Workshop 3D: Caring For Seniors In The Community

8/10/2019 Workshop 3D: Caring For Seniors In The Community

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Community Based Services


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Introduction

Shirley Weaver LOTR, MSOL

Director of Community Based Services for Seniors

Bonney Dahlgren DosSantos BSW, CMC

Director of Saint Monica Eldercare Program


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Boomer Generation

In 1966, Time magazine declared that the

Generation Twenty-Five and Under would be

its Persons of the Year.


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Population Trends


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Population StatisticsSource: http://www.aoa.gov/Aging_Statistics/Profile/index.aspx


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Population StatisticsSource: www.aoa.gov/Aging_Statistics/.../PopAge1900-2050-by-decade.xls


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Living Arrangement over 65Source: http://www.aoa.gov/Aging_Statistics/Profile/2012/docs/2012profile.pdf


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Community Dwellers

2012: 11.8 million or 28% of non-institutionalized

older persons live alone

Median income in 2011 was $27,707 for males and

$15,362 for females Households headed by persons 65+ median income

$48,538

2012: 9.1% was the poverty rate for people 65+

Source: Administration on Aging: Profile of Older Americans: 2012

https://www.census.gov/hhes/www/poverty/about/overview/


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Source: http://www.aoa.gov/Aging_Statistics/Profile/2012/9.aspx


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Philadelphia

2010: 45% of seniors live at or below 200% of

poverty level

2010: 36% of seniors are 75+

26% of seniors have less than high school education

45% of older adults with incomes less than 200% of

poverty level have less than high school education

Source: PCA Area Plan 2012-2016


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Philadelphia

2003: Second among 23 US cities in population of

residents 65 and older

Increasing age 2025:

85+: 18% increase

75 to 84: 22% decline

65 to 74: 28% Increase

Source: PCA Philadelphia Aging Population, 2006


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Trending Results

Number of older adults continues to grow

Increase age results in increased chronic disease

Management of chronic disease places increased

demands on healthcare system

Management of chronic disease places increased

financial demands on the individual


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Aging in Place

Older adults express a desire to remain in their

homes and communities

Remaining in the community is less costly than

institutionalization Seniors also desire to stay in a particular residential

setting as long as possible


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Managing Chronic Disease

Impact


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Re-hospitalizations

Quality of Service

30 day hospital readmission rate

Approximately 2.6 million seniors

Nearly 1 in 5 Medicare patients discharged from a hospital

Readmission cost of over $26 billion every year

2013: 2,225 hospitals penalized for Medicare

reimbursement Acute Myocardial Infarction (AMI), Heart Failure (HF) and

Pneumonia (PN);

Source:http://innovation.cms.gov/initiatives/CCTP/index.html


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Reasons for Re-hospitalizations

Lack of physician follow up

Medication mismanagement

Lack of understanding of signs/symptoms ofexacerbation of chronic conditions

Poor transfer from one setting to another

Lack of use of home health services

Poor patient self management

Insufficient care giver support Lack of availability or awareness of community

resourcesSource: Polisher Research Institute


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Remaining in the Community


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Community Support

Area Agency on Aging: Various projects Federal/State Funding

Senior Centers

Program for All Inclusive Care for the Elderly (PACE/LIFE):

Transitions Care Management Programs

Naturally Occurring Retirement Community: Public/Private funding

Geriatric Care Management: Private and Insurancefunding


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Residential Support

Independent Living

Personal Care/Assisted Living

CCRC: Continuing Care Retirement

Community

Life Care at Home


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Response


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Build a Network of Services

Link Medical and Social Models

Support

Provide resources

Network with existing programs


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Senior

EldercareHelpline

SeniorHousing

SeniorClubs

SeniorCenters

SeniorCare

Partners

SaintMonica

EldercareProgram

In-HomeSupportProgram


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Community Nurse Liaison

Provision of Nursing services where seniors gather

Goal

Self Management of Chronic disease

Omaha System

Health Promotion

Facilitate collaboration with Medical systems

General Education


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Ask the Nurse Day

Health Consulting

Analyze programs and develop new programs to address

the health issues Health Education

Articles on health & wellness for seniors

Monthly presentations


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Evaluation Based on a Standardized tool

Develop a care plan

Reassessment upon next visit

Care Plan revision as necessary

Document all patient contact


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The Omaha System Problem Categories: Environmental, Psychosocial,

Physiological, Health-related Behaviors

Consists of three, five-point scales measuring the

range of severity for the concepts: Knowledge: Understanding and management of the

specific problem.

Behavior: Persons ability and approach towards managing

their problem.

Status: Measures signs/symptoms of the problem.


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Ask the Nurse Day

Services rendered since Nov. 2013

247 Unduplicated Seniors

Reassessment on 104 unduplicated seniors

491 Total Patient Visits 234 Repeat Visits

71.2% of patients show improvement

38.2% average improvement from initial score


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Senior

EldercareHelpline

SeniorHousing

SeniorClubs

SeniorCenters

SeniorCare

Partners

SaintMonica

EldercareProgram



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CCOPE(Catholic Care Options Program for the Elderly)

No-fee resource information and referral service

Managed through Senior Care Partners

Entry point for internal and external services

Resource for community, professionals, pastors


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Senior

EldercareHelpline

SeniorHousing

SeniorClubs

SeniorCenters

SeniorCare

Partners

SaintMonica

EldercareProgram



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In Home Support

Partnership with PCA

Evaluation and resource coordination

South Philadelphia area

Target population

Early intervention and prevention services for 60+

individuals

Temporarily homebound or require assistance or

supervision to leave home


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In Home Support

Case Management Services

Short Term Services: Less than 6 months

Home care, chore service, minor home repair

Long term services: Home-delivered meals, transportation, and senior

companions.


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In Home Support

Number of Open Cases: 274

Impact:

Home delivered meals: 2,112

Transportation requests: 1,554 Light House keeping services: 888

Adaptive Equipment: 44


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Senior

EldercareHelpline

SeniorHousing

SeniorClubs

SeniorCenters

SeniorCare

Partners

SaintMonica

EldercareProgram

In-Home

SupportProgram


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Senior Housing

St. John Neumann Place 75 one-bedroom Independent Living apartments for

income-eligible residents at the former SJN High

School

Casa Carmen Aponte Section 8 housing with 35 apartments

Located above Norris Square Senior Community

Center

St. Mary Residence

Former convent with supportive housing for women

over 60 years old


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Senior Housing

In Process

Name Units Primary

Funding

Total

Cost

Timeline

Nativity B.V.M. Place

(Port Richmond, Philadelphia)

63 HUD 202 $12.5m Start Construction: Jan 2015 (maybe sooner)

Ready for residents: February, 2016

St. Francis Villa(Kensington, Philadelphia)

40 LIHTC $12m Start Construction: March, 2015Ready for residents: April, 2015

St. John Neumann Place II

(South Philadelphia, Philadelphia)

52 LIHTC Ask John Applying for funding: January, 2015

If awarded funding, start construction: April,

2016

Ready for residents: May, 2017


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Senior Housing

St. John Neumann Place


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Senior Housing



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Senior Housing



Average monthly patient visits: 10

Active Care Management cases per month: 20

Referrals: 315 (Benefit Programs, Health Care Services,Legal Services, Financial Services, Crisis Support)

Hospice: 2 within 12 months

Life Program: 12 residents

PCA LTC Program: 11 residents


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Senior

EldercareHelpline

SeniorHousing

SeniorClubs

SeniorCenters

SeniorCare

Partners

SaintMonica

EldercareProgram



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Senior Citizen Clubs

The Archdiocesan Senior Citizen Council (ASCC)

Approximately 75 senior clubs

Self-directed, independently incorporated

Approximate combined membership 7,000

Connecting

Participate in Club fairs and meetings

ASCC Newsletter: CHCS Health and Wellness Marketing availability of services and programs


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Senior Club members working on a Prayer

Square Quilt for Victims of Abuse


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Senior

EldercareHelpline

SeniorHousing

SeniorClubs

SeniorCenters

SeniorCare

Partners

SaintMonica

EldercareProgram



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Senior Community Centers

Funding- Philadelphia Corporation for Aging

- Catholic Health Care Services

- United Way

Philadelphia Locations- North Central: Norris Square: Hispanic

- Port Richmond: St. Anne: Polish

- West Philadelphia: Star Harbor: African American

- South Philadelphia: St. Charles: Chinese AfricanAmerican


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Participants are 60 + and residents of Philadelphia Total impact: 5,338

Daily attendance: 239

Unduplicated seniors: 1,965 last fiscal year

Information and Assistance: 3,373 seniors Program Focus

Social Isolation

Health and Wellness

Food Insecurity


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Menu of Programs and Services

Congregate meal (lunch)

Social programs

Recreational activities

Day TripsArts and Music

Consumer/Health Education

Programs

Spirituality Program

Physical exercises (yoga,

tai chi, dance, aerobics)

Computer lab and classesHealth Screenings

Nutrition Education and

Supplemental food

programs


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Social Isolation

Social events

Trips

Depression Screening Program

Counseling Services

S i C it C t


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Food Insecurity Food Insecurity Program

Breakfast Program: 29,057 meals

Congregate Lunch: 56,393 meals

Commodities Boxes: 4,041 boxes Produce Vouchers: 949 vouchers

S i C it C t


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Food Insecurity Nutritional Risk Assessment

Pa. Dept. Aging nutritional assessment tool

321 new members over 8 months

140 or (43.62%) were nutritionally at risk. Reassessed: 90 after 6 months

S i C it C t


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Food Insecurity Outcomes 2

21.12% remained the same no change in risk score

44.44% improved with a decrease in risk score

34.44% were at increased risk Plan

1.Investigate reason for the increased risk

attendance

accessibility to food suppliers/stores

financial supports/resources

2. Continue assessment program

S i C it C t


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Health and Wellness Enhanced Fitness:

307 classes

6,846 attendees

Health Promotions: 1,876 classes/sessions

25,355 attendees

Health Education

569 sessions/screening

10,086 attendees

S i C it C t


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Health and Wellness Ask the Nurse Day

Memory Screening

Other Services

Podiatry

Glaucoma screening

Falls risk screening


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YOGA FOR OUR SENIORS


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CHRISTMAS IN JULY AT THE CENTER


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Senior

EldercareHelpline

SeniorHousing

SeniorClubs

SeniorCenters

SeniorCare

Partners

SaintMonica

EldercareProgram



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Background

Funded by the Farrell Townsend Trust, initially

established in the 1940s

Serves registered parishioners and their families

in Saint Monica Parish in South Philadelphia Started in September 2003

Provides direct service, connects to other

services, fills in gaps


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SMEP Core Services

Information and Referral: 125 calls per year

Service Delivery for open cases

Care Partner

Care Management Form completion

Connecting to organizations

Facilitating Family meetings

Spiritual Care and Guidance


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Operations

Number of Employees

1 FTE, Director CGCM (Certified Geriatric Care

Manager)

3 part time Care Partners

4 occasional Care Partners

10 hour/week Pastoral Care Partner

10 hour/week Administrative Support

Budget: $194,356 per year


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Focus

Overall well being

Quality of Life

Care giver support

Impact Reduction in re-hospitalization

Reduction in nursing home placement

Fills gaps in other available services


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Data Collection

July 2010,2011,2012

89 participants studied

Gathered data for all participants

Demographic Services rendered

Health information

Diagnoses, hospitalizations

Disposition

Demographic Characteristics


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Demographic Characteristicsfor 89 sample

Mean Age all members: 84.6 years (SD 32.5) Range

44-97 years ( 2 individuals: 44 & 47)

Mean Age 85.1 years; Range 57-97 removed 44 &

47 26% Live Alone

51% Receiving a psychotropic medication

30% Display Cognitive Impairment: Observation*MMSE test implemented in March 2013 indicate 28.5%cognitive impairment

Demographic Characteristics


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Demographic Characteristicsfor 89 Sample

Average length of time in SMEP3.5 years

Average total number of self-reported medicaldiagnoses = 4 (range 0-12)

66% Female

Average annual documented income for 33individuals is $12,882

10 or 11% were receiving services typical of a

nursing home population (LIFE program, Waiverservices, hospice, 24 hr. private duty aides,family care givers)


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Percent of Members Receiving Services


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Percent of Members Receiving Services


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Percent Receiving Other Vital Services

Visualization of SMEP members connected to services


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Red Dots = participants in the SMEP N=89

Blue Squares = services and referrals

Visualization of SMEP members connected to services

Visualization of SMEP members connected to direct services


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Direct Services Diagramsubset from above

Visualization of SMEP members connected to direct services

Visualization of SMEP members connected to referrals


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Referrals to other Programs (subset of entire graph above)

Visualization of SMEP members connected to referrals


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Satisfaction Survey

74 questionnaires mailed to current members(including family if member was unable to

complete)

103 questionnaires mailed to past members(including family if member was deceased)

N=107 Returned Questionnaire

61% response rate


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Satisfaction

Information provided helps me resolve myissues: 81 % strongly agreed, 17% agreed

How Important is to you that St. MonicaEldercare Program is associate with your parish:

90% extremely important, 9% important, 1% notimportant

Would you recommend St. Monica EldercareProgram to neighbors, friends or family:

100% yes


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Community Partners Responses

Questionnaires mailed to all businesses thatthe SMEP refers clients

28 questionnaires mailed to community

business partners 68% response rate

N=19


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Business Satisfaction

Being aware of the Saint Monica EldercareProgram has increased my awareness of the needs

of the senior community

64% strongly agreed

36% agreed

My business has benefitted from the relationship

with the Saint Monica Eldercare Program

68% strongly agreed

32% agreed


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Rogers Family

Adult Child of Joe & Sue called program in 2003 torequest services for Parents

Joe (age 78; services from 2003-2004)

Sue (age 78; services from 2003-2007; 2009-2011)

Son Jim (age 48;services from 2003-2005)

Daughter-in-Law Becky (age 62; services from Jan-July 2012)

Sues sister, Paula (age 89; services from 2011 present)

Rogers Family


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Rogers Family

2003

One of first Program participants9/2003

Care Management for Sue, Joe, and Jim

Sue was caregiver for Joe and Jim

Services accessed 2003-2007

2003 - CCT for Joe and Sue, Rx assistance for

Sue, Medicaid Waiver Program for Joe


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2004

Establishment of trust for Jim All legal documents for Joe and Sue prepared

Sue: Medicare Advantage enrollment

PACE for Sue, LIHEAP, RE Tax Rebate, discount plansw/ PGW, PECO

Jim: advocated for in home care when Jim could nolonger attend workshop


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2004

Joe hospitalized, ST rehab at Methodist NursingCenter, home w/ services

Joe passed away in August; assisted Sue and Jim inreceiving SS benefits on his record


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2005

Jim: Arranged in-home assessment by

gerontologist; Primary diagnosis of dementia

Jim: Assisted with first floor set up;

recommended physician who made house calls Jim passed away in October after short

hospitalization


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2006-2007

Sue: Continued care management

Sue: Bereavement support group offered

Sue: Submitted application for VA benefits;

denied as expenses were not high Pro bono legal work completed

Sue agreed that case could be closed in spring

2007


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2009-2010

Case reopened after call from son

Sue diagnosed with dementia

Care Management services initiated

Initiated long term planning

Care Partner assigned


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2011

Sue sustained stroke, hospitalization, shortterm rehabilitation

Sue: Coordination of medical home care

Sons chose reverse mortgage to pay for care athome

June: Sue passed away at home

Paula: Sues Sister Paula fell and broke hip

Becky: December diagnosed brain cancer


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2012

Paula admitted to St. Monica Manor in January

Care Management initiated

Home renovations

Private pay home care

July: Becky passed away at home

/


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2013/2014

Paula: March returned home with 24 hour live incare

Doing Well at home with live in caregiver

Physician who makes house calls

Therapy at home PRN

Communion in her home

Prayer Partner program

R F il Ti li


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Rogers Family Timeline

Visualization of Rogers Family Connected to Services.


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Joe & Sue- Husband and WifeJimAdult Son with Downs Syndrome

BeckyDaughter-in-law

PaulaSues Sister


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System Impact

R f Di h N 37


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Reasons for Discharge N=37

Does not include those individuals still actively receiving services

System Impact


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Non Institutionalization

54% or 20 individuals were discharged due to

death

11 died in their homes

4 died during short term NH stays (average 18 days)

2 during rehab stay

1 during hospice stay

1 who would have converted to Long Term care 5 died during brief hospitalizations (average 3 days)

System Impact


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Nursing Home Placement

SMEP had 5% versus 11% national average for

nursing home placement of individuals age 85+

SMEP SMEP: 4

National average projection: 10

Result: 6 fewer long term admissions

System Impact


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Financial

Average length of stay in nursing home in

Pennsylvania for long term care: 183.94 days

Average cost per day in PA: $221

Savings for one individual: $ 40,651

Source: http://www.amwarnerinsurance.com/ltc-insurance/cost.php

System Impact


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Hospitalization

SMEP average hospitalizations is 45% versusnational average of 58% for individuals 85+

Difference in hospitalization rate: 11%

Average cost to Medicare per hospitalization:

$7,200

Source http://www.hcup-us.ahrq.gov/reports/statbriefs/sb103.jsp

http://www.hcupus.ahrq.gov/reports/factsandfigures/2009/pdfs/FF_2009_exhibit4_3.pdf

System Impact
http://www.hcup-us.ahrq.gov/reports/statbriefs/sb103.jsphttp://www.hcup-us.ahrq.gov/reports/statbriefs/sb103.jsphttp://www.hcup-us.ahrq.gov/reports/statbriefs/sb103.jsphttp://www.hcup-us.ahrq.gov/reports/statbriefs/sb103.jsp


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Philadelphia Corporation for Aging

At the time of the study about 2,000 evaluatedindividuals are on the Options waiting list forPCA services.

16% or 14 of the 89 SMEP members wereassessed by PCA for the Options program

Three people died while waiting for services to begin

Five people waited an average of 142 days forservices to begin (Range 32-427 days)

Six people were still waiting (to date average 505days)

System Impact


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Philadelphia Corporation for Aging

SMEP

No waiting list

Services parishioners who are waiting

Provides support after PCA initiates services

Continued Growth and Development


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Incorporation of Nurse Educator/Consultant Ask the Nurse events

Telephone consultations, in home visits, assessments

Replication of Program



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ShopRite Shop at Home Phone in orders, same day delivery

No charge to parishioners

Call Partner Program

Requested by study participants

Allows homebound parishioners to remain activeparticipants in parish life

Fosters communication between members of both

churches

Eldercare


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Senior

EldercareHelpline

SeniorHousing

SeniorClubs

SeniorCenters

SeniorCare

Partners

SaintMonica

EldercareProgram


Our Services


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Our Services

Transitional Care Management SNF to Home

Traditional Care Management

Serves private paying clients and caregivers wishingto remain at home in the community

Assessment

On-going coordination

On-going monitoring

Senior Care Partners: A Geriatric Care


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Management Program

Certified Geriatric Care Managers

Programs Skilled Nursing Transition Program

Care Management Program with Senior Bridge/Humana

Traditional Geriatric Care Management

Parish Based Programs

Preventing Hospital Readmissions


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Preventing Hospital Readmissions

Readmission cost of over $26 billion every year Average Cost of preventable readmission: $7,200

Most critical time frame: 72 hours post discharge

50.2% of re-hospitalized patients did not have billed

physicians office visit Coaching chronically ill older patients and caregivers

may reduce rates of re-hospitalization

Source :Internal Medicine/vol. 166, 2006

Assessment Components


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Assessment Components

Physical Environment Activities of Daily Living Status

Medication Management

Nutritional Support Cognitive Status

Social and Spiritual Support

Community Medical Appointments Scheduled

Identify Additional Community Resources

Traditional Geriatric Care


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Management Assessment

Development of Care Plan

Collaboration with Client/Family

Coordination of Services Continued monitoring

Education

Advocacy Family caregiving coaching

Skilled Nursing Facilities


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Skilled Nursing Facilities

Adds a medical component to our Continuum of Care

Skilled Nursing Facility (SNF), short term rehabilitation services,

respite stays, medical care in a social environment

Understanding of Medicare and Medicaid coverage, regulations and

billing

Allows CHCS to leverage clinical resources in the community setting

Focus on ease of transitionsbetween care settings

Skilled Nursing Facility Program


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Eligibility: ST stay at a CHCS Skilled Nursing Facility

Admitted from a participating hospital

SCP connected thru daily census report

SW informs SCP discharge planning meetings

CM attends discharge planning meeting andschedules initial in-home assessment

Timeframes


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Timeframes

45 day follow up services Telephonic

Site visit if needed

Post Discharge from SNF

Day 7 Day 10

Day 14

Day 21

Day 30

Day 45

Additional unscheduled follow-ups as necessary



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In-home assessment scheduled within 24-48 hoursof discharge

Written summary completed submitted to hospital within 5 business days of assessment

Service provided Discharge Completed

summary is submitted to the hospital within 5 businessdays

Parish Based Program


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Services General Information and Referral

Traditional and Transitional Care Management

Volunteer Navigator/Senior Companion

Intergenerational Programing

Funding

Parish Grant

Exploration of funding models: membership, donation



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Our Lady of Good Council Partially implemented

Maria Goretti

Senior Advisory Council Parish survey

St. Rose of Lima

Parish advisory council

Humana/SeniorBridge


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Humana/SeniorBridge

TransitionsProgram Hospital or SNF to home

Long-Term In-Home Program

Identified as high-risk for hospitalization Geriatric Care Management Consults

One-time assessment and development of care plan and

appropriate resources

Traditional Care Management through CareManagement Network

Clients Served


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Clients Served

Traditional Care Management Program Initiated July, 2011

Clients Served: 31

SNF Transitional Program November, 2012

Clients served: 280

Clients Served


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Clients Served

Senior Bridge/Humana Initiated March, 2013

Clients Served: 13

Our Lady of Good Counsel Initiated January, 2014

Clients Served: 28

Re-Hospitalizations


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Re Hospitalizations

Readmission following discharge from SNF State Average: 20.6%

Senior Care Partners: 18.6%

Cost Savings: $36,000 (52 vs. 57 )

Source: Pa. Health Care Cost Containment Council 2012, 2013)

EldercareH l li


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Senior

Helpline

SeniorHousing

SeniorClubs

SeniorCenters

SeniorCare

Partners

SaintMonica

EldercareProgram

In-Home

SupportProgram

Quotes


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Quotes

"Aging is not lost youth but a new stage

of opportunity and strength."

Betty Friedan (1921-2006)


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QUESTIONS

Documents

Workshop 3D: Caring For Seniors In The Community