Focusing on Risk Factors to Live Well at Home

Transcription

1 Focusing on Risk Factors to Live Well at Home November 21, 2013 Training via Video Conference from Aging and Adult Service Division, Minnesota Department of Human Services

2 Presented by Ryan Boosinger, Live Well at HomeSM Project Consultant, Aging and Adult Services Division Jane Vujovich, Live Well at HomeSM Project Manager, Strategic Planner, Aging and Adult Services Division. Diane Raff, Director, Living at Home Network Deb Lindamood, Program Director, Volunteer Services of Carlton County Jill Corbin, Community Service Representative, Home Instead Cindy Conkins, Senior Planner, ARDC Arrowhead AAA

3 Agenda Introductions and Housekeeping Live Well at Home SM Overview Stories from the field: Diane Raff Rapid Screen Education Stories from the field: Deb Lindamood Website Tour Mobile App Tour Stories from the field: Jill Corbin Moving Forward with Live Well at Home SM Stories from the field: Cindy Conkins Q&A

4 Handouts Power Point Presentation Live Well at Home SM Overview Live Well at Home Rapid Screen Virtual Ad for the New Mobile App

5 Goals and Expectations of today s session Gain a basic understanding about the Live Well at Home SM model Learn about the Live Well at Home Rapid Screen including the seven foundational risk factors, screening process, and new mobile app. Discover opportunities for moving Live Well at Home SM into your community Hear examples of Live Well at Home SM in action including development work by the Area Agencies on Aging on coalition building.

6 Beyond that Armed with an elevator chat that enunciates the drive and function of Live Well at Home SM Increase screening using the Live Well at Home Rapid Screen (10,000 in 2014) Download the Mobile App, and show it off Visit and explore the website connect others

7 Strengthen risk management Eager to initiate or perpetuate opportunities to expand usage of Live Well at Home SM through collaborative effort such as coalitions Understand the importance of successfully supporting older adults in their goal to live well at home longer and stronger in the setting of their choice.

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9 Live Well at Home SM Live Well at Home SM is a statewide coordinated and integrated framework of practice that helps older adults live well at home longer as they age.

10 Guiding Principles Person- Centered Risk- Managed Live Well at Home Self- Directed Evidence- Based

11 Objectives of the model: Build relationships that support community living goal Extend community living Stabilize risk factors Preserve client choice and control Keep informal support system intact Decrease use of emergency care, hospitals and skilled nursing facilities Slow use of Medical Assistance Identify people upstream from medical assistance Take action before crisis hits

12 Why Live Well at Home SM? Capacity Affordability Sustainability Complexity

13 Capacity: Aging population growth MN s Projected 65+ Population

14 Capacity: Aging population growth MN s Projected 85+ Population

15 Affordability: Options and Cost Comparisons For Individuals (2010) $60,000 $50,000 $40,000 $30,000 $20,000 $10,000 $0 Home with hired help from family or friends Home with help from agency services Assisted Living or Nursing Home

16 Sustainability: Shift in Medicaid Spending Medicaid Enrollment vs. Spending Enrollees: 52.4 mil. Expenditures on benefits: $353 billion 9% 16% 48% 27% Elderly Disabled Adults 12% 19% 26% Children 43% Note: Total expenditure on benefits excludes DSH payments. Source: Kaiser Commission on Medicaid and the Uninsured estimates based on CMS, CBO, and OMB data, 2004.

17 Complexity: Putting Services Together Adult Day Service Hospital/Primary Care Transportation Caregiver Support Transitional/Sub-acute Care Assisted Living Housing With Services Memory Care Nutrition Home Care

18 History Developed by the MN Board on Aging in 2007 under two grants from the Administration on Aging Researched, developed, and validated with the assistance of Dr. Joseph Gaugler, PhD., University of MN, School of Nursing and three Area Agencies on Aging ( ) Implemented by 7 Area Agencies on Aging

19 Live Well At Home SM was born: Rapid screen tool developed and validated Data collection Risk Management Planning process developed Program Manual and Training Materials produced LWAH Provider Standards developed and providers recruited Self Directed Services for private pay w/cost share implemented Tracking forms and processes developed Website, Kiosk Cards, Tip Sheets produced Evidence-based program interventions promoted within communities

20 Major Tools LWAH website and new Mobile App Validated risk screening tool (60+ years) Consumer education Direct linkages to evidence-based interventions and supports Risk management protocols Outcome measurement Program manual Professional and Consumer toolkits

21 Target Group Private pay Age 60 years and older Upstream from Medical Assistance and Alternative Care Incomes between 200 and 250% federal poverty guidelines or above.

22 Funding Support Services are funded under: Title III funds and cost sharing State funded CSSD grants Cost sharing and private contribution

23 Process: 4 easy steps Risk Screening and Education Risk Management planning Taking action Review of results that include a rescreening

24 Step 1: Know your risk Take the quiz Learn your risks, and why they matter, and what you can do

25 Step 2: Make your choices Older Adult view: Express a community living preference Engage a Live Well at Home SM Provider Create a risk-management/ action plan Hold a family meeting Make choices from evidence-based classes and community-based services

26 Step 2: Make your choices Professional view: Conduct risk screening and educate Deliver key messages and engage in taking action Assist person to define the Community Living Goal Provide support planning services Help prioritize risks and approaches Develop education and action plan address the Rapid Screen results and 7 risk factors information Assist person directly to evidence-based programs or supports Identify, plan, manage, provide scheduled follow-up and evaluate results Collect data and routinely communicate results/progress Provide support for family caregivers

27 Step 3: Take your actions Develop a budget for selfdirected or agency services Hire a family member or friend and/or arrange for agency or other supports Determine need for home modifications Enroll in a class like Matter of Balance or Living Well with Chronic Conditions Assist with community integration and caregiver support, memory care support.

28 Step 4: See your Results Measure your progress Routinely re-screen Continue to take new actions to meet your changing needs Track results

29 Outcomes for older adults Established relationship with community provider Stabilization of risk factors including fewer crisis events, hospitalizations, etc. Improved health Continued family caregiver involvement Continued input and self-direction Purchase of less expensive, customized help Extended living in the setting of choice support quality of life factors

30 Outcomes for system Keeps increasing number of older adults in their homes/reduces permanent entry to nursing facilities and assisted living communities Slows spending of Medical Assistance Increases usage and effectiveness of array of services as older adults are connected to the information, community supports, and risk management resources need for on-going community living

31 Guest Speaker Tales from the field Diane Raff, Director, Living at Home Network

32 Live Well at Home Rapid Screen Standard measure for identifying older adults most at-risk of moving permanently to assisted living or a nursing home facility, and spending down to Medical Assistance. Validated tool Critical for measuring outcomes Springboard into conversation

33 The Quiz: Key Chat Points Short and easy to use 7 questions identify present risk factors Generates a risk score Older adult and proxy versions For persons 60+ who are living at home Can be taken on your own, with assistance, or by another Re-take the quiz if health or situation changes, but at least once a year

34 The 7 Risk Factors:

35 Modes of Delivery Brochures Website Printable from Website Mobile App

36 Additional questions Memory concerns Financial Help to align services and supports

37 Scoring and Risk Category Score Risk Level 0 None 1 Low 2 Moderate 3 or more High

38 Screening Process In-person screening in preferred Telephone screening acceptable Score the screen and record Inform person of results Assure information is kept confidential

39 Who should be taking the quiz? Persons 60 and over At least annually Current clients Callers and those requesting information/ presenting with a need Those participating in healthy aging program classes i.e. falls prevention Chronic disease management Medication management

40 Screen Family Caregivers Family caregivers who score + for stressed caregiver risk factor continue with TCARE screen Offer to family caregivers of current clients, attending support groups or education classes, calling for information, etc.

41 Who could be offering the quiz? Points of information, help, or trusted relationships: Aging network including Title III providers Caregiver support Memory Care Support Homemaker, chore, rides, respite, companions Private duty home care Senior LinkAge Line and senior outreach Communities of faith Long-Term Care Consultation Hospital discharge planners and clinics Senior Housing Coordinators

42 Rescreening High-Moderate Risk Category: quarterly or as needed to evaluate progress or changes Use the Rapid Screen as an assessment tool as noted in step 4 of the framework. Low Risk Category: annually People can self-screen using any of the modes of delivery Use to follow-up and keep the relationship alive

43 Use of the LWAH- Rapid Screen tool The LWAH- Rapid Screen is a copyright protected tool and the property of the Minnesota Board on Aging

44 2013 Documented Rapid Screen numbers 98 agencies statewide using the framework Brochures LAH/BNP Total st quarter, Website: since July 1 st, taken Mobile App: since July 1 st, ,722 taken

45 Guest Speaker Tales from the field Deb Lindamood, Program Director, Volunteer Services of Carlton County

46 Website Tour mnlivewellathome.org

47 Mobile Application Tour

48 Mobile App: Getting Started Free of Charge through Apple Store and Google Play Apple users: Requires ios 6.1. Some iphones may require a computer connection for download. Search for Live Well at Home Rapid Screen Accessible through website mnlivewellathome.org

49 Mobile App Take Quiz: Instant Access. About Quiz: a brief description of LWAH services and rapid screen. Learn More: information on accessibility, privacy policy, data collection and sharing, security, contact, and copyright.

50 Privacy Privacy Policy Only collects anonymous information No personal data is stored or can be identified Only keeps anonymous data for an indefinite time Collection and Use Only non-identifying information Usage Anonymous health or medical information Device information VOLUNTARY demographic information Sharing of Information Location Services Security

51 Additional Information Accessibility The information is available in other formats to people with disabilities Copyright The quiz is a validated and copyrighted tool Credit Made possible through funding provided by the Minnesota Department of Human Services and Minnesota Board on Aging

52 Taking the Quiz Easy, guided questions Bars to show progress Easy back/next navigation Scores Automatically Provides Risk Assessment Skip to Results Summary beginning with demographic information.

53 Results Summary Learn More What your risk category means Things you can do Access to Website Retake Quiz Results

54 Guest Speaker Tales from the field Jill Corbin, Community Service Representative, Home Instead

55 What Next? Start the conversation of Live Well At Home SM. Connect to the mnlivewellathome.org Download the mobile app Engage within network Cross referrals Coalition development Projection of value to community 10,000 screens in 2014 Launch into social media

56 Guest Speaker Tales from the field Cindy Conkins, Senior Planner, ARDC Arrowhead AAA

57 Review Gain a basic understanding about the Live Well at Home SM model Learn about the Live Well at Home Rapid Screen including the seven foundational risk factors, screening process, and new mobile app. Discover opportunities for moving Live Well at Home SM into your community Hear examples of Live Well at Home SM in action

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59 Contact: Feel free to contact Live Well at Home Project Consultant, Ryan Boosinger, with any questions or comments, or to sign up for our contact list. Success stories are welcome!

60 Many Thanks!