CONFIDENTIAL – Do not reproduce or distribute

#AGS18

A Human-Centered Model of CareIntegrating community-based dental, social and health services

Eliah Aronoff-Spencer, MD, PhD,Consultant and Principal Investigator, West Health Institute

R E S E A R C H S P O T L I G H T S

CONFIDENTIAL – Do not reproduce or distribute

Project Collaborators

2

Serving Seniors Joe Gavin

Marissa MackiewiczMelinda Forstey

Paul Downey

Gary and Mary West Senior Dental Center Karen Becerra

Vicki PetropoulosLizbett ChavezAyrielle Franco

West Health Team Paddy Asgari

Ian PierceTracy FinlaysonJose UnpingcoRishi GrahamWesley Vetter

CONFIDENTIAL – Do not reproduce or distributeCONFIDENTIAL – Do not reproduce or distribute

No financial conflicts of interest to disclose

CONFIDENTIAL – Do not reproduce or distribute

Project Goals: Human Centered Health Design

4

Co-Design a collaborative ecosystem for Human-

centered care

Utilize comprehensive assessments for real time

triage and referral

Generate whole-personand system data to drive

program evaluation

Improve Health Outcomes

CONFIDENTIAL – Do not reproduce or distribute

Gary and Mary West Senior Wellness and Dental Centers

5

CONFIDENTIAL – Do not reproduce or distribute

From Whole-Person Assessment to Whole-Person Care

6

First CGA With Dental

…..Order Matters

CONFIDENTIAL – Do not reproduce or distribute

From Person to Population

7

Individual Snapshot

Population Dashboard

CONFIDENTIAL – Do not reproduce or distribute

Outcomes and Patient Assessments

8

Programs ClientsComprehensive Geriatric Assessment

1000

Oral Health Education 841Basic Screen Survey 828Dental Care Referrals 796Care Coordination Referrals 148Case Management Referrals 78Mental Health Referrals 27Post Assessments 176

CGA Elements (n=1000) PercentAverage age 72 ± 7.6Below poverty 55%Live alone 67%Have medical conditions 75%Have mental health diagnoses 25%No dental visit in the past year 53%Limit food due to dental problems 59%Difficulty chewing 49%Dental pain 43%

DemographicsReferrals

CONFIDENTIAL – Do not reproduce or distribute

CGA inter-item correlations (n=1000)

9

Comprehensive assessment gives us a whole-person view of our clients

Pain and health problems are tightly coupled to:• Functional limitation• Depression• Lower quality of life

CONFIDENTIAL – Do not reproduce or distribute

CGA inter-item correlations (n=1000)

10

Mental health problems are highly correlated with:• Isolation • Lower quality of life

Comprehensive assessment gives us a whole-person view of our clients

CONFIDENTIAL – Do not reproduce or distribute

CGA inter-item correlations (n=1000)

11

Dental symptoms highly correlated with:• Depression• Isolation• Quality of life

Comprehensive assessment gives us a whole-person view of our clients

CONFIDENTIAL – Do not reproduce or distribute

CGA inter-item correlations (n=1000)

12

Isolation is the strongest negative correlate of:• Depression • Lower quality of life

Comprehensive assessment gives us a whole-person view of our clients

CONFIDENTIAL – Do not reproduce or distribute

Summary and Key Learnings

13

• I D E N T I F Y needs by whole-person assessment

• C O O R D I N AT E order and type of services by real-time metrics

• F O S T E R innovation through co-design and iteration

• G R O W and learn by evidence-based Continuous Quality Improvement