Aging in Place
 Craig Jones, MD
 Molly Dugan
 Kevin Loso
 Nancy Eldridge
We All Want to Stay Home
• Home centric
• Consumer driven
• Unlicensed
WE BUILT AN
EDUCATION SYSTEM
FOR THE BABY
BOOMERS IN 1953
NOW THEY NEED A
LONG TERM CARE
SYSTEM!
A Network of Care Management HUBS

 All Incomes,
Ages and
Settings
 Medicare
 Dual Eligibles
 Others??
+
150 HUBS
Housers at Health Reform
Table with the State
Home
Health
Housing
Hospital
Funder
Mental
Health
AAA
PACE
University
The Technology Embedded Home
 Central Clinical
Registry
 iPads
 Tele-Tai Chi
 Broadband for all!
 Cyber Seniors
THE SAVI!!
THANK YOU
ENTERPRISE
COMMUNITY
PARTNERS!!
How Will Our Residents Benefit?
HEALTHY HOMES
CARING COMMUNITIES
POSITIVE AGING!
Housers Working Together
Non-Profit
Housers
CCRC’s
Public
Housing
Authorities
Land Trusts
Assisted
Living
Residential
Care
Facilities
Department of Vermont
Health Access
Vermont Blueprint for Health
Community Systems of Health
Housing Assistance Council
June 5, 2012
4/13/2015
10
Department of Vermont
Health Access
Building A Foundation For The Future
Advanced Primary Care Practices (PCMHs)
Community Health Teams (core)
Community Health Teams extended(MCAID CCs, SASH Teams)
Multi-insurer payment reforms
Health Information Infrastructure
Evaluation & Reporting Systems
Learning Health System Activities
4/13/2015
11
Department of Vermont
Health Access
Hospitals
Advanced
Primary
Care
Specialty Care & Disease
Management Programs
Social, Economic, &
Community Services
Community Health Team
Nurse Coordinator
Social Workers
Nutrition Specialists
Community Health Workers
Public Health Specialist
Advanced
Primary
Care
Advanced
Extended Community Health Team
Primary
Medicaid Care Coordinators
Care
SASH Teams
Advanced
Primary
Healthier Living
Care
Workshops
Mental Health &
Substance Abuse
Programs
Public Health
Programs & Services
Health IT Framework
Evaluation Framework
Multi-Insurer Payment Reform Framework
4/13/2015
12
Department of Vermont
Health Access
Financing
Payment Reform
Fee for Service - Volume
$ PPPM (NCQA) - Quality
Medicaid
Medicare
BlueCross
MVP
Cigna
Self Insured
Delivery System Reform
Advanced Primary Care
NCQA Standards
Patient Centered Care
Access
Communication
Guideline Based Care
Use of Health IT
Community Support
Shared Costs - Utility
Community Health Teams
MCAID CCs
SASH Teams
Specialized Services
4/13/2015
Hospitals
Specialty Care
Mental Health Services
Substance Use Services
Family Services
Social Services
Economic Services
Long Term Care
13
Nursing Homes
Blueprint Information
Technology Architecture
Hospital-owned
Primary Care
Practices
Hospital hosted EMR
Central Registry
• Visit planners
• Care coordination
• Reporting
Data
warehouse
Core data elements
FQHC-owned
Primary Care
Practices
Vermont
Core data elements
FQHC hosted EMR
(VHIE)
Core data elements
Unique
Patient
identification
information
EMR
Web
Access
Primary Care
Practice
No EMR
Central Clinical
Registry
(Covisint-DocSite)
Web
Access
Independent
Primary Care
Practices
Core data
elements
Health
Information
Exchange
Core data elements
Community
Health Team
Blueprint Expansion
January 2012
4/13/2015
15
Department of Vermont
Health Access
16
4/13/2015
Gifford CME 3-2-2012
17
Department of Vermont
Health Access
Care Management Begins at Home
Multi-payer Advanced Primary Care Practices
(MAPCP) Medicare Demonstration States

Maine

North Carolina

Michigan

Pennsylvania

Rhode Island

Vermont


Minnesota
New York
Integrated Care for the Dually Eligible








California
Connecticut
Colorado
Massachusetts
Michigan
Minnesota
New York
North Carolina
Oklahoma
 Oregon
 South Carolina
 Tennessee


Vermont
Washington
 Wisconsin

Department of Vermont
Health Access
Data Sources & Evaluation
 Central Clinical Registry
 Multi-payer Claims Database
 Chart Reviews
 NCQA Scoring
 Public Health Registries
 Patient Provider Qualitative Assessment
 Patient Experience
Department of Vermont
Health Access
Early Trends – Inpatient Discharges
50%
38%
40%
30%
20%
Inpatient Discharges Participants
13%
10%
Inpatient Discharges Controls
7%
Inpatient Discharges Statewide
5%
2%
1%
0%
-2%
-10%
-10%
-16%
-20%
% Change 2007-2008 (Baseline) % Change 2008-2009 (Start-up)
% Change 2009-2010
(Operations)
Department of Vermont
Health Access
Early Trends – Inpatient Discharges (Rate / 1000)
60.0
50.0
40.0
30.0
Inpatient Discharges Participants
Inpatient Discharges Controls
Inpatient Discharges Statewide
20.0
10.0
0.0
2007
2008
2009
2010
Department of Vermont
Health Access
Blueprint Team
Craig Jones, MD
Lisa Dulsky Watkins, MD
Jenney Samuelson
Terri Price
Diane Hawkins
Beth Tanzman
Pat Jones
Julie Trottier (Milbank Fellow)
4/13/2015
25
SASH is a System, Not a Type of Housing




All settings – all ages – all incomes
Access to information for housing based staff
Population based – plus targeting
SASH as an extender to the Blueprint for HealthVT’s Medical Home Model.
What are the Essential Elements?





Person-centered – Population based
SASH Staff
Team Based Care Management
Information Sharing through Technology
Prevention and Wellness through Healthy
Living Planning
 Volunteers
SASH Keeps “Katie” in the Driver’s Seat
SASH Staff = Trusted Guides
Multi-Agency Team Based Care
Management
Nonprofit
Housing
PACE
Comm.
Mental
Health
Agency
Visiting
Nurse
Assoc.
Area
Agency on
Aging
The SASH Teams
 Care Manager
 Assessments
 Wellness Nurse
 Person Centered Plans
 Acute Care Nurse
 Individualized Supports
 Case Manager
 Transitions Support
 Mental Health Expert
 Self-Management of
 PACE Intake
Chronic Conditions
 Care Coordination
Prevention and Wellness
Volunteers!
Where are we now?
 Started rolling out in October 2011
 Currently have 19.5 panels up and running!
 1,950 people have access to SASH supports.
 57 affordable housing sites are SASH sites
 DocSite- Statewide Repository of Data is online.
Vermont’s SASH Goes Statewide
SASH and the Blueprint for Health
• An Extension of the Community Health Team
• Support for Goals of the Medical Homes
• CHT Case Manager Representation on Functional Team
• SASH Representation on CHT Planning Committee
• SASH Representation on CHT Referral Committee
Rutland County SASH Community
Partners
•
•
•
•
•
•
•
Rutland Regional Medical Center (RRMC): Social Work Department
RRMC: Case Management Department (Discharge Planners)
RRMC: Community Wellness Programs
Rutland Area VNA & Hospice – Nursing and Wellness Services
Southwestern VT COA– Case Management and Programming
PACE Vermont – Intake Coordination
Rutland Mental Health Services – Elder Care Clinician & Case
Management
• Southern VT Area Health Education Center – Interns
• Vermont Department of Health – Programming
• Castleton State College, School of Nursing – Interns
SASH and the Blueprint for Health










The Pines of Rutland (SNF) – Discharge Planning
Vermont Division of Disability & Aging Services – Choices
For Care
Community Health Center of the Rutland Region (FQHC) –
Medical Homes
Albany School of Pharmacology – Interns
The BUS – Transportation
Local Farmers – Nutrition Programs
Castleton Community Center – Programming
Retired Senior Volunteer Program – Volunteers
Lions Club – Vision Program
LensCrafters – Vision Program
SASH Local Table

Engages key community leaders in SASH

Provides support, guidance and general oversight

Represents interests of the SASH population

Members include leaders representing community
partners, other providers, and other community
stakeholders
SASH Local Table Roles & Responsibilities

General promotion of SASH to the community

Reviews strategic direction and priorities

Reviews protocols and services

Support in seeking funding sources

Reviews reports

Provides specialized experience

Reviews processes, data and outcomes

Supports overall development and sustainability
SASH Local Table
Roles
Responsibilities
Profile
of&Residents
Templewood Court
 49 residents enrolled
 39 females
 10 males
 Average age: 72 years old
 Average # of prescription
medications taken: 7
 Have 3 or more medical
conditions: 90%
 Have 5 or more medical
conditions: 55%
Sheldon Towers
 40 residents enrolled
 17 female
 23 male
 Average age: 58 years old
 Average # of prescription
medications taken: 6
 Have 3 or more medical
conditions: 80%
 Have 5 or more medical
conditions: 55%
Profile of Residents
Templewood Court
 Failed cognitive
screening: 39%
 Used ER: 43%
 Have self-reported
mental health concern:
33%
 Have moderate to high
nutritional risk: 83%
Sheldon Towers
 Failed cognitive
screening: 12%
 Used ER: 48%
 Have self-reported
mental health concern:
45%
 Have moderate to high
nutritional risk: 75%
Profile of Residents
Templewood Court
Sheldon Towers
 Top 5 Medical Conditions
 Top 5 Medical Conditions
–
–
–
–
–
Vision
Arthritis
High Blood Pressure
Heart or Circulatory Problems
Chronic Pain
 33% have fallen in last year
–
–
–
–
–
Vision
High Blood Pressure
Arthritis
Depression
Chronic Pain
 33% have fallen in last year
Community Program Support
 Castleton State College Nursing Programs Internship Program
 Vermont Center for Independent Living Hunger Free Vermont Nutritional Program
 Council on Aging; AmeriCorps Members – Tai
Chi, Walking Program
 Beauchamp & O’Rourke Pharmacy – Brown
Bag Medication Review, Diabetes Education
 Castleton Community Center – A Matter of
Balance
 RRMC – Eat Well Feel Great
Information Sharing
Housing
Staff
Nursing
Homes/Rehab
Facilities
Community
Providers
(VNA, AAA,
Mental
Health)
Primary Care
Provider
Community
Health Team
Family Support
Persons
Hospital
Benefits to Residents
 Enhanced quality of life
 Decreased isolation
 Increased physical activity
 Improved nutritional status
 Increase in primary care
 Vision issues addressed
 Reduction in ER and SNF utilization
 Earlier treatment of health issues
SASH Benefits To Housers
1.
2.
3.
4.
5.
6.
Added supports for a changing resident population
Liability exposure reduced
Increase in on-site support staff
Operate without a blindfold
Application of evidence-based practices
Integral part of home & community-based services
aging network
7. Part of linking non-profit assets
8. Sustainable funding for services
9. Place at the health care table
10. Benefit from a collaborative network