Helping Older Adults
Live Well at Home Today

•
Understand the structure, roles and funding streams for the Aging Network, including volunteer support
• Explore the value of non-medical, in-home services in avoiding rehospitalization
• Identify critical points in care pathways to make referrals to AAA Senior LinkAge
Line® services
• Learn about the infrastructure of community-based Chronic Disease Self-
Management Program (CDSMP) and Matter of Balance class offerings
• Identify new resources for patients to develop the skills needed to manage their chronic conditions on a day-today basis and increase self-management skills in preventing falls
• Learn about partnership opportunities with Area Agencies on Aging to develop additional capacity in selfmanagement of chronic disease and/or falls prevention

 Area Agencies on Aging created via the Older
Americans Act
 Nation-wide home and community-based service system that develops and delivers non-medical services to help older adults maintain independence at home

MN Board on Aging designates Area
Agencies on Aging for statewide coverage:
 Six regional “ AAAs ” and 1 Tribal “ AAA ”
 Nonprofit corporations, quasi-governmental or tribal organizations
 Experts on community services, caregiving, volunteer support, housing options, Medicare and public benefits
 Hub organization for local vendor networks and broader regional “ Aging Network ”

 Consult on-on-one with older adults and their families about services, housing choices, caregiver support,
Medicare, benefits, county services
 Help older adults transition across settings
 Identify needs and distribute federal and state resources to fund services for seniors and caregivers
 Partner to develop new services and programs


Person-centered consultation over the telephone via the Senior
LinkAge Line
®
, web chat or at home to:
 Evaluate complex living situations

Connect to housing options and services such as homemaker, meals, transportation, respite, medication management, home modifications, chronic disease self management programs

Answer Medicare and insurance questions
 Follow-up to ensure that needs are met
 New statutory referral requirements in law for clinics and hospitals

 Root Cause = Absent or insufficient enlistment of short or longterm services and supports
 Response = Community-based services provided Area Agency on
Aging and local Aging Network
 Medication Issues : Link to Title III-funded Medication Therapy Management services and other medication management resources; enlist SHIP counselor to resolve payment issues/identify more cost-effective Part D plan; connect informal caregiver to training; address memory loss
 Lack of follow-up with PCP: Link to transportation provider
 Additional help needed at home: Provide information about and/or arrange home health care services, environmental modifications, assistive devices, meals/grocery delivery,
PERS, homemaker and outdoor chore services, caregiver respite, consultation, support, training, Senior Companion, block/parish nurse, Long-Term Care Consultation/Waiver

Living Well with Chronic Conditions (CDSMP) - Increase self-confidence in the ability to control symptoms and manage the affect of multiple chronic health issues (6 weeks, 2.5 hrs./week)
A Matter of Balance (MOB) - Reduce the fear of falling and increase the activity level (8 weeks, 2 hrs./week)
Powerful Tools for Caregivers - Family caregivers learn skills to care for themselves while caring for others
(6 weeks, 2.5 hrs/week)

– Disseminate EBHP programs through implementing partner organizations
– Train leaders and provide licensing, start-up materials, and fidelity monitoring
– Provide technical assistance on program implementation, marketing materials, promotion strategies to generate participants for classes, local referral partnerships
– Limited funding through Older Americans Act

 Long-term Care Options Counseling and personcentered support coordination
 Care transitions and service delivery expertise
 Evidence-based health promotion and chronic disease management services
 Bridge connecting acute and clinical health care with community-based services to provide better care with follow-up; reduce health care costs; support better health
 Partner to develop comprehensive community approaches to care transitions that improve outcomes for patients

For Providers: Interested in becoming leadertrained to offer classes or host a class?
Contact your local Area Agency on Aging www.mn4a.org
For Seniors: To get more information or to find a class in your area call:
Senior LinkAge Line
®
1-800-333-2433
Or visit www.mnhealthyaging.org

Lori Vrolson, MA, Executive Director
Central Minnesota Council on Aging lori@cmcoa.org
320-253-9349
Dawn Simonson, MPA, Executive Director
Metropolitan Area Agency on Aging dawn@tcaging.org
651-641-8612

Minnesota Association of Area Agencies on Aging www.mn4a.org
Minnesota Board on Aging/MN AAA EBHP and chronic disease management information www.mnhealthyaging.org
Minnesota Board on Aging and MN Dept. of Human
Services Database www.MinnesotaHelp.info

Topic:
Meaningful Use and Electronic Health Records for the RARE
Campaign
Date: Friday August 24, 2012
Time: 12 Noon – 1p.m. CDT
Future Topics:
To suggest future topics for this series, Reducing
Avoidable Readmissions Effectively “RARE” Networking
Webinars, contact Kathy Cummings, kcummings@icsi.org