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DISABILITY RIGHTS EDUCATION & DEFENSE FUNDWEBINAR: PROMISING PRACTICE: AN INNOVATIVE THREE-WAY COMPLEX CARE COLLABORATION: BERKELEY CENTER FOR INDEPENDENT LIVING (CIL), LIFELONG MEDICAL CENTER, AND ALAMEDA ALLIANCE HEALTH PLAN, BERKELEY, CALIFORNIAThursday, September 24, 20154:30 p.m. – 6:04 p.m.

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>> Mary Lou Breslin: Good afternoon, everybody. I'd like to welcome you to the second webinar in a series entitled “Promising Practice,” collaborations between Independent Living Centers, ADRCs, Area Agencies on Aging, Managed Care plans, healthcare providers and other partners.

Before we begin, I'd like you to just take note that if you want access to captioning for this webinar, MAC users should click on the Media Viewer located in the lower right-hand corner of your webinar window. For Windows users, click on the Media Viewer located in the upper right-hand corner of the webinar window. You can read a transcript of the webinar in realtime. On the bottom right-hand corner of your screen, click Show/Hide Header. During the event, another window might cause the Media Viewer to collapse. Click the Media Viewer icon in the upper right which will bring the window back.

We will be taking questions following presentations by Kathryn Stambaugh and Thomas Gregory. You can type your questions in the chat box. We will answer as many questions as time permits. A transcript from the webinar along with the slides will be posted on the DREDF website, DREDF.org. That will be posted within a week of the presentation.

Let me just get started now. My name is Mary Lou Breslin. I'd like to welcome all of you. This is the second in a series of three webinars featuring promising collaborations between Independent Living Centers, aging and disability resource centers, Area Agencies on Aging, Medicaid Managed Care plans, healthcare providers and other partners. The Disability Rights Education & Defense Fund is pleased to be presenting these webinars in collaboration with Aging and Disability partnership for managing long-term support and services established by the National Association of Area Agencies on Aging as part of a project funded by the Administration for Community Living. The project partners include the National Disability Rights Network, Justice of Aging, Disability Rights Education & Defense Fund, and Health Management Associates.

The goal of the aging and disability partnership for managing long-term support and services is to leverage the Aging and Disability network’s extensive infrastructure, service capacity, and expertise to ensure delivery of high-quality managed long-term support and services to seniors and people with disabilities. The purpose of this webinar series is to share promising practices and collaborations between Independent Living Centers, ADRCs, AAAs, Managed Care plans healthcare providers and other partners.

The second webinar in this series being present today features a collaboration between the Center for Independent Living in Berkeley, California, the Federally Qualified Health Center, LifeLong Medical Care and the Alameda Alliance. It will feature a program of the Independent Living Center,

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Access to Independence, and healthcare plan in San Diego, California. Check the DREDF website for registration information for this last webinar in our series.

The goals in presenting these webinars are to illustrate how collaborations between these groups and organizations have the potential to infuse the Independent Living philosophy and services into Long Term Support and Services and Managed Long Term Support and Services, improve health outcomes and increase community living for older adults and people with disabilities. These collaborations hold potential to also generate cost savings.

Presenters for our webinar today are Thomas Gregory, Deputy Director, Center for Independent Living, Berkeley, California, Kathryn Stambaugh, Geriatric Service Director with LifeLong Medical Care. Thomas will discuss how independent peer coach and registered nurse teams work at health centers in Berkeley to improve health and foster community living skills. Silvia Yee, our Senior Attorney with DREDF, will conclude the webinar with a discussion of policy implications for this program.

I'd like to extend our deep appreciation to our presenters for working with us to bring this webinar to you. With that I am going to turn this over to Kathryn Stambaugh.>> Kathryn Stambaugh: Great. Thanks so much.

I'm Kathryn Stambaugh. I work at LifeLong Medical Center. We are a safety net provider of medical, dental, and behavioral health services in the San Francisco Bay area's East Bay. And we have 14 locations in Alameda County and Contra Costa County. We serve about 45,000 people each year.

When we first started, our vision was really about bringing the philosophy of Independent Living into the medical setting. And LifeLong and Center for Independent Living set out to offer two new services, on-site peer coaching and nurse care management. Both provided with Independent Living as the philosophical basis for these services. And in doing so, we hoped to improve health while reducing costs with better health outcomes and fewer ER visits and inpatient admissions.

So what do I mean when I talk about the Independent Living philosophy? People often think that this means living outside of an institutional setting. And for many people that could be part of it but it's actually a lot deeper than that. Independent Living is really about living by your own rules and making your own choices about all aspects of your life, where you go, where you live, how you support yourself, and in this case how you receive healthcare. Independent Living also doesn't mean doing everything for yourself necessarily. It means having control over your life and the manner in which you might receive health if you do receive help. So key to this is the recognition that people with disabilities are the best experts on their lives and they inherently have the right to make all decisions regarding any aspect of their lives no matter what their disability.

Another piece of this is the social model of disability. And that's the idea that the experience of disability is largely a result of how society is organized rather than characteristics of an individual person. And we have a cartoon to illustrate this point. So there's a picture in the cartoon of a woman using a wheelchair. She's positioned at the foot of a set of stairs. She's frowning. To me she looks frustrated. There's a sign pointing up the stairs. It says, “Way in. Everyone welcome.” There's a text balloon on the left labeled the Medical Model of Disability. In this balloon it says, “Her impairment is the problem. They should cure her or give her prosthetics.” And then on the other side, a text balloon labeled the Social Model of Disability says, “The stairs are the problem. They should build a ramp.” And that's the critical idea, that ability or disability is largely a function of the environment.

So that's the philosophical basis. Now, what did we actually do? We embedded teams of peer coaches and nurse care managers at three health centers in Berkeley. Typically a peer coach and nurse were partnered. At one site we had two part-time nurses with one peer coach. Consumers could choose any combination from the nurse care management, one-on-one peer coaching and living well workshops which were health and wellness workshops that I think Thomas will describe more later. Both roles helped consumers recognize and reinforce their strength, learn new skills and make independent decisions.

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You might ask why embed peer coaches in a health center and not just really make a concerted effort to just refer patients to ILC. That might be a little simpler. And there are a few reasons for that. Our two organizations really wanted to work together in an intensely meaningful way to test our assumptions and really learn from each other. LifeLong is part of that, wanted to expose health center staff to Independent Living principles and practices which wouldn't happen as much if we were just referring to an offsite program.

Also, we theorized consumers would be more likely to prioritize peer coaching if they were easy to access and it were suggested by their medical provider. Transportation was really challenging for many of our consumers, so co-location allowed consumers to see their primary care provider and their care manager and their peer coach all with the single round trip and that was really important. So it was a combination of philosophy and practicality that led us to our model of embedding peer coaches into the health center.

So generally, the nurses addressed medical concerns and the peer coaches worked on other concerns. But there was a lot of overlap in the roles. So we're going to provide some examples later through case studies to illustrate the roles a little bit more.

Over the two and a half years of this project, 227 people enrolled. And of these, 106 received peer coaching, 200 received nursing, and 79 received both. And the staff included three FTE, full-time equivalence, of care managers, four people, and 1.5 FTE of peer coaches.

The consumers that we worked with were all members of the Alameda Alliance for Health. They were generally folks with an aging or disability-related Medicaid aid code. Alameda Alliance gave us a list of eligible consumers. We had to stick with that list because we wanted to track inpatient utilization. This was part of our MOU, that they would provide this data for us.

The list of eligible people had a few thousand names on it. So way more than we could possibly work with. So we had to narrow it down. We did that a couple of ways. We identified the people with a risk score of 1.2 or greater using the Johns Hopkins ACG system. And actually our average was closer to eight or nine but the cutoff, the minimum, was 1.2.

And ACG, Adjusted Clinical Groups, is a pretty well-established predictive model that many health systems use to predict future hospitalizations and costs. It's an algorithm that uses demographic information, medical diagnosis and prescription drugs and use of different resources and some other variables that come up with the score.

So we had the risk score. Then we also asked health center staff who they thought would benefit from peer coaching or nurse care management. We basically said: Who are you most concerned about? And staff and providers had names for us right off the bat. They knew who they were concerned about. So then the nurses reached out to the patients and asked them if they were interested in participating.

On the next slide here I have some demographics. The age range was 22 to 91 years with 64% under age 65 and 36% aged 65 or over. For race, we had the largest group was African Americans at 47%, white at 28%, Asian or Pacific Islander 3%, other races was 15%, and unknown was 7%. Unknown basically means that the person declined to state a specific race. 12% identified as Latino or Latina, 63% were female, 37% were male, and 80% of enrolled consumers had a behavioral health diagnosis; most notably, anxiety at 50%, depression at 66%, and/or substance abuse at 29%. 76% had hypertension, 59% had diabetes. People had lots of other medical issues as well. So this is just a snapshot. 6% identified as homeless. And many, many more had unstable housing situations.

So you're probably wondering how we paid for all of this. So we got a healthcare Innovation Award. It was a three-year cooperative agreement with CMS. And that paid for the nurse care managers, some of the peer coaching expenses, staff training, consumer transportation, supplies, administrative coordination, and then some of the data collection and analysis. In addition to that, Alameda Alliance for Health agreed to pay for peer coaching visits and living well workshops. Since that's a pretty innovative part of our collaboration, I'll say more about how that worked.

After consumers said they were interested, then the peer coaches worked with them to create Independent Living Plans, or ILPs, that set out the consumer's personal goals and steps towards

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achieving those goals. The Alliance paid for up to five hours for this process at a negotiated rate, in the contract they had with CIL. Then CIL submitted this ILP to the Alliance. And the Alliance reviewed it and then preauthorized a certain number of peer coaching services or living well workshops, like X hours over Y months they preapproved. After the services were provided, CIL would submit a claim for payment to the Alliance, similar to billing for a medical visit.

So now I'm going to turn the mic to Thomas Gregory from Center for Independent Living who is going to tell you more about peer coaching. >> Thomas Gregory: Thank you. This is Thomas Gregory with the Center for Independent Living. We're the Independent Living Center, the Title VII disability agency whose federal catchment includes the cities of -- all of Berkeley and Oakland and various other cities in northern Alameda County. We serve approximately 1,000 consumers each year and we answer about 4,000 to 5,000 requests for information and referral. We also are one of the core partners in Alameda County's Aging and Disability Resource Connection and we're one of, I believe -- I think we're the eighth county in California to establish an ADRC.

I just wanted to introduce CIL a little bit before I started. Now I'm going to talk a little bit more about the peer coaches.

The peer coaches were CIL employees. They were hired and trained by CIL. And as Kathryn mentioned, they worked on site at three of LifeLong's health centers in Berkeley, California. As Kathryn referred to, it was more than simply co-locating the peer coaches with the clinicians. The peer coaches were part of a multidisciplinary team. There was a lot of mingling. Peer coaches would attend -- not always but would frequently attend team meetings with the nurse, with the clinic staff. And they really did work in tandem and hand-in -hand much of the time.

Peer coaches -- I divide the peer coaches' work into two categories. One was providing one-on-one support with eligible consumers to identify the consumers' goals and develop and implement specific plans to achieve those goals. A lot of times implementing a plan involved the peer coach providing information and referral about community resources along the way and also providing skills instruction as needed to pursue those goals. So the one-on-one work was one big component of the peer coaches' duties. Peer coaches would also facilitate a series of workshops called Living Well with a disability. Typically a series consisted of eight to 12 workshops of about an hour and a half to two hours each session. Usually the sessions were weekly. We did experiment with some semiweekly but we kind of settled on weekly being the rhythm that most suited participants.

The health and Wellness workshops, the Living Well workshops, were based on a curriculum developed by the University of Montana's Rural Institute. Our workshop facilitators were certified by the University of Montana as qualified to implement this curriculum. The curriculum focused on a different sub topic each week. Health and wellness was the broad topic. One week might focus on nutrition. Another week might focus on socializing and recreation. And another week might focus on physical fitness and remaining active. Participants would go through the subject matter in a group setting, not just with the peer coach who was facilitating the group but with other consumers as well. So it was a room full of peers. And if they wanted to reinforce the learning one-on-one, they had access to a coach to follow up on the subject matter in a one-on-one fashion.

We offered about between four and six series of workshops per year. We would alternate between English language series of workshops and Spanish language series of workshops. As far as the one-on-one work goes, a full-time peer coach typically worked with about 12 active consumers at a time. That would fluctuate but that was sort of a rough average.

I wanted to touch on what we mean by a peer. A peer coach was a peer in the sort of standard ILC sense of the word which basically means a person with a disability offering counseling services. So cross-disability peer support means a staff person with any disability working with a consumer with any disability. So that was the primary meaning of what we meant by a peer. But in this context peer also meant that the person providing the peer coaching was not a medical professional. They were a peer in the sense that they weren't a doctor or a nurse. They might have some knowledge

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about health and wellness but they were coming at the subject not from their perspective of a medical provider.

Sometimes the peer coaches would be peers in other senses of the word but that was not always the case. So, for example, one of the three clinics that we were embedded in was called the Over 60 Clinic. As the name implies, the patients at that clinic were older adults. And the peer coaches -- there was a little staff turnover which I'll get to later but it wasn't necessarily the case that the peer coach embedded at the over 60 clinic was a senior.

The main qualifications to be a peer coach was a solid understanding of Independent Living philosophy and principles and a rich knowledge of local resources, typically low cost and no cost resources but resources relevant to our consumers was essential, and knowledge of those resources was essential.

Peer coaches also needed to be able to provide people with encouragement and support and skills training when necessary. And it's very important to have a positive can-do attitude. A lot of times that can-do attitude is about what the consumer can do as well as what the peer coach can do for the consumer.

The consumers who worked with our peer coaches had a wide range of goals. They broke down as follows. About 88% of our consumers, peer coaching consumers, had goals pertaining to accessing community resources. About 56% of the consumers had goals pertaining to obtaining or maintaining housing. About 31% of the consumers had goals that pertained to better accessing their healthcare and making the most of their medical treatments.

And I found this interesting. I wasn't part of this project at its inception but my understanding is that originally the idea or the assumption was that many or most of the goals pursued would pertain to healthcare in some fairly direct sense. For example, a patient -- all of our consumers were patients, too, because they were patients at the clinic. They might have trouble keeping up with the medication regimen that their medical providers were recommending and maybe their goal would be to better manage their medication routine.

I think it was interesting to me that only 31% of the goals had this direct correlation with medical care. Fortunately, LifeLong, much like CIL, had a very broad or expansive idea of what wellness meant. So the goals that weren't obviously and directly pertaining to medicine often did have a big impact on someone's health and wellness. So if you look at health from a very expansive or holistic point of view, then one could argue that pretty much any Independent Living goal is going to promote health and wellness.

About 26% of the consumers had goals relating to building their own motivation to embark on some enterprise. About 23% of the consumers had goals pertaining to money management or financial education. And about 20% of the consumers had goals pertaining to self-advocacy.

We have had a chance to get consumer feedback. Consumers on their own accord often reached out to either LifeLong or CIL to provide feedback. Also, back in May of 2014, an agency called NORC, National Opinion Research Center, did a multi-day site visit at the clinics. NORC was contracted by CMS to analyze data for their project. And at the site visit NORC interviewed consumers and held focus groups and also interviewed staff, both the care managers and the peer coaches. And they did get a lot of feedback from consumers.

And the feedback was largely positive. It was almost overwhelmingly positive. Consumers told us that working with a peer coach helped them build confidence in their ability to achieve their goals. It helped them really narrow down what they were trying to accomplish, sometimes setting a concrete goal is the first goal. Consumers told us that peer coaches helped them to access information about community resources and find resources like food and housing. And also a lot of times the consumers needed help completing paperwork or understanding what the paperwork was asking of them and peer coaches often helped them understand the paperwork they needed to submit, be it for medical purposes, housing, a wide variety of purposes.

And now I'm going to give an example of a specific consumer who received peer coaching. We'll call her Miss L. She was a 70-year-old woman with a cognitive impairment that was the result of

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atraumatic brain injury. She also had various other health conditions, including hypertension, depression, anxiety, and she had also experienced a stroke and had cancer. And at the time that she signed up for peer coaching, she was homeless. So she had a lot of challenges she was dealing with, not just health-related challenges.

This consumer, she participated in the Living Well workshop series. She reports that this series of workshops helped her to transition to permanent housing. And she also availed herself of the one-on-one peer coaching and she reports that that helped her learn to advocate better for her needs. And after receiving services, she felt more secure about her ability to accomplish her goals and she felt less isolated and ashamed of the problems she was experiencing. And she feels better able to manage her own chronic medical conditions.

Another participant in the program, we'll call her Ms. W, was a 63-year-old woman. She was living with various medical conditions, including asthma, hypertension, pre-diabetes and sleep apnea. She also experienced depression and agoraphobia, which I believe is the reluctance to go out into public in social situations with other people. And during a three-month period she worked with one of the care managers, the registered nurses, that were -- that staffed a project. And she also worked simultaneously with a peer coach on her more non-medical goals. During this time, this person's blood pressure and her depression scores improved. She became much more able to self-manage her medical conditions according to her self-reporting.

This same individual, Ms. W, was definitely a success. She considered herself a success. We also consider her a success because after receiving services she felt more empowered and within several months she overcame some of her anxiety. She applied for and received in-home support services, county-subsidized personal attendant services, and she also worked with a public authority to hire a caregiver. She also successfully advocated for herself for some of her -- to get her -- ensure -- to get her insurer to meet some of her needs. And she also decided to attend one of the Living Well series of workshops and discuss health and wellness goals with a group of peers.

This same person also cleaned up some clutter at her house. Cleaning up clutter can be a really big deal. If you're on a housing subsidy, you have to pass a housing inspection each year. And clutter, if it's bad enough and is blocking entry and such, you could actually lose your housing subsidy due to clutter. So clutter is -- for many folks on housing subsidies, clutter is a very important issue that if not addressed, could jeopardize housing.

This person also researched and selected a phone vendor. I believe this means that she applied for a free -- a cell phone and minutes through the Affordable Care Act. She also learned to better communicate with the nurse at the clinic. So instead of just not knowing what to do about health problems and just waiting until it got so bad that she had to go to an emergency room, now she is comfortable calling her nurse before her medical issues become so severe that she feels the need to go to the emergency room. And she also feels more in control of her own life and making her own decisions.

The next slide is just some pictures of some peer coaches in action on the job. The upper left picture is a photo of a peer coach working with a consumer at a LifeLong clinic. And then the picture on the bottom right is a picture of a peer coach working with a consumer here at CIL's offices.

Consumers -- the peer coaches were embedded at the clinics but consumers had the option of choosing to meet the peer coach at the clinic or at CIL's offices if they preferred to meet at CIL's offices. And consumers often did choose that option. So sometimes peer coaches worked out of CIL's site.

The picture of the peer coach on the upper left, the woman wearing the blue top, that peer coach was bilingual and offered services, one-on-one services and group facilitation, in both English and Spanish. I can't tell from the photo which language she was using but she had the ability to communicate with folks who preferred to speak in English and also with folks who preferred Spanish. And she was very deliberately embedded in the West Berkeley clinic, which was the LifeLong clinic among the three clinics in this project. That was the clinic that had the highest number of Spanish-speaking patients. That's one of the reasons that peer coach was assigned to that clinic.

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And now I am going to pass the mic back to Kathryn Stambaugh of LifeLong. I'm doing that right now. >> Kathryn Stambaugh: Great. Thanks, Thomas.

I'm going to talk a little bit now about the nurse care managers, more about what they did. The nurse has quite varied responsibilities. We weren't prescriptive about their role because we wanted them to be flexible and patients to tell us what they need and have flexibility to do what they said they needed.

So the nurses provided care coordination, systems navigation a lot of advocacy. They helped with medication. They provided a lot of advice about health concerns, help with chronic disease management, health education, and assistance with a lot of social challenges such as housing and transportation. You know, just being someone to call was really important.

Patients were all given the nurse's cell numbers and could reach them directly during work hours. It wasn't 24/7. But while the nurse was on her shift during work hours, patients could just call and reach him or her directly.

The nurses visited with consumers in the health center and at home and at other locations sometimes. They often accompanied patients to specialty appointments as well. They served as a main referral source for the peer coach. And they worked with about three consumers at any given time.

The nurses reported to us that they felt like advocacy work and helping patients navigate the system were really among their most important tasks. In our project, consumers faced barriers at every turn as they attempted to deal with multiple organizations. They had the clinic, the pharmacy, the insurance carrier, home health agency, medical equipment supplier.

It is so complicated to be a patient. And referrals or orders would be rejected over acquire additional documentation. Faxes and phone messages got lost. So many things went wrong. So following a process, for example, like getting an oxygen tank delivered to your house, following a process like that from start to finish required a really strong attention to detail and sometimes kind of an insider knowledge of the healthcare system. That's where the nurses were really helpful because of their clinical expertise, their insider knowledge, and their access to various components of the healthcare system.

Also super important was the amount of time that nurses could spend with individual patients. Medical visits are 15 minutes, maybe more but not a lot of time to cover the multiple medical issues plus all the social factors. I think we were really recognizing or just as important if not more so than all the medical stuff.

I'd like to just share a quote from one of the doctors at one of the clinics. He gave us some great feedback. So this is a quote from him. He said, "If any of my patients needed closer management than I was able to offer, such as homelessness or complex medical conditions, different social problems, disabilities, the program was invaluable. We were able to do outreach and some home visits with these patients. Some who would have fallen through the cracks got support and care. I can't emphasize enough how important the care managers were." So obviously, we were really pleased to get that level of support from this physician in our practice.

I'm also going to share a couple of examples. First, someone we'll call Mr. P. He's a 50-year-old man with major complications from diabetes who was referred to a nurse care manager following a seven-day hospital stay. He had lost a great deal of his eyesight. He could no longer function as he had before. Many of the strategies he developed for coping with low vision in the past were really just no longer viable for him.

So he worked with a nurse care manager for seven months, three or four times per month for the first three months and then monthly after that. During this time the nurse care manager arranged transportation for his medical and specialty appointments, tracked down lab results, and multiple missing prescriptions, including a really critical insulin pen, and obtained a strangely elusive copy of county medical records certifying his legal blindness. That was something necessary for him to apply

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for some services. And these are all things that shouldn't be that hard to get but somehow in our disjointed system became very complicated and time-consuming.

So Mr. P described the nurse care manager as follows. This is a quote of what he said. "He was there through the worst of not being able to cope. He listened to my priorities. He has been up to bat for me on countless occasions. Less so now, I've become more functional, so he's not involved as much precisely because he's already helped me. I have managed to turn my health around to a large extent."

So this is a great success story for us because Mr. P requested a lot of help up front with these logistics like transportation and tracking down documents and prescriptions. And he got a lot of health education related to his diabetes, manage his disease given his worsening eyesight. And then he started to do more for himself. As his health improved, he began working with a peer coach on other life goals, including employment.

I think that's a good point to make right there, that Mr. P wasn't really ready to work with a peer coach at first because he was overwhelmed with his health challenges. And then once those challenges started to resolve, then he had the energy and the space to work on some other things.

Here is another example. This is an example of the importance of social determinants of health. Consumers often face social situations just as complex if not more so than their medical challenges. So Mr. G, we'll call him Mr. G, is a 57-year-old man with multiple medical and behavioral health issues. He first began to work with a nurse care manager on a variety of these medical concerns. And then a housing crisis absolutely took priority. He was facing eviction, and he worked with his care manager to fill out 16 housing applications and to research emergency shelters. So with the help of the nurse and also his sister, Mr. G found housing in Berkeley the day before he would have become homeless.

This was a person with major, major health issues, including depression, schizophrenia, diabetes, glaucoma, hypertention, COPD, peripheral vascular disease, even more. It's a long list. His priority was housing not those health issues.

I think this is also a good example of a case where the nurse and the peer coach roles might overlap. You might say, well, why didn't the peer coach step in to help with housing since that's not a medical issue? There's definitely a gray area here. In this case, Mr. G had already started working with the nurse. So there was a comfort level there with that relationship. Things were also falling apart for him pretty fast. So it just made some sense to stick with one person rather than bring in someone new. And he had so many medical issues that having close contact with a nurse was pretty helpful.

Also, the peer coaches, by definition, don't really do things for a consumer. Thomas talked a bit about this. They coach consumers to do more for themselves. At this particular time Mr. G wanted someone to do more for him than a peer coach maybe normally would. Again, there's a gray area. Peer coaches do sometimes do things for consumers kind as a temporary support to get them to a higher level of self-sufficiency but that's not typically the norm with peer coaching.

So a little more about Mr. G. Housing crisis averted, Mr. G was able to continue working on medical issues with his nurse. And he also began pursuing other goals such as learning to read and navigate public transportation with a peer coach. Mr. G reports that he now feels better equipped to deal with his challenges because -- this is a quote from him. "I'm surrounded by people who want to help me and that's good. It gave me a whole new outlook on life. I'm thinking a whole lot better and clearer."

He also reported some medical benefits. He says he now gets his medications on time, that he makes it to most medical appointments, which is a big improvement, and he's reduced his ER use from two to three visits per year to no visits so far this year.

Here we have a photo of one of our nurses with a consumer. It's in a medical exam room. The photo shows an older white man who is using a motorized wheelchair sitting next to a white woman with long brown hair who is seated on a stool taking the man's blood pressure.

I should note that none of the photos correspond at all with the stories we've shared. These are different people than the case studies. These are just the folks who wanted their pictures taken.

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So moving on to outcomes. We've had some good successes. I'm going to describe those. First, I want to mention or actually I have to mention that this outcomes data was compiled by our project. As Thomas already mentioned, CMS has hired an independent evaluator, NORC, to conduct its own analysis. And that's not finished yet. So there is fine print at the bottom of these slides. And what it says is, quote, the research presented here was conducted by the awardee. Findings might or might not be consistent with or confirmed by the independent evaluation contractor.

So that said, I think we've got some promising findings to report. More than half of the consumers who received peer coaching achieved at least one goal from their ILP. That's a good success. 70% of the consumers that we interviewed reported either an emotional improvement, like an improvement in optimism, feeling empowerment and well-being, or a health improvement.And 30% reported both.

Now in terms of outcomes data, we looked at depression scores, patient activation scores, and some responses to health literacy questions from the CGCAP group of surveys. I'm going to explain each one of these.

First the depression scores. We saw a 28% improvement in PHQ9 scores comparing the average scores of enrollment and then after participation for people with a baseline score of nine or more. So the baseline score of nine or more is indicative of at least moderate depression, possibly worse. And on average, scores were 28% better after receiving services. That doesn't mean that everyone did 28% better. 75% of the consumers PHQ9 scores went down, which means they got better. 22% went up, which means they got worse. And then 3% stayed the same. So we were really pleased with this result. You might recall from the earlier slide that 66% of enrolled consumers had a diagnosis of depression.

So next we looked at patient activation using the PAM or Patient Activation Measure. That's a tool which assesses a person's readiness to engage in their own healthcare. And we used the 13-question version in English and in Spanish. It asked people to agree or disagree within statements like, for example: I know how to prevent problems with my health; or I'm confident that I can tell a doctor concerns I have; or taking an active role in my own healthcare is the most important thing that affects my health. So it's 13 questions, sort of along those lines. It's a robust tool in validated in a lot of peer-reviewed studies. We use it especially because it's thought to be predictive of future utilization patterns and costs. The people who license it claim that a one-point increase in PAM correlates to a 2% decrease in hospitalizations and a 2% increase in medication adherence. And they have lots of data to back this stuff up.

So we saw an improvement in PAM score of 6.3 points or 12% among consumers who had five or more visits and 8.44 points or 17% among consumers with 10 or more visits. So we thought that was exciting. It reinforced what consumers told us about the value of the program.

So finally, we used five CGCAP health literacy questions to help evaluate consumer satisfaction with communications with health center staff. CGCAPs stand for clinician and group consumer assessment of healthcare providers and system. And it's a standardized tool to measure patients perception of care provided by physicians in office settings. You can find the survey tools on the AHRQ website, Agency for Healthcare Research and Quality. And all of these tools, the CGCAP stuff is all in the public domain, unlike PAM. You have to pay for PAM.

Consumers were asked to respond to questions using a six-point scale: it almost never, sometimes, usually, almost always, and always with almost always and always kind of being what we were going for. 91% of consumers showed an increase in their total score or they maintained a positive response of almost always or always.

So to begin to make some estimates about utilization patterns and cost savings, we compared emergency room visits and inpatient admissions among patients before and after participation in LCCI using data that we got from the Alameda Alliance for Health. Overall, patients showed a decline in all the variable that we looked at. So we looked at ER visits, inpatient admissions, inpatient length of stay, and skilled nursing bed days. We had a statistically significant reduction in the number of ER visits after enrolling in LCCI compared to the same number of months prior to enrollment. And we're going to

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be redoing this analysis with a more complete dataset. So we're hoping to show statistical significance with all the variables. We shall see.

So, on the slide I included the actual numbers. Consumers showed a reduction in ED visits from 368 visits to 286, a reduction in inpatient days from 117 to 75, and skilled nursing days from 208 to 79.

To get a sense of potential cost savings, we assigned a value to each avoided visit using some publicly available average cost data for these services. So we used $1,233 for the average ED visit, $3,002 for an average inpatient day in California. That's a figure from 2012. And $260 for the median cost of a shared room in a skilled nursing facility in our geographic region, East Bay of the San Francisco Bay area. After kind of multiplying and adding it up, we ended up with $330,000 as an estimate of our total savings. This number is rough. Our numbers were small. We used average costs when really there's actually a lot of variation in the costs of an ER visit, for example.

I don't want to overstate it but at the same time we are so encouraged by these preliminary results and we are really excited and looking forward to our own further analysis and also the final evaluation by NORC.

So, now I am going to turn the mic back over to Thomas to talk about some of our challenges and lessons learned. >> Thomas Gregory: Thanks, Kathryn.

The format here is we were going to get to questions at the end but one of the attendees has asked a very pertinent question to my segment right now so I'm just going to jump in and try to answer that.

The participant typed in the chat box, this person asks: What differences, if any, are there between the kinds of services provided by the peer coaches in this LifeLong care -- LifeLong Complex Care Initiative and those normally provided by IL generalists, often called peer counselors, in an Independent Living Center? Are there differences in the required skills?

That's a great question that represents to what I'm going to talk about. I'm going to try to give you a straight answer to that question but unfortunately I'm going to give you two alternative straight answers.

My first straight answer is there is no difference. A peer coach is exactly the same as a peer counselor, often called an independent living generalist. They have the same responsibilities which as I mentioned earlier was basically help consumers identify goals and create specific written plans to reach those goals and then implement the plans providing INR along the way as needed and providing skills instruction along the way as needed. So on the one hand, they are the exact same job, a peer coach is a sin minimum for a peer counselor or an IL generalist.

On the other hand, my alternate answer, there's a big difference because of the nature and structure of this partnership. One difference is unlike an IL generalist or a peer counselor that works at an Independent Living Center, every single consumer that a peer coach saw had a significant health issue that they were seeing doctors and nurses about. That is not the case with the general population. So I believe that that affects the peer coach's ability to deliver services. I'm not exactly sure how it affects it but I believe when a consumer is facing often a wide host of acute medical issues, that is going to impact their ability to pursue any goal, whether the goal pertains to those medical issues or not. So that's one big difference.

Another big difference was the fact that the peer coach, unlike a peer counselor that works at an ILC, the peer coach is part of a multidisciplinary team. A peer counselor working an ILC, first of all, is on site and has access to colleagues at the ILC and, second, is not working in tandem with medical professionals that are on site. So on the one hand it's the same job but on the other hand it's delivered in a different context to a different target population. And so in that sense it's a very different job.

So I hope I answered that question.And so, that segues into some of the challenges that our peer coaches faced. To start off

with, there's the fundamental challenge that the peer coach had in common with the peer counselor

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that is stationed in an Independent Living Center and that's helping the consumer achieve their goals. That's the work. That's the job. That's challenging in and of itself.

In addition to that, there were challenges that resulted from the structure of this collaboration. And these challenges included practical and logistical difficulties as well as philosophical problems.I'll start with some of the practical or logistical challenges.

As I mentioned, peer coaches, although they occasionally worked out of CIL sites, they primarily worked offsite. They worked at the clinic. So that meant that there was no -- their supervisor was not on site. So they couldn't easily, you know, walk six feet away and ask their supervisor a question. Of course, their supervisor could be reached by phone or e-mail but it's not the same as having someone on site.

And also, they didn't have any Independent Living Center colleagues on site. At most CILs, I assume, and certainly at CIL staff, worked in a collegial manner. And you're often asking your staff for their input. You might be helping a consumer apply for paratransit or taxi strips but they have a question about IHSSS -- I'm sorry, IHSS. You might not know the answer so you can quickly and easily just ask a colleague. The peer coaches that were embedded at the clinics didn't have the luxury of having 25 other ILC staff under the same ceiling. So that made their life difficult. And it required the peer coaches to have a really strong understanding of Independent Living philosophy and their role as a peer coach. And they had to be particularly confident and assertive in order to be able to explain their role to understand their role themselves to explain it to others, and to reject tasks that they felt were not within their jobs and/or weren't consistent with IL philosophy.

A clinic can be a very hectic and fast-paced environment. There's a lot of need for a lot of people to pitch in and do a lot of stuff. And our peer coaches were flexible and they wanted to help out but they needed to be able to identify when someone was asking them to do something that just wasn't within their job description and to decline to do that. When you're the only CIL staff person at a clinic, it can be hard to draw boundaries or make decisions all by yourself when you're sort of off on an island with a bunch of folks who are I'm sure, great to work with but they're not your co-workers strictly.

So we've discovered that a peer coach was successful when they were a veteran. They had a lot of experience delivering IL services. They had a very rich knowledge of available community resources. A peer coach can research the answer to a question but it really helps to have a base, a very solid base, of what's available in your community that is relevant to the consumers' needs. So that was one challenge, the fact that the peer coaches were not working at the Independent Living Center.

Another logistic challenge -- there was lots of travel time. So one of the peer coaches split her time between two different clinics. So in her case, she had to travel back and forth between one clinic to another. And both peer coaches spent time traveling back and forth between their respective clinic or clinics and CIL where we would have weekly meetings.

And also, there was travel time for the care managers, not just for the peer coaches but for the administrative leads on this project, Kathryn and myself, as well as for the care managers, in other words, the registered nurses, as well as the peer coaches. There was travel between all the various sites, the clinics, CIL, and LifeLong's administrative office. At some point or another, everybody had to travel at different places.

There was also double training required, particularly on each company's policies and procedures. And I'm particularly thinking about their data systems. CIL has our electronic consumer database. We have our protocols for timesheets and things. LifeLong has its own electronic databases and their own policies and procedures. So the peer coaches had to be trained in LifeLong's processes as well as they needed to master CIL's processes. And oftentimes they didn't have a supervisor, a CIL supervisor that could support them in LifeLong systems.

For example, the peer coaches had to become conversant in NextGen and another system, i2i, and they received training from LifeLong staff so they learned how to do it. But if they had had a problem, they wouldn't be able to turn to me or anyone else at CIL to help them because nobody else at CIL had a mastery of those systems. So, of course, they could ask for help from LifeLong staff but they didn't have the luxury of asking CIL staff for help because they were sort of -- they were the only

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CIL staff who knew anything about those systems. So that was another logistics challenge that was simply more to learn as far as administration and just protocol.

Another challenge was that the peer coaches -- I forgot to skip a slide. I'm skipping two. Peer coaches had limited control over their work flow. If a peer coach -- sorry. If a peer counselor or an IL generalist doesn't have enough consumers on their caseload, they can solve that problem by doing outreach, theoretically, at least, finding and recruiting more consumers by doing outreach in a community.

The nature of this project was that not everyone with a disability is eligible for the peer coach service. There was a list of people that were potential eligibles. So that meant that peer coaches couldn't simply do outreach whenever they wanted to because if they reached out to community members, the vast majority of those people would never be eligible for the service so there's no point in reaching out to them. So they largely relied on the care managers to be what I would call their marketing department to make referrals to the peer coach.

And, of course, care managers didn't have control over the list of eligibles either. So this meant that a peer coach, in this project, had less control over their work flow than a peer counselor would who was stationed at an Independent Living Center.

Also, it doesn't sound like a huge deal but it is important. Confidentiality and HIPAA are very important. Within CIL, when a CIL staffer is e-mailing any other staffer, our e-mail system is encrypted. And anything we send internally is protected from hackers. That isn't the case when a peer coach was communicating from her LifeLong e-mail account to staff at CIL. And as I'll get to later, there was a lot of communication about authorizations and billing and you had to talk about who someone was and you couldn't name them in e-mails if it wasn't purely internal. So there was some minor challenges in making sure we were not sending confidential information out into the internet in a way that was not encrypted. So that sort of added a layer of complexity to the work.

In addition to those practical or logistical challenges, there were philosophical challenges. We had always expected that to be an issue. As Kathryn mentioned towards the beginning of the presentation, one of the rationales for CMS funding this innovation project is to introduce Independent Living philosophy into the clinical setting. So there is a built-in tension to some extent because the medical model of delivering services and the IL approach to delivering services. So that, as expected, did come up.

So peer coaches, their priority is to do with not for. We use that phrase all the time here at CIL. It's basically another way of that old cliche of if you give someone a fish, they eat for a day but if you teach them how to fish, they eat for the lifetime. We really are always encouraging consumers to do as much as they can for themselves. We would much rather be with them as they do it themselves than to do it for them.

Oftentimes, you know, that's not feasible. Teaching can be a very organic process. Sometimes you start by doing it for them as you watch them and then do it together, and then they do it while you just sit back and watch them. But whenever possible, we're asking the consumer to do as much as they can for themselves. We put a huge emphasis on the consumer being one to direct their services and take the lead in those services and the consumer being the ultimate decision maker, being the person in the driver's seat, so to speak.

Care managers, who were registered nurses and other clinicians and other medical providers, have a different priority and understandably so. Medical professionals, their chief priority is the physical health and well-being of the consumer or the patient. And we understand that. And oftentimes those two approaches can cause some tension. So as a result, and as expected, there were periodically differences of opinion in regarding the manner in which services should be delivered. This was particularly so in urgent cases, in medically urgent cases, and it was also particularly so at the LifeLong's geriatric practice, the Over 60 Clinic. And that was because a significant number of those consumers, patients, experienced some degree of cognitive limitations, such as dementia, which made doing for someone more acceptable because it was more unrealistic to expect that person to do a particular task for themselves. So a lot of times the care manager or other clinicians in the clinic,

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weren't so -- weren't as comfortable as the peer coach was in letting the consumer take the driver's seat.

I'll give an example of such a situation. A consumer wasn't happy with the positioning of her legs in her wheelchair so she planned to order some extensions to change the angle a bit. The peer coach was working with the consumer to do that for herself and navigate the red tape of asking the insurer to clear the way to get the new durable medical equipment that was required. The consumer wasn't moving as fast as others might have expected in making this happen. And the peer coach in this case was content to go at the consumer's pace. And if the consumer was taking the lead at a leisurely pace, then that was the pace we would progress at.

The medical providers had a different view. From their point of view, this was more urgent than a social need. The legs were at a bad angle and too much blood was rushing down and could potentially cause swelling that could be dangerous. And waiting until the consumer got around to making these new wheelchair leg extensions happen wasn't acceptable from the medical model point of view. The clinician needed to step in and make this happen quicker than the consumer was making it happen.

I think what's very interesting is that in addition to the clinicians getting a better understanding of the Independent Living approach to achieving goals, CIL staff, the peer coaches, and the rest of us here, we got a taste of what the medical provider was trying to accomplish. And we came to understand why sometimes a medical provider might not have consumer self-direction as the top priority. We came to understand why medical needs could, in a nurse's mind or a doctor's mind, trump everything else. I think it was -- the learning was a two-way street.

Another example along those lines was the consumer was going to start using oxygen. And the consumer was worried about the storage of the oxygen in her home and wanted to build a shed outside of the home but the shed was taking a while to construct. The peer coach was working with the consumer to get a contractor to make that shed happen. But it was moving a little bit too slowly. Understandably, the clinicians point of view was that the consumer needs the oxygen tanks. And if they have to be delivered before the shed is ready, then that's the way it has to be.

So in situations like this, we found that sometimes medical priorities and the principles of consumer self-direction didn't always -- weren't always completely harmonious and something had to give.

Another challenge that we ran into was the idea of the peerness of the peer coach. On the one hand, we wanted the peer coaches to be integrated into a multidisciplinary team at the clinic so that the peer coach and the care manager who was a nurse could work very much in tandem but we ran into the problem that the more they became integrated, the less of a peer they seemed. And one clear example is the more the peer coach was privy to the consumers' medical information and records, the more the peer coach seemed less and less like a non-medical peer and more and more like an adjunct clinician. They just sort of became like sort of a -- not a full nurse but sort of a -- like a nurse's -- a nurse -- the very fact that they had information about the consumer's medical information kind of changed the flavor of their role.

And that sort of goes back to how I started this segment. Being a peer coach, even though your responsibility on paper might be identical to an IL generalist, it's very different when you have gone to the consumer's records, you're seeing what medical conditions they have; where often ILC staff are not privy to that information.

Another phenomenon was that when peer coaches and care managers were both working very closely with the same consumer, the result could be a scenario where quote/unquote too many chefs are spoiling the broth. The consumer and the peer coach could be working on an objective while the consumer and the care manager were simultaneously pursuing the identical objective and oftentimes the consumer would be duplicating efforts that they were making with the peer coach by working with the care manager and vice versa. And sometimes more than duplicating efforts but sometimes the two teams could be working at cross purposes or performing tasks, at least from the ILC's perspective that the consumer should have and should have -- could have and should have been

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performing on her own and not having the care manager do it for her. So that was another philosophical -- I guess there's a practical component to that too, challenge we ran into.

Another challenge was related to this being partially a fee-for-service program. As Kathryn mentioned, some of the funding was grant funding from CMS but a significant portion of the peer coaches services were paid for on a fee-for-service based by the Alameda Alliance for Health, a Managed Care organization serving Alameda County. And because those services were delivered on a fee-for-service basis we had to seek authorizations and we had to -- once the authorizations had been issued and the services delivered, we had to bill. That creates a layer of administration above and beyond the work involved when an IL generalist is delivering services at an Independent Living Center using funds that are coming from 704 funds or state 204 funds. There isn't as much administration to do because there's no billing to do. So Alameda Alliance would only bill -- I'm sorry, would only authorize for a maximum of three months at a time. So we would have to present them with the independent living plan that we developed with the consumer and get Alameda Alliance to approve the plan.

They were very easy to work with. I don't know how closely they scrutinized the plan but it was very rare that they would object to an element of the plan. So they were very generous in approving what we submitted. However, a plan might be a long-term plan. Some of the consumers would only see a peer coach once a month when they would come in and see their medical practitioner. So a lot of times these plans contemplated working for six or nine months but we were only able to authorize three months at a time.

So even before we got started, it was a sure thing that we would have to get reauthorizations in order to finish working with the consumers. And then we had to keep track of when the authorizations would expire, what date they would expire. We had to keep track of how many hours had been exhausted because if you exhaust the hours even if the expiration date hasn't rolled around, you still need a new authorization. And keep track of when we needed to seek reauthorization. So that created a level of administrative complexity that is something new to an ILC who primarily or historically has been funded through grants and not fees for service.

Another issue, struggling to maintain the ratio of billable time to unbillable time. My goal that I received from my boss was to try to get 70% of the peer coaches time to be billable. And I did not meet that goal. Our full-time peer coach hovered around 50% of her time being billable. And the problem is without the Innovations Grant from CMS it would be very difficult to replicate this project. It just wouldn't be financially viable without the grant funding from CMS or someone else operating -- delivering the peer coaching service in this manner on a purely fee-for-service basis would be extremely challenging. And at this point CIL would not be able to do this in a way that did not lose money.

I am hoping that CIL or other ILCs can eventually solve this problem but we haven't yet.So our peer coach hovered around 50% billable time on a fee-for-service billable which is I think is respectable but wasn't sufficient to make this a self-sufficient program if it were purely fee-for-service program. And the part-time peer coach wasn't even able to achieve the 50% billable time. He hovered around 30% billable time. So that was another challenge involved in the financing of the project.

And moving on to lessons learned. We learned a lot of lessons. One is that as designed, the program did allow CIL staff to share an appreciation and understanding of IL philosophy with the clinical staff at the three LifeLong sites. And as I just mentioned a few minutes ago, that learning was a two-way street. CIL staff came to better understand the pressures and priorities of medical providers. We came to more appreciate how serious the medical needs of a consumer can be. We also came to learn that while collaborating between two partnering agencies, and if you count Alameda Alliance as a funding partner, then three agencies, it's a great way to leverage each other's resources and serve more people, and serve people more comprehensively.

It's a fantastic idea collaborating but there's also a lot of complications involved in collaborating with other agencies. For example, and this was a very real example. Staff turnover at the one agency has an immediate, direct, and fairly profound impact on the staff of the other agency. And

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there was turnover on both ends. I talked earlier about the need for the peer coach to be a seasoned veteran. We started out -- three years ago our first choices -- our first candidates that we filled these positions in were not seasoned veterans. That created problems. We eventually had to do some staff rotating and switch folks so that the more -- the longer term employees with a more solid foundation in IL philosophy and delivering IL services were the ones serving as peer coaches. We eventually stabilized. But when there was instability in terms of the peer coaches, it had an effect on the care managers being able to do their work and vice versa. There was some instability with the LifeLong care managers. And when that was the case, the peer coach very much felt that instability because of the peer coaches and the care managers working in tandem.

Another big lesson we learned, maybe the biggest lesson we learned, is that when you're doing a new project, an innovative project – this pairing of peer coaches with the care managers, that was the innovation that qualified this project for an Innovation Award. When you're going to do something new and something that hasn't had all the kinks worked out, you need to really devote time up front to sorting out what the different folks' roles are and how people work. I think if we had to do this all over again, not that we didn't spend a significant amount of time upfront prepping for the project before actually beginning to serve consumers, but we would have spent even more time clearly defining what people's roles are, clearly defining how referrals are going to work, and how, for example, how a care manager might help a consumer pursue a goal that wasn't particularly medical in flavor and/or how a peer coach might help a consumer pursue a goal that did have a strong medical component and how the roles would overlap with the peer coach or how they would not overlap.

Coming into something new like this you really want to spend a lot of time up front making sure the players know the other players' roles and expectations. It even goes beyond the staff that were involved in this project. Because the LCCI staff were embedded in clinics where there was lots of staff that weren't involved in the LCCI, it's also important to educate everybody who is going to have interactions with this team to have at least some level of understanding of what the team's all about. That's one lesson we learned. We realized it's very important to have a constantly open line of communication.

Before the project was over, there was a regular routine of meetings. All team meetings where administrators, nurses, and peer coaches would all meet. There were peer coach meetings where the peer coaches would meet. There were meetings where the nurses would meet with peer coaches without administrators. It's very important to stay in constant contact with the people you're coordinating with to make sure everybody is on the same page. So the importance of communication.

I think another lesson that was either learned or reinforced was that -- the importance of social determinants in health. Good health and well-being doesn't involve pills and procedures and durable medical equipment but it also involves all the other aspects of life.

The consumers in this project reinforced this lesson. They were asked to describe the most important assistance that were provided by the peer coaches and/or the registered nurse care managers. A lot of patients shared stories about housing, unemployment and other needs that didn't have a clear and obvious medical nature.

An example that I like, that was a real example from this project, is one of the consumers had her main hobby, the way she relaxed, was gardening. And she was a renter. She had a little plot of garden on site at her apartment house where she was free to garden and she had been using her landlord's hose and water to do the gardening. The landlord basically cut her off, cut off her access to the hose, which made it impossible for her to continue her gardening at her apartment house. And her goal was basically to figure out other ways that she could indulge in her passion for gardening.

And not coming from a medical background -- one of the first things that struck me was how this goal had at first glance like nothing to do with healthcare. But it really did have to do with healthcare because this was how this woman had fun, this was how she relaxed and decompressed. So without access to a means to garden, her health was going to suffer. Who knows? Maybe her blood pressure would go up. Maybe that would aggravate heart conditions. But health and wellness is

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broad and includes all the aspects of life. Whether it's attenuated or not, pretty much every avenue of life if things aren't going well, that could well have a negative impact on your health.

So continuing on with its subject of lessons learned, we learned that for a consumer to benefit from peer coaching, the consumer needs to be able to understand the consequences of the choices and they need to be ready or almost ready to make changes. As I've discussed, a peer coach is always expecting the consumer to do what is possible for herself. If a consumer can't do something, you know, a CIL staff will do it for them but we're not going to do it for them if we believe they could at least attempt to do it for themselves.

A consumer might come in not quite able to identify their goals. We're going to help them along but ultimately if they're not able to identify a goal and buy into that goal and putting in the effort, we're not able to help them because so service depends on them participating themselves. A peer coach can't really help someone who is not ready to put an effort to help themselves. And part of the peer coach's training is to identify and assess whether that consumer is ready to take responsibility for putting in the lion's share of the effort needed to achieve a goal.

We also learned that if a consumer is facing acute medical issues, then they are less likely to benefit from the peer coaching until after those acute medical issues are stabilized. Pursuing a goal is hugely important but if you are experiencing headaches or dizziness and you're falling down because of some lack of medicine, that really is a prerequisite to being in a position to put an effort to pursue a goal. You have to have your basic medical needs addressed before you're in a position to put in energy to try to change your life.

We also learned that the RN care manager was very helpful in the case of consumers whose medical needs were not being met and when the consumer required a specific nursing service, such as a health education or assessments of their symptoms or if they were needing medication reconciliation, registered nurses are experts in nursing and a peer coach isn't. So there's a lot that a peer coach just simply can't do for you. When the Independent Living philosophy rejects the medical model of disability, we're certainly not rejecting medicine. Medicine is good and RNs and doctors are hugely handy when you need an expert on medicine.

Also, the RNs had more freedom to do home visits than the peer coaches did. So when home visits were necessary for consumers who were unable to travel to clinic, then the care manager was a huge resource when home visits were necessary.

Also, when the consumer's biopsychosocial situation was very complex, it really did require a registered nurse to understand the complexity of their medical situation. >> Mary Lou Breslin: Thomas, I just wanted to remind that you we are a little bit over time. You might want to sum up. Thank you. >> Thomas Gregory: I'm going to speed through. Basically what we learned is that there is a huge value to a partnership between community health centers and local Independent Living Centers. Once the challenge of figuring out how to finance those partnerships is solved, I think there's no doubt that there is a benefit to the community by partnering.

And these wraparound services involving service providers to address complex health issues as well as psychosocial issues is very beneficial and it's important whether you're delivering medicine or social services. It's very useful to keep in mind that the consumer has to be a key decision maker in the delivery of their services, be they healthcare services or otherwise. And that the social wellness is a huge factor in someone's medical wellness as well.

That takes care of the presentation. I'm just going to slide through a photograph of some of the team. Not every team member was in this photo but that's most of the folks involved.

And now I am going to pass the microphone to Silvia Yee. Oh, it's already passed to her.>> Silvia Yee: Thank you, Thomas. And thank you, Kathryn.

Since we are a little over, I'm going to take the opportunity -- if anyone -- you've all been so great about sticking around. If you do have a specific question, this is your chance. Please type them into the chat box. We'll try to take as many as we can just in a couple of minutes that we have. So you will have an opportunity to give us your questions.

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I am not going to go over each of the slides that I have at the end with regards to the Medicaid Managed Care rule, the federal Medicaid Managed Care rule that is going to have a significant impact on all delivery of Managed Medicaid, including Managed Medi-Cal. The slides are as thorough as I can make them. It addresses a number of key questions that are of particular importance to community-based organizations like Independent Living Centers as well as all of California's plans and all Medicaid delivery Managed Care plans in the country. So please look at those when you can.

I'm just going to check over. There are a couple of questions that I'm going to raise. One is: Kathryn, do you see a way to continue the program with existing funding limitations? Is there a way to do it since the innovation grant has now ended? >> Kathryn Stambaugh: That's a great question. At this point we are not pursuing this project in the exact way that it's been because hiring nurses is a very expensive endeavor and we don't have the funding to hire the nurses. So the nurse care managers are no longer working with LifeLong or they might be working with LifeLong but not in this role.

I think the elements that we can continue is the partnership with Center for Independent Living. One of our health centers has recently moved into the same building where Center for Independent Living is located so that really helps us continue our partnership, that close proximity. And we've been in conversation with our partner, the Alameda Alliance for Health. The idea when we started this project with them was that if we showed good cost savings, that they would be interested in paying for the service going forward. They have had a lot of transition in the meantime with a whole different leadership team now than when it started. So there was a little instability there but they're back on their feet again. So now we're having a conversation with a new leadership team. So I'm pretty optimistic that we'll be able to if not work something out with them, figure out a way to be able to do this again in the future. But it's not immediate. We're not doing it right now.>> Silvia Yee: Thank you. Maybe one final question that both of you can address. And that's do you think that the consumers in your program would have sought services from Center of Independent Living on their own and separate from the LifeLong clinic visits? >> Thomas Gregory: I can address that. So the vast majority of the consumers who enrolled for peer coaching or the Living Well workshops -- I'm not talking about the consumers who just worked with the care managers but the vast, vast, overwhelming majority of them were not in our consumer database prior to enrolling in the LifeLong Complex Care Initiative. I guess that doesn't prove whether they would have sought services from CIL but it does prove that they had it. That's something. They didn't. So I believe that this partnership with LifeLong allowed CIL to touch folks who we otherwise would have never reached. >> Kathryn Stambaugh: I would agree with that. I think co-location is important; largely for just practical reasons. We were working with people who often missed appointments because they couldn't afford bus fare to get there. If they're budgeting like that, to be able to combine two things in the same location and really makes a huge, huge difference.>> Thomas Gregory: I'd like to add that some of the consumers that we originally -- you know, initially encountered through this project are still availing themselves at CIL when they need us even now that the project is over. So there's -- so they were introduced to us through the project but we still remain a resource available to them that is useful to them.>> Silvia Yee: That's great.

Well, thank you, both of you, for your time and information. The slide that's up there has our e-mails, all of us, Kathryn, Thomas, Mary Lou and myself. If you have questions about any of the slides, please let us know. You can contact us through our e-mails. As indicated, slides and the transcript will be placed on the DREDF website in a few days.

Something to note for California is that the Medicaid Managed Care rules, as I briefly mentioned, they will have implications in terms of care coordination for all Managed Care plans, both the CIL ones -- both the CCI ones and those who are not participating in the CCI such as Alameda County.

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Thank you, again, for all of your time and your patience. Thank you to Thomas, Kathryn, and Mary Lou.

Bye-bye.