aging Care Connections

• Establishment of outcomes that can be measured across

community partner sites

• Work towards sustainability from multiple sources by demonstrating

quality and cost savings to health care providers

• Streamlined communication

• Acquiring data on health outcomes from several sources within

HIPPA guidelines

Continued development of the collaboration between Community

Memorial Foundation, Rush Health and Aging, and Aging Care

Connection holds great promise for the future of aging in our

community

Thank you

• Our thanks to the Community Memorial Foundation for

their vision and belief in the collective impact that can be

achieved when communities work together.

• Thanks for your role as conveners of discussion and

action to bring about change

• Thanks to Rush Health and Aging; they bring such

knowledge and expertise to our community so that we can

continue to learn and grow.

Small Group Brainstorming

If you were developing a model

to engage neighborhood assets

to help keep seniors safe and

well in the community, what are

three elements or resources or

strategies that MUST be

included?