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April 29 - May 1, 2015
Community and Home-Based Solutions for All Ages- Community Health Navigator Program
Agenda
• Introduction to LIVE WELL Initiative
• Strategic Partnerships
• About Our Program
• Goals And Results
• Benefits To The Community
• Lessons Learned And Challenges
United Way of Tarrant County’s LIVE WELL Initiative
OUR BOLD GOAL: We will have improved the lives of 17,000 adults with ongoing health concerns by the year 2020.3 Core Values:
Care for Caregivers - Provides support for the people who take care of loved ones with ongoing health concerns
A Healthier Me - Provides services to adults in our community with ongoing health concerns
A Healthier Community - Helps to educate and provide information for a healthier Tarrant County community
Strategic PartnershipsA Healthier Me- Community Health Navigation Program’s partners and
key stakeholders
Insignia Health
Texas Christian
University
Area Agency on Aging of Tarrant
County
Federally Qualified Health
Centers (FQHC)
Managed Care
OrganizationsDepartment of
Aging and Disability Services
Other Community
Based Organizations
Goals And Results Total clients served since 2012: 807 Homebound older adults
A low cost high impact program
Primary Outcome: To improve consumer’s capacity for disease self management.
Participants will:
Decrease hospital and emergency care admissions
Improved health status
Patient Activation Measure (PAM) level advancement
Goals
24% ↓in hospitalizations or emergency department visits for 6 months following the intervention
81 % of clients showed positive changes in at least one outcome variable
75 % of clients advanced at least 1 level of health activation after 6 months of CHN Intervention using the PAM Model
Results
Benefits To The Community
Source: Is Patient Activation Associated with Future Health Outcomes and Healthcare Utilization Among Patients with Diabetes? Journal of Ambulatory Care Management, Oct/Dec 2009
Texas Department of State Health Services calculated that from 2008-2013, adult residents (18+) of Texas received $49,010,136,451 in charges for hospitalizations that were potentially preventable.https://www.dshs.state.tx.us/ph/state.shtm
Lessons Learned
Use of neighbor to neighbor module
Person-centered philosophy- Community Health Navigators (CHN)
Hybrid program
Challenges
Unique needs of older population
New use of technology
Establishing boundaries
Lessons Learned And Challenges
CHNs-students/retired individuals
PAM-a supported coaching tool