elder services of the merrimack valley, inc. area …...since 1974, elder services of the merrimack...

Elder Services of the Merrimack Valley, Inc.

Area Plan on Aging

Federal Fiscal Years 2014-2017


Table of Contents The Planning and Service Area Map ...........................................................................................3

Executive Summary .......................................................................................................................4

Context ............................................................................................................................................7

Major Goals & Objectives ...........................................................................................................21

Strategies .......................................................................................................................................23

Quality Management ...................................................................................................................23

Required Attachments: Attachment A: Area Plan on Aging Assurances and Affirmation

Attachment B: ESMV Information Requirements

Attachment C: ESMV Organizational Chart

Attachment D: ESMV Corporate Board of Directors – Form 1

Attachment E: ESMV Advisory Council Members – Form 2

Attachment F: ESMV Funded Services Document – Form 3

Attachment G: ESMV Focal Points Document – Form 4

Attachment H: Projected Budget Plan – FFY2014

Additional Attachments:

Attachment 1: Census Data and Projections.

Attachment 2: Needs Assessment

Attachment 3: Green Book

Attachment 4: Healthy Living Programs

Attachment 5: Health Living Center of Excellence Materials

Attachment 6: Homecare Brochures (HC)

Attachment 7: Supportive Housing

Attachment 8: ACO/ICO/SCO One Care Plan Overview

Attachment 9: Community Care Transition Program (CCTP)

Attachment 10: Protective Service Training Materials

Attachment 11: Volunteer Programs

Attachment 12: Annual Report


ELDER SERVICES OF THE MERRIMACK VALLEY 2014 -2017 AREA PLAN NARRATIVE EXECUTIVE SUMMARY Since 1974, Elder Services of the Merrimack Valley (ESMV) has provided an array of programs and services to meet the diverse and changing needs of elders, adults with disabilities, families, caregivers, and the general public. Most of these programs and services are targeted to those in the greatest economic and social need. Our primary catchment area is the 23 cities and towns of the Merrimack Valley, but many of our efforts now extend throughout Massachusetts and beyond. ESMV’s mission supports an individual’s need for choice and self-determination, and helps to strengthen the social fabric of communities for those individuals, families and caregivers managing chronic illness, disability, or challenges related to aging.

During the last 3 years, ESMV has experienced considerable growth and emerged as a leader on the local, state and national level, due to seeds that were planted years ago beginning to bear fruit. Specifically, ESMV invested in: Stanford University’s evidence-based chronic disease self-management programs; community partnership development, especially in the health care arena; transition coaching and care coordination; patient-centered medical homes; Aging Disability Resource Consortium (ADRC) integration and its consumer-directed approach and empowerment focus; building capacity to address elder risk factors such as mental/behavioral health, economic security, and elders’ reliance on caregivers and racial/ethnic/cultural diversity. We expect these efforts to continue and to expand, as ESMV pursues opportunities in this emerging “Healthy Living” era, accelerated by major healthcare reform and demographic projections of an exponential increase in the older adult population. (See Attachment 1: Census Data and Projections)

ESMV’s mission, efforts and plans clearly reflect the missions of the federal Administration for Community Living (ACL – formerly the Administration on Aging/AoA) and the state Executive Office of Elder Affairs (EOEA):

• US Administration for Community Living Mission Statement: To develop a comprehensive, coordinated and cost-effective system of home and community-based services that helps elderly individuals maintain their health and independence in their homes and communities.

• Elder Affairs’ Mission Statement: We promote the independence and well-being of elders and people needing medical and social supportive services by providing advocacy, leadership, and management expertise to maintain a continuum of services responsive to the needs of our constituents, their families, and caregivers.

Our Vision: Choices for a life-long journey. Our Mission: To ensure that choices of programs and services are available and

accessible to meet the diverse needs and changing lifestyles of older adults. Our Values: We believe home-based care, community services and supportive living programs maintain the dignity of human life by promoting self-determination and by

encouraging the maximum independence of the people they are designed to serve.


OLDER AMERICANS ACT CORE PROGRAMS Since 1965, the Older Americans Act (OAA) has made explicit our nation’s commitment to provide comprehensive services to improve the lives of older adults. The largest OAA program, Title III, created critical programs and structures, and authorizes funding of supportive services which must be available to any person aged 60 and older regardless of income. However, the OAA targets the rural elderly and those with greatest economic and social need, especially low-income minority older adults.

Title III services include:

Title III-B Supportive Services: ESMV will continue to allocate its Title III-B funds to address critical needs in our service area, through: outreach, advocacy and education to minority and at-risk elders; emergency shelter and supportive services to homeless elders; legal assistance to low-income elders and minority or immigrant elders; help with medication expenses; and access to Health and Wellness activities, including evidence-based Chronic Disease Self-Management Programs (CDSMP). Our recent Community Needs Assessment identified these critical needs faced by elders in the Merrimack Valley, ranked in order of priority: Economic Security; Health Care; Housing; and Maintain Independence. (See Attachment 2 for Needs Assessment details) These needs will continue to drive our Title III-B allocation and our community partnership development.

Title III-C Nutrition: ESMV continues to subcontract with the Merrimack Valley Nutrition Project (MVNP) to provide Home-Delivered and Congregate Meals across the Merrimack Valley. MVNP’s services support local COAs in delivering nutritious lunches at low cost, enhancing their efforts to encourage social interaction and build a sense of community. MVNP’s Home-Delivered Meals bring nutritious meals to home-bound and isolated elders, however, as federal and state Elder Lunch and Nutrition Services funding has been reduced and also has failed to keep pace with the rising costs of food and gasoline, ESMV has recognized the need to explore all options to ensure access to healthy food.

Going forward, ESMV has identified Food Security as a major priority for Community Programs to address across the Merrimack Valley. We plan to join forces with other community organizations to create a Merrimack Valley Food Collaborative to maximize all available resources to address hunger and “food insecurity” among older adults in the Merrimack Valley.

Title III-D Disease Prevention and Health Promotion Services: Only a small portion of Title III funds are allocated to Disease Prevention and Health Promotion. Given ACL’s priority focus on evidence-based programs, we will continue to use the majority of these funds to pay a portion of our CDSMP Program Manager’s salary; she is heavily involved in promoting and delivering our Healthy Living Programs. We also will continue to add the Title III D funds targeted for Medication Management to an appropriate Title III-B Supportive Services grant.

Title III-E National Caregiver Support Program: ESMV’s Family Caregiver Support Program (FCSP) staff will continue to serve caregivers, providing counseling, training, and support, including respite scholarships; other ESMV resources also will continue to assist caregivers. Our ability to continue offering camperships for grandparents raising grandchildren will depend on available funding. We will continue to facilitate a monthly support group at St. Michael’s Parish in Andover, and continue to run the Tewksbury Men’s Group we established to support male caregivers. In collaboration with the Lawrence Senior Center/Council on Aging, we developed a


Latino Caregiver Outreach Project which contributed to our Community Needs Assessment – we will continue to seek funding to help us ensure access to culturally sensitive respite and supports for Latino caregivers. We will continue to explore other options to support Merrimack Valley caregivers: caring conversation series; coffee hours with speakers; social gatherings to promote networking and friendship, and outreach to local businesses to discuss opportunities to support working caregivers.

NETWORK OF COMMUNITY CONNECTIONS In addition to Councils on Aging and a variety of home care agencies and Visiting Nurse Associations (VNAs), ESMV works with physicians groups, hospitals, and health centers, Senior Care Options (SCOs), Accountable Care Organizations (ACOs), behavioral health providers, family service agencies, local law enforcement, as well as local Housing Authorities and housing agencies, the Alzheimer’s Association, local banks who support our Financial Resource Program, food banks, university and college internship programs, and private foundations.

HEALTHY LIVING AND COMMUNITY CARE TRANSITION INITIATIVES In 2000, ESMV and Hebrew Senior Life (HSL) established a partnership to implement Healthy Living Programs to consumers. In 2008, we created the Healthy Living Center of Excellence (HLCE) to disseminate 12 evidence-based programs to empower individuals to manage a chronic disease or other health concerns. Over the years, our partnership garnered more than $1,000,000 in federal funding and over $700,000 in private foundation funding. In 2013, the HLCE was awarded $1,325,000 from the John A. Hartford Foundation (through a sub-grant to Partners in Care in Los Angeles) and Tufts Health Plan Foundation. This significant additional funding will enable the HCLE to integrate community-based Healthy Living Programs within health care delivery programs in Massachusetts, and supports the sustainability of the Center.

In 2011, ESMV submitted an application to CMS for Community Care Transition Program (CCTP) funding under Section 3026 of the Affordable Care Act, in partnership with 5 local area hospitals. ESMV was awarded a multi-year CCTP grant – one of the first seven in the nation.

We officially began offering Care Transition services as planned on February 1, 2012, and subsequently added Lowell General Hospital (which merged with Saints Medical Center). Our goals for this program will continue to be: to deliver high quality, cost-effective coaching and appropriate interventions in order to reduce the overall rate of admissions at our partner hospitals, empower clients to more effectively manage post-hospital recovery, and strengthen our community collaboration throughout the health care arena in order to improve access, service delivery, and client outcomes. We are confident that CCTP services will be beneficial to other entities in the healthcare arena: SCOs, ACOs, and Integrated Care Organizations (ICO/One Care Plans), and ESMV will continue to market these services to help sustain our Care Transition Program.


CONTEXT Elder Services of the Merrimack Valley (ESMV) is respected as a leader in the field of elder care and has demonstrated its commitment to older adults through advocacy, education efforts and innovative programs. ESMV is the state designated Aging Services Access Point (ASAP) for the Merrimack Valley under contract with the Massachusetts Executive Office of Elder Affairs (EOEA) and federally designated Area Agency on Aging (AAA) for the Merrimack Valley. Elder Services also manages a number of contracts and programs through funding and support from the US Administration for Community Living (ACL), the Centers for Medicare and Medicaid Services (CMS), the MA Division of Medical Assistance (Medicaid), and private foundations and public organizations. The following 23 cities and towns make up the Planning and Service Area (PSA) of ESMV: Amesbury, Andover, Billerica, Boxford, Chelmsford, Dracut, Dunstable, Georgetown, Groveland, Haverhill, Lawrence, Lowell, Merrimac, Methuen, Newbury, Newburyport, North Andover, Rowley, Salisbury, Tewksbury, Tyngsborough, Westford and West Newbury. According to EOEA’s 2010 demographic data, these communities are home to an estimated 73,800 adults age 65 and over.

As the AAA for the Merrimack Valley, ESMV receives an annual allocation from the federal government under the Older Americans Act and provides nearly $950,000 dollars in funding to several community agencies for community-based programs that provide community elders with services such as nutrition programs, legal services, transportation, minority outreach and other supportive services. We directly manage and/or fund over forty (40) different programs, contract with sixty nine (69) community agencies, and oversee more than 100 services through contracts chosen for quality and cost.

ESMV has more than 235 full-time employees and over 300 volunteers; our volunteer programs include Medical Advocacy, Friends in Deed and Medical Transportation, SHINE, and Money Management. Our staff composition reflects the cultural and linguistic diversity of our catchment area: over 30% of staff are bilingual, giving us the capacity to serve consumers who speak Spanish, Khmer, French, Portuguese, Greek, Italian, Hindi, Creole, Gujatati, Micmac, Swahili, and Hmong. We serve more than 18,500 consumers annually who reside in 3 major urban areas: Greater Lawrence, Greater Haverhill, and Greater Lowell, as well as smaller, more rural areas, and Southern New Hampshire towns served by our local hospital partners. We serve one of the state’s poorest communities, Lawrence, where 24% of older adults live below the poverty line, and Lowell, with 15.4% of older adults living below the poverty line. These urban centers also add to the ethnic and cultural diversity of the region: 73.8% of Lawrence’s population is of Hispanic or Latino origin; Lowell’s population is 20.2 % Asian/SE Asian, including the largest Cambodian population in the state. The Merrimack Valley has the second highest Cambodian population in the nation.

Based on data from the 2010 United States Census, the total population of our PSA is over 607,000 and nearly 17.5% of the total population is age 60 and older. This represents an increase from the 2000 US Census data, which indicated that 14.7% of the population was age 60 and older. Statewide, the 2010 Census reported 19.4% of the population is age 60 and older, an increase statewide of 2.1% from 2000. The 2010 growth projections, however, are staggering, especially among some of the smaller towns in our PSA. Tyngsborough, for example, is expecting the percentage of elders 60 and older to grow by 182.4% between 2010 and 2020; seven other cities/towns expect to increase by over 100%; eight more expect to grow by more than 50%. Although the growth projection is not as dramatic in the larger cities (for example,


Lawrence projects only a 12% growth of people age 60 and older and Lowell projects a 27.2% increase), the “Baby Boom” generation will continue to have a significant impact on our elder support system.

Estimates of disability among our Merrimack Valley residents are hard to locate; the latest American Community Survey data on disability prevalence released by the US Census Bureau is reported by county. Where disability was defined as “self-care difficulty”, Essex County had an estimated 5,129 and Middlesex County an estimated 9,323 individuals aged 18 and above fitting that category. Where disability was defined as “independent living difficulty” the numbers increased to 10,195 in Essex County and 17,314 in Middlesex County. The number reported as “institutionalized” for the 23 cities and towns we serve was 5,405.

Trends suggest that the number of minority elders in our PSA will continue to increase, especially the Asian and Hispanic populations. Trends also suggest that the number of elders living in poverty, especially minority elders, may also continue to rise. These trends validate our continued emphasis and expanded outreach to minority populations, the most needy and vulnerable populations in our PSA.

FOCUS AREAS 1. OAA CORE PROGRAMS Title III-B Supportive Services: health, including mental health; transportation; Information and Assistance; housing; long-term care; legal assistance; services to encourage employment of older workers; crime and abuse prevention; and, Councils on Aging (COAs) and Senior Centers ESMV utilizes its Title III B allocation to address critical needs identified in our service area: access to Health and Wellness activities, including those related to prevention, evidence-based Chronic Disease Self-Management Programs; outreach, advocacy and education to minority elders; emergency shelter and supportive services to homeless elders; legal assistance to low-income elders and minority or immigrant elders – issues re: housing and tenancy (foreclosure, eviction), citizenship and family reunification, accessing benefits, and community education on legal issues.

Our recent Community Needs Assessment identified these critical needs faced by elders in the Merrimack Valley, ranked in order of priority: Economic Security; Health Care; Housing; and Maintain Independence. (See Attachment 2 for details) Far too many of our elders are struggling to meet basic needs: paying for rent/mortgage; paying for food, utility bills; paying for medication; etc. We have responded in several ways to help older adults meet these “basic necessities”. We will continue to help older adults meet these “basic necessities”, building on the foundation of supports and services ESMV has created, including:

• an “Elder Care Fund” to assist elders in emergency situations or with an urgent otherwise unmet need (with funds raised/donated throughout the year);

• a “Basic Necessities program” to assist elders with paying for rent, food, utilities, furnishings, medication, etc., (funded through grants from local foundations such as the Katherine Pierce Trust, the George C. Wadleigh Foundation, the Griffin-White Foundation) and to help support ESMV’s Assistance Response Team (ART) which is a specialized team trained to work together to respond to crises. Team members include protective services, nursing staff, and mental health clinicians. Legal counsel is available


for consultation and advice. Our experience has taught us that indigent, frail elders require assistance that offers quick resolutions, adequate resources to pay for basic necessities, and then long term commitments of care and assistance to address complex needs. The Basic Necessities Program provides the spectrum of this care with efficiency, expertise, and quality effort;

• our Elder Brown Bag program with community partners in Lawrence, Haverhill and Lowell; across all 3 sites, we deliver 2,740 bags per month. This program is operated with no funding – food is obtained through our partnership with the Greater Boston Food Bank and site distribution is coordinated by ESMV staff, working with staff at COAs, and committed community volunteers. For example, we have been able to reach an increasing number of elders in Lowell due to the dedicated support of off-duty firefighters from Lowell and Chelmsford;

• our Financial Resource Program which encompasses Money Management, Financial Literacy and Representative Payee). The state’s Money Management Program is a free service helping low-income elders who are at risk of losing their independence due to an inability to manage their own finances. Jointly sponsored by the AARP, Mass Home Care, and EOEA, this program is operated locally through ESMV. This Program matches a trained, insured, and supervised volunteer with an older adult who needs help with bill paying and other routine financial tasks. Available services range from organization and keeping track of financial and medical insurance papers to establishing a budget, helping write checks, balancing checkbooks, interpreting statements, and sorting mail. The Representative Payee helps elders who are incapable of managing their own finances. This service is similar to Bill Payer assistance, except the Social Security Administration identifies the elder and refers the person to the manager of the Financial Resource Program. This manager pays the individual’s monthly bills, provides a monthly stipend, and manages their overall financial resources. We will continue to seek investment by a variety of community partners (banks, private foundations) to enhance our ability to deliver these services.

Mental Health Care Management: A 2012 Massachusetts Profile reported that nearly 5 percent of people served by the state mental health system were ages 65 and older (3.9 % were ages 65 to 74 and 0.7 % were ages 75 and older). Our Mental Health Care Management Team continues to see a large number of referrals from Protective Services and Care Managers (CM) in Home Care. The Team has grown with the hiring of a 4th Mental Health Care Manager and includes a Clinical Nurse Specialist. They are typically working with 95 clients and there is a Wait List of referrals from Home Care CMs looking to transfer their clients to Mental Health. We are seeing increased referrals for elders in their early 60s who will potentially be clients for a longer period of time. The needs of these elders and the lack of involved informal supports often require intensive care management on a weekly or bi-weekly basis.

The Hoarding Program continues to be an important aspect of mental health clinical services at ESMV. Hoarding conditions are almost always the result of untreated mental health conditions, and the effects of unaddressed hoarding often lead to eviction, homelessness, self-neglect and unfit living conditions. Our in-house expert frequently consults with assisted living facilities and nursing homes to determine how best to address hoarding issues related to their residents. She has a real gift for establishing rapport and building trust with elders who seem trapped in a cycle of hoarding – understanding the emotional and psychological underpinnings of this behavior and


recognizing that overcoming it requires a process and partnership with the elder in order to succeed.

In addition, our expert is responsible for educating area professionals about the effects of compulsive hoarding, and effective treatment strategies, in order to extend the intervention to other community and medical supports. As a matter of fact, EOEA just released a Hoarding Best Practices Guide, to which 2 ESMV clinical managers were significant contributors. We will continue to seek external resources to help support ESMV’s Hoarding Program and enable us to expand its outreach to meet increased demand.

Title III-C Nutrition: Congregate and Home Delivered Nutrition Services. The OAA provides for the establishment and operation of nutrition projects in a congregate setting and for homebound individuals. In FFY 13, our Nutrition Services provider, Merrimack Valley Nutrition Project (MVNP) delivered congregate meals to 2,271 clients (including 83 with High Nutrition Risk) and Home-Delivered Meals to 2,607 clients (including 824 with High Nutrition Risk). We will continue to work with MVNP to ensure their capacity to meet the nutritional needs of elders who receive their meals. Senior Farmer’s Market Coupon Program: ESMV’s Director of Housing & Community Programs worked with MVNP to broaden the distribution of this limited resource (only 1300 coupons in 2012) by designing a pilot expansion of distribution sites from 4 (Lawrence, Lowell, Methuen, Dracut) to 7 sites (adding Amesbury, Billerica and Haverhill). Although the response at each of the new sites was less than we had hoped for in the first year of the pilot, all coupons were ultimately distributed. In 2013, we distributed our allotted 1256 coupons across the 7 distribution sites and increased our community outreach and marketing efforts in an effort to improve participation in the newer sites – early results indicate that our efforts were helpful. We plan to continue these efforts, in partnership with MVNP and the COA Directors, and will work to encourage broader participation by Merrimack Valley Farmer’s Markets in the Senior Farmer’s Market coupon program.

OTHER FOOD ACCESS INITIATIVES In addition to working to expand our Elder Brown Bag program to meet increased demand, we have begun to meet with key community organizations involved in food assistance and plan to convene key stakeholders from across the Valley in a “Food Summit” by the end of 2013; hopefully leading toward the creation of a Merrimack Valley Food Collaborative. These initiatives will enable us to identify: what’s happening and available, resource locations, gaps in resources, access and distribution issues, and how to increase collaboration and/or resources so we can feed more elders. We recognize the need to move beyond emergency food relief and will focus our efforts on creating connections between food production (farms, greenhouses, Community Supported Agriculture, community gardens), food recovery (local restaurants and supermarkets), and food delivery (mobile food pantries, brown bag volunteers, etc.) in order to promote a community-based response to elder hunger and nutritional needs.

Title III-D Disease Prevention and Health Promotion Services: Preventive health services educate and enable older persons to make healthy lifestyle choices, promoting the OAA goal of increasing the quality and years of healthy life. While Title III only allocates minimal funding to Disease Prevention and Health Promotion, these funds are intended to support ACL’s priority focus on evidence-based programs. We will


continue to use the majority of these funds to pay a portion of our CDSMP Program Manager’s salary; she is heavily involved in promoting and delivering our Healthy Living Programs. We also will continue to add the Title III D funds targeted for Medication Management to an appropriate Title III-B Supportive Services grant.

Title III-E National Caregiver Support Program: This Title was funded for the first time in 2000. It helps the millions of people who provide the primary care for spouses, parents, older relatives and friends by offering information to caregivers about available services, assistance to caregivers in accessing supportive services, individual counseling, and respite care. In FFY 13, ESMV’s Family Caregiver Support Program (FCSP) coordinated Respite Scholarships for 41 caregivers, totaling over $11,000 in support, as well as camperships for 11 grandparents raising grandchildren. Our ability to continue to provide these camperships will depend on future funding levels. We continue to facilitate a monthly support group at St. Michael’s Parish in Andover, serving a combined total of 50 caregivers during the year. We are aware of the various support groups for caregivers across the Merrimack Valley, and connect caregivers to these local resources. We also know that many caregivers are seeking other forms of support and will continue to explore opportunities to develop alternative approaches, including options within multicultural communities. In response to an unmet need, we also established a Men’s Group to support male caregivers in Tewksbury, MA. This well-attended group meets twice monthly and has grown to nearly 20 participants – a testament to male caregivers’ need to have a place to bond, share their experiences and challenges, and learn more about how to manage the caregiving journey. We will continue to identify other opportunities to serve male caregivers elsewhere in the Merrimack Valley.

In collaboration with the Lawrence Senior Center/Council on Aging, our FCSP also created an outreach project targeted to caregivers within the Latino community in Lawrence, MA. Our Latino Caregiver Outreach Project developed a comprehensive assessment tool to capture the needs of both the caregivers and care recipients. In 4 weeks, outreach workers completed assessments with 50 caregivers. The data we gathered was incorporated into ESMV’s Community Needs Assessment and will help us explore the caregiver’s role within the Latino community and how best to respond to their needs. We also have trained two bilingual staff from the Lawrence Senior Center to become lead trainers in Powerful Tools for Caregivers (PTC) classes and be able to deliver that training in Spanish – which will be a unique resource in the state’s aging service network.

This effort is part of an overall capacity-building strategy undertaken by the FCSP Program Manager – she has reached out to several COAs in the Valley to re-engage with them, re-introduce the FCSP and its services/resources, and enlist their help in building local PTC training capacity. The ongoing goal is to have each COA have 1 staff or volunteer trained to become a Lead PTC Trainer and partner with an FCSP staff member or trained volunteer co-lead PTC classes within their community. We also are increasing our connection to the grant-funded Amesbury Caregiver Education (ACE) program operated by the Amesbury COA; assisting them with building community awareness, increased referrals, and offering PTC training to their staff.

As a member of the Merrimack Valley Alzheimer’s Partnership, we hosted the 25th annual Alzheimer’s Conference on April 27, 2013: Caregiving… focusing on the moments that matter, 2013, with over 220 participants. FCSP and ESMV staff will continue to participate in the Alzheimer’s Walk of Merrimack Valley to help raise awareness and funds, and to


demonstrate our support for individuals, families and caregivers affected by Alzheimer’s Disease. ESMV plans to work with the Merrimack Valley Alzheimer’s Partnership to expand the Partnership’s efforts beyond the annual conference. Looking forward, our FCSP staff would like to: continue efforts to promote PTC and build capacity across the Merrimack Valley; build on our collaboration with the Lawrence Senior Center, Mary Immaculate ADH and Home Health VNA to design a respite program that is responsive to Latino caregivers – and then seek funding for it; reach out more to the local business community to educate them about what we can offer their employees as “working caregivers”; nurture our Men’s caregivers’ group and connections to Grandparents as caregivers in the Merrimack Valley; and work more closely with our own Community Care Transitions Program (CCTP) staff to offer education and support to caregivers they might encounter while coaching consumers and their families. However, the reality of sequestration and looming impact on OAA-funded programs makes it hard to know what, if any, growth will be possible.

LGBT OUTREACH Recognizing the lack of opportunities in the Merrimack Valley, ESMV has partnered with the Merrimac Council on Aging (COA) to create a welcoming forum for Lesbian, Gay, Bisexual and Transgender (LGBT) elders to socialize, network, and create a sense of community among peers. Our first gathering drew 10 individuals, all of whom expressed their happiness that such an opportunity is being created; the second gathering saw the group expand by 5 new members and the positive energy was infectious. We plan to meet on the third Thursday of each month; although Merrimac COA is hosting the group, all agreed that outreach and membership will be open to LGBT elders across the Merrimack Valley. We will make every effort to reach out to elders who may be isolated or disenfranchised from friends and family because of their LGBT status. ESMV is excited to work with the Merrimac COA on this important project.

2. ACL DISCRETIONARY GRANTS

ADRC In 2004, ESMV partnered with the Northeast Independent Living Program (NILP) to become the first state-designated Aging & Disability Resource Consortium (ADRC) in Massachusetts and has since become the model for other ADRCs across the state. The Merrimack Valley of the ADRC (MV-ADRC) continues to assist elders and people with disabilities seeking services and supports, regardless of age, disability or income, through a coordinated and seamless interagency system of information and access. MV-ADRC continues its collaborative effort to provide a “no wrong door” for efficient and effective access to long-term services and supports. ESMV and NILP Information & Referral (I&R) staff developed a Consultation Form that was the basis for the Statewide ADRC I&R form; staff from each agency have periodically been cross-trained in key functions in order to ensure easy access for consumers, a collaborative approach to service and care management, and shared expertise. We will continue to respond to opportunities to improve access to the systems of care sought by elders and adults with disabilities.

One tangible example of our ongoing collaboration is “The Green Book – An Aging & Disability Resource Guide for the Merrimack Valley”, a consumer directory to programs and services in the Merrimack Valley for elders and people with disabilities that was published jointly with NILP. Thousands of copies have been distributed throughout the area and the state since the last version was published in 2012; the current version also is available in Spanish. We will continue


to collaborate on producing this highly valued resource and look for ways to improve its content and accessibility. (See Attachment 3 for a copy of the current Green Book.) In 2010, ADRC-MV held a joint Legislative Forum. Mike Festa, Executive Director of the Carroll Center for the Blind, was the keynote speaker. Nearly 100 people attended, including local State Senators and Representatives, consumers, staff from ESMV and NILP, and members of ESMV’s and NILP’s Board of Directors, and ESMV’s Advisory Council. We have begun discussions regarding joining forces on another legislative event/forum.

In response to the recent ADRC-SHINE grant, MV-ADRC plans to train 2 current NILP staff as SHINE Counselors who will focus on providing high quality, up-to-date health insurance information and assistance to Medicare beneficiaries who also have a disability residing in the Merrimack Valley and certain Cape Ann communities. ESMV will train and supervise the 2 SHINE Counselors who will be housed at NILP in Lawrence. NILP will assist us in spreading the word about this initiative within the disability community, promote the value of SHINE counseling within their membership, partners and support the ADRC-SHINE Counselor in their outreach and engagement efforts. ESMV is taking a team approach to ADRC coordination (rather than a single ADRC Coordinator role) and we are working with NILP to develop a schedule of meetings and initiatives to strengthen our partnership moving forward.

HEALTHY LIVING PROGRAMS ESMV is proud to have been an early adopter of evidence-based programs developed by Stanford University to address chronic disease, health, wellness and safety. We recognized that by empowering elders to take better care of their health, to stay active, to manage chronic illness and painful conditions, and to maximize the benefits of supportive services, we help to enable them to remain independent, exercise a wider range of options, and have a better quality of life. Highlights of the evolution of ESMV’s role and our sustained investment in these critical programs are included in Attachment 4 in order to illustrate our ongoing objectives and to fully appreciate what we envision going forward.

Born in 2000, the innovative partnership between ESMV and HSL led us to create the Healthy Living Center of Excellence (HLCE) in 2008 to disseminate the CDSMP and promote healthy living statewide. The HLCE recently hired a full-time Administrative Assistant who was trained in February, 2013 in the CDSMP and the CPSMP. The HLCE also hired a Program Coordinator to assist with program dissemination, statewide program fidelity and quality assurance. She is bi-lingual in Spanish and trained in both English and Spanish versions of CDSMP, DSMP and the HE program. Since 2008, the HLCE has expanded to assist other programs and services offered to older adults, and to promote sustainability, including 6 regional collaborative that provide readiness for statewide payer contracting and integration of CDSM Education Programs as a funded intervention under CCTP, and with ACOs and Patient-Centered Medical Homes.

The HLCE was recently awarded $1,325,000 in grants from the Tufts Health Plan Foundation and the national Hartford Foundation, both of whom are very enthusiastic about our work. The project aims to use the model and our infrastructure in Massachusetts to demonstrate to the medical community the value of community-based organizations in helping to reduce health care costs, improve the quality of health and increase patient activation. Our focus will expand from our statewide coalitions to helping educate other organizations across the country as to how they can develop their own coalitions. (See Attachment 5 for HLCE materials)


3. PARTICIPANT-DIRECTED/PERSON-CENTERED PLANNING

Our commitment to the “Community First” philosophy is reflected in our extensive participation in the state-funded Home Care Program. ESMV provides in-home supportive services for more than 5,000 older adults in any given month. Elders are eligible for these programs based on income, frailty and need. Services include care management, adult day care, certified home health services, personal care, homemaking, home delivered meals, transportation, companionship and other services designed to address specific activities of daily living. Some of the specialized programs offered though the Home Care program include the Community Choice Program that offers a wide range of in-home services for nursing home eligible MassHealth (Medicaid) enrollees for an average monthly cost of approximately $1,250. This is about ¼ of what an elder would pay privately for a nursing home. Other programs managed within the Home Care Department include the Home Care Basic Program, Enhanced Community Options Program (ECOP), Personal Care Attendant Program (PCA), and Group Adult Foster Care (GAFC). (See Attachment 6: Home Care program brochures)

In December, 2009, ESMV stepped forward to ensure that agency staff were prepared to embrace the philosophy of Consumer Direction. One of our Home Care Directors and 2 HC middle managers conducted six separate 3-hour trainings on Consumer Direction and trained 183 staff. Our staff learned that Consumer Direction is a philosophy and a way of doing business that allows the consumer to have as much involvement and control over decisions regarding their care as possible. The foundation of this philosophy is that self-determination is a basic human right. This training was simply our initial step in ESMV’s continuing efforts to improve our approach to serving our consumers.

Our Home Care staff work with a population that is significantly more impaired than in the past, whether by acute illness or chronic disease, dementia-related behaviors, earlier cognitive decline, substance abuse/addiction, mental health issues such as depression and anxiety disorders, and/or multiple challenges. Many also face increasing financial distress; abuse, neglect, and financial exploitation are regrettably more common. ESMV is proud of the skill and dedication of our Home Care staff and we invest considerable time and resources to maintain the necessary level of expertise to meet the complex needs of our consumers. We will continue to do so, and as we begin to work with an increasing population of “dual eligibles” (individuals who receive both Medicare and Medicaid) and younger adults with disabilities, we will ensure our staff are able to address their needs and support their choices.

SUPPORTIVE HOUSING Another key aspect of “Community First” is to ensure that people have access to stable, affordable housing, ideally in their community of choice, and that they have access to supports as they age-in-place, and can be part of a community. Supportive housing – both state-supported models and federal HUD 202 models, offer these benefits to elders. ESMV continues to play an important role in making these options available. ESMV continues to provide Resident Service Coordinator (RSC) services for senior housing sites in Amesbury, Billerica, Chelmsford, Methuen and Westford. Looking forward, we will continue to advocate for more RSCs throughout our catchment area. This truly valued service is a great addition to any housing location. As needs change and our population increases in diversity and complexity, we will continue to redefine/adjust the RSC’s role to best meet the needs and desires of elder residents.


ESMV also has been active in the development of supportive housing for low-income seniors and adults with disabilities, in partnership with local housing authorities and non-profit housing managers. ESMV brings extensive experience in elder care services to the table, and our partners offer the management expertise and experience of housing providers. To date, we have developed 86 units of HUD 202 supportive elder housing in Chelmsford and Westford; our third 202 project was awarded in 2011 – 32 units in Tewksbury (plus an additional unit for an on-site manager) which will bring the total to 118 units. We celebrated our Groundbreaking ceremony on June 11, 2013 and construction has begun, with completion expected by June of 2014. (See Attachment 7: Supportive Housing materials)

It is unclear what the future holds for the HUD 202 program or whether other funding sources will emerge to support development of affordable housing for seniors. Given the demographics that lie ahead, we will continue to advocate for ongoing investment in housing options (including rental assistance such as Section 8) for low-income elders.

PATIENT-CENTERED MEDICAL HOMES Patient-centered medical homes (PCMH) “embrace the following principles: each patient receives individualized care from a team of primary care providers including physicians and nurses; the team is responsible for a patient’s ongoing care, for the ’whole person’; a patient’s care is coordinated across the health system and community; quality and safety are hallmarks of the practice; enhanced access to care is offered through open scheduling, expanded hours, and new care options, such as group visits; and the payment structure recognizes the enhanced value provided to patients (EOHHS August, 2009, citing The Commonwealth Fund 2008).” As EOHHS recognized, “because the PCMH concept promotes both payment reform and practice transformation, they are a linchpin in any plan to improve transitions in care.”

Back in 2009, EOHHS’s strategic plan for PCMH had a stated goal of transforming all primary care practices into “high-performing and advanced medical homes by 2015” and participating practices were to begin implementation before the end of 2010. At the federal level, Medicaid was required to design and implement a PCMH Demonstration project, involving Medicaid managed care organizations such as MassHealth, which established the Massachusetts PCMH Initiative. One of the project’s priorities was to increase the PCMH’s use of existing community-based resources, such as ASAPs and ADRCs. During 2010, ESMV became involved in the PCMH initiative, recognizing that this model enabled medical practitioners to consider and address social and environmental factors, as well as medical needs, which can impact a patient’s care, recovery and overall wellbeing. One key element of the PCMH model is Care Coordination – an area where the value of ESMV’s expertise is clear. ESMV’s Care Coordination role includes: assessments of health, functional status, informal and formal support systems and home safety as well as Information and Referral, medication reconciliation, completion of a Personal Health Record, assistance with Advance Directives, assistance and encouragement to adhere to doctors’ orders, caregiver support, Transition Coaching and the provision of evidence-based programs to manage chronic disease.

Our involvement with PCMH began with 2 local medical practices: Pentucket Medical Associates (PMA) and Harvard Vanguard Medical Associates’ (HVMA) Chelmsford office. We installed a Medical Care Coordination Specialist at PMA, with office hours 15-20 hours/week, who received referrals from PMA doctors and nurse practitioners looking for assistance with patients needing transportation, in-home evaluations, access to durable medical equipment and


other services. Despite being pleased with the service, PMA ultimately decided that the timing was not right for them to make an investment in medical homes coordination, particularly since it lacked a financial incentive to pay for care coordination; our proposal to PMA was put on hold.

Our Medical Care Coordination Specialist assigned to HVMA in Chelmsford was not on-site but received referrals via fax and email. We hoped to build on this pilot with HVMA (and their parent company – Atrius) to explore the feasibility of expanding to other Atrius/HVMA sites. We continued to work with Atrius/HVMA in Chelmsford on the development of the Medical Care Coordination role (including cost) and expanding it to include Transitional Care, and by the end of January, 2013, we had negotiated a contract with them to have a staff person assigned to the Chelmsford practice 2/3 of their time. In addition to being a Medical Home, HVMA is one of the ACOs approved by CMS. Our work with an ACO and PCMH, especially one that has significant reach such as Atrius/HVMA, is somewhat groundbreaking for ASAPs in Massachusetts as well as of interest nationally.

ACO, ICO DEVELOPMENT Another systemic change in the health care arena has been the emergence of Accountable Care Organizations (ACO) and Integrated Care Organizations (ICO). An ACO is a healthcare organization characterized by a payment and care delivery model that seeks to tie provider reimbursements to quality metrics and reductions in the total cost of care for an assigned population of patients. A group of coordinated health care providers form an ACO, which then provides care to a group of patients. The ACO may use a range of payment models. The ACO is accountable to the patients and the third-party payer for the quality, appropriateness and efficiency of the health care provided. According to CMS, an ACO is "an organization of health care providers that agrees to be accountable for the quality, cost, and overall care of Medicare beneficiaries who are enrolled in the traditional fee-for-service program who are assigned to it." ESMV has had discussions with a number of organizations interested in becoming ACOs to explore our scope of services, expertise and network, and the role we might play in their system.

Another new health care option is ICOs (now called One Care Plans) for Massachusetts adults, age 21-64, who are eligible for both MassHealth and Medicare (dual eligibles). The program combines funding from MassHealth and Medicare. By using an integrated managed care system, One Care Plans aim to provide higher quality care at a lower cost than MassHealth and Medicare provide separately. Originally, there were 7 One Care Plans that would serve all, or part, of our area. We met with 5 out of the 7 to discuss what we have to offer and what role we might play, e.g., Long-Term Services Support Coordinator (LSSC). Ultimately, only Commonwealth Care Alliance (CCA) will serve our area, and we are working with CCA for the One Care Plan. We will provide services with the One Care Plan with LSSCs and also utilize ESMV Registered Nurses to assist the CAA RN’s in completing the Comprehensive Assessments for the enrollees. (See Attachment 8: ACO and ICO/One Care Plans overview)

COMMUNITY CARE TRANSITION PROGRAM (CCTP) ESMV’s growing interest in care transitions took on a sharper focus in early 2010, as our Directors of Home Care began to explore the work being done by Dr. Eric Coleman, with the University of Colorado – Denver, School of Medicine. They learned about the “Coleman model” and how it was being implemented, and began to explore potential partnerships with local hospitals. The Coleman Model aims to empower consumers with the knowledge and


skills to better manage their health and recovery from hospitalization. The Coleman Model’s intervention focuses on four conceptual areas, referred to as The Four Pillars®:

1. Medication self-management: Patient is knowledgeable about medications and has a medication management system.

2. Use of a dynamic patient-centered record: Patient understands and utilizes the Personal Health Record (PHR) to facilitate communication and ensure continuity of care plan across providers and settings. The patient or informal caregiver manages the PHR.

3. Primary Care and Specialist Follow-Up: Patient schedules and completes follow-up visit with the primary care physician or specialist physician and is empowered to be an active participant in these interactions.

4. Knowledge of Red Flags: Patient is knowledgeable about indications that their condition is worsening and how to respond.

ESMV ‘s efforts built upon our work with all 6 local area hospitals in their State Action Against Avoidable Re-hospitalizations (STAAR) programs by: participating on STAAR Program Committees, attending rounds for certain population groups (e.g., cardiac patients), offering Transition Coaching services, and offering CDSMP presentations.

In April 2011, CMS announced a significant funding opportunity for Community Care Transition programs: $500 million nationally to assist hospitals identified as having high 30-day readmission rates to reduce readmissions by working with community agencies to implement Transitional Care. ESMV had anticipated this announcement and looked to build on our experience in Transitional Coaching with local area hospitals as well as Care Coordination and more targeted referrals to our CDSM Programs.

In August, ESMV submitted an application to CMS for Community Care Transition Program (CCTP) funding under Section 3026 of the Affordable Care Act, in partnership with 5 of our local area hospitals. This submission required extensive work with multiple key constituencies to conduct an in-depth root cause analysis to identify reasons for high readmission rates, detailed analysis of hospital data and cost projections for proposed interventions, as well as a required projection of savings to Medicare resulting from our CCTP model. On November 18, 2011, ESMV received formal notification that CMS awarded us a multi-year CCTP grant – one of the first seven CCTP programs funded in the nation. We officially began offering Care Transition services as planned on February 1, 2012. Since that time, ESMV’s CCTP program has expanded to include Lowell General Hospital (which merged with Saints Medical Center). Four of the original 5 hospitals were fully ready on that date, having piloted with ESMV for several weeks prior to the start date to ensure that their systems of referral, risk assessment and integration of lead coach and coaches of the day proceeded smoothly. As with most innovative, demonstration projects, this is a “learn as you go” process – as ESMV and CMS continue to learn more about high risk patient population, what interventions are most effective, how best to address billing issues, how best to deploy coaches and what attributes, training, experience best predicts a successful Care Transitions Coach, as well as the kind of support and infrastructure necessary to enable them to succeed. In addition to addressing the needs of elders in care transitions, we have developed a Mental Health Clinical Care Transition Coach role, particularly in response to the challenges hospitals face with younger Medicare recipients who have mental health issues. We fully expect this program to continue to evolve, as we learn from our experience, current partners and future collaborators.


In the 18 months since implementation began, our CCTP has accomplished the following:

Over 12,412 hospital admissions referred to the program; Encouraged a collaborative strategy between partners to reduce hospital readmission; All partners embraced the program as part of the support offered to Medicare patients; Enhanced the program to include a high risk screening tool at all hospitals to target

eligible patients, increasing the efficiency of eligibility determination; Expanded the program to offer CDSMP to patients.

Beginning September, 2013, ESMV’s CCTP will begin an innovative 6 month pilot with one of our SCO partners, United Healthcare, with the goal of working collaboratively on reducing hospital readmissions and other outcome metrics.

Our goals for this program will continue to be: to deliver high quality, cost-effective coaching and appropriate interventions in order to reduce the overall rate of admissions at our partner hospitals, empower clients to more effectively manage post-hospital recovery, and strengthen our community collaboration throughout the health care arena in order to improve access, service delivery, and client outcomes. (See Attachment 9: CCTP materials)

4. ELDER JUSTICE

NURSING HOME OMBUDSMAN PROGRAM ESMV’s Nursing Home Ombudsman Program remains the largest in the state, covering 46 facilities (nursing homes and Transitional Care Units) and close to 4900 residents. By the end of September 2012, 34 volunteer Ombudsman were re-certified over 3 sessions. Our program employs a Director and Assistant Director who also cover some facilities along with coordinating, training and supervising the volunteer Ombudsmen. All Ombudsmen receive monthly supervision on topics such as effective interview techniques, regulatory updates/changes and a review of case studies. The Ombudsman local office continues to receive well over 100 intakes monthly. The Ombudsmen provide information and referral to community resources as requested when appropriate. In FY 2013, our Ombudsman Program saw 1800 residents a month and reported 5096 contacts/month (combined residents, families and staff). The influx of requests regarding residents who are experiencing mental health issues or who have developmental disabilities has continued. Our Ombudsmen will continue to work with facilities to see that these issues are addressed either through in-house clinical resources or short-term hospitalizations. At the state level, the Program Director continues to advocate for more attention to the needs of elders with disabilities.

The new Section Q initiative offers increased opportunities for nursing home residents to exercise choice, with the assistance of Long-Term Options Counselors and NH Ombudsman if needed. Section Q requires that every resident is asked if s/he would like information or to talk to someone about moving out of the nursing home and back into the community. If a resident says yes, the nursing home must initiate care planning and may make a referral to a Local Contact Agency (LCA), which then provides information to the resident about community living services and supports. Each resident should be meaningfully engaged in his/her discharge and transition plan. The nursing home will continue to be responsible for discharge planning as required by state and federal regulations. Like other ADRCs statewide, ESMV and NILP are continuing to develop and refine our collaboration in dealing with Section Q referrals.


SENIOR MEDICARE PATROL (SMP) Since 2000, ESMV has been proud to host the Massachusetts Senior Medicare Patrol Program (MA SMP), which is a partnership between community-based organizations and mainstream agencies. The program’s objective is to reach and educate all Medicare and Medicaid beneficiaries, family members, and caregivers on the importance of becoming engaged healthcare consumers to prevent healthcare errors, fraud and abuse. The MA SMP Program is designed to engage elders, particularly isolated, hard-to-reach, underserved, un-served, limited English speaking and Native American elders. Nationally, $106 million in total savings to Medicare, Medicaid, beneficiaries, and other payers has been attributed to the SMP projects. The MA SMP Program is very active and visible in communities across the state and parts of New England, e.g., staff participated in the NERSC (New England Residence Service Coordinators) Conference in Providence, RI. On May 3, 2012,, SMP staff joined the Rhode Island SMP Program Director to disseminate the SMP Program message and promotional materials. On May 4th the MA-SMP Director, RI SMP Director and CMS’ SMP Liaison conducted a 1.5 hour workshop for RSCs from across New England. The MA SMP Program held its 4th Annual Statewide Conference in May, 2013 in Lowell, MA. The conference was attended by 104 healthcare providers from across MA, RI, NH and ME. We achieved our objective to broaden the reach of the SMP Program and to build momentum among service providers to encourage healthcare consumers to become actively engaged in their healthcare and better understand the importance of preventing Medicare and Medicaid fraud. In September, 2012 the MA SMP program was awarded its third SMP Capacity Building Grant in the amount of $202,411; 2013 begins the last year of SMP’s 3 year continuation grant, with $167,955 in funding.

The MA SMP Program has expanded its capacity to more effectively reach a higher number of beneficiaries and has continued to work with grantees to build capacity of volunteer corps to increase outreach and education contacts. The most recent SMP Program Capacity Grant has enhanced SMP grantees’ ability to manage simple inquiries, complex issues and the referral process. The overall MA SMP Program has intensified its complex case management and inquiry resolution efforts. The Program has increased collaborations with partner organizations, increased interface with CMS, Medicare contractors, OIG, and other partners and has been successful in implementing and expanding media and public awareness campaigns. The MA SMP Program increased the number of volunteer-led educational sessions and outreach venue events; however, more volunteer recruitment and nurturing is needed to fully mobilize a ground force of volunteers to take a more active role in community education.

PROTECTIVE SERVICES (PS) Despite the mandatory statewide triage of lower risk PS cases out of services (implemented Oct. 1, 2010) our program continues to operate above caseload capacity. Since this triage was implemented, we have triaged 23 lower risk cases in accordance with state guidelines. Thankfully, we have been able to refer most of these elders to other ESMV programs for follow up. In December 2010, our PS screened in and assigned 84 new reports for investigation – the highest total for all PS programs across the state. Our PS program numbers continue to grow from year to year. In calendar year 2012, we saw 1754 new reports of abuse, neglect and exploitation, an average of 146 reports each month with 1232 assigned to Protective Services Workers for investigation, an average of 103 new investigations each month. This represents a


16.7% increase in reports from 2011 and a 10.9% increase in new investigations. Our PS program has also seen an increase in complex court involved cases. The quality of our investigations and acceptance of our recommendations by the Probate Courts in Middlesex and Essex County continues to be commented on by the various Judges we appear before. Protective Services Workers are uniformly recognized by various Judges of the Probate Court as truly having the protection of elders as their primary concern, willing to go the extra mile in assisting the client, and working with the court for a just outcome.

In June of 2013, our PS staff geared up for the 8th annual World Elder Abuse Awareness Day (WEAAD) which was recognized on June 15th. ESMV was very pleased to initiate a number of elder abuse awareness activities in honor of World Elder Abuse Awareness Day throughout the month of June. These activities targeted mandated reporters and the general public. Throughout the year, we offered public speaking workshops to professionals across the Merrimack Valley to help them understand the issues of elder abuse and their role as mandated reporters. All of our WEAAD activities were spotlighted by the National Center on Elder Abuse.

In June 2012, we launched a new Elder Abuse online training video, targeting mandated reporters that we have been unable to reach through our face-to-face training efforts. The on-line training is accessible through the Protective Services page of our website www.esmv.org. This gives mandated reporters easy access to training and the forms they need to fill out after filing a verbal report. Also, as part of our WEEAD activities, we are expanding our education forums to reach elders themselves. Throughout the month of June 2013, Protective Services Staff again visited the 23 Councils on Aging throughout the Merrimack Valley to talk about elder abuse with seniors. Along with purple balloons and chocolates, we distributed Elder Abuse awareness palm cards to seniors that they can carry in their wallets or purse. These cards provide contact information to access help if they or someone they know may be a victim of elder abuse. We also advertised our activities through media vehicles including: a question and answer column hosted in local newspapers, our quarterly newsletter, a radio program hosted by ESMV, etc.

For 2013, we have decided to focus our Protective Services training and outreach efforts on First Responders. Our PS program staff will be meeting with the COA directors, Police Chiefs and Fire Chiefs in every city and town to develop opportunities for education and training and to facilitate stronger collaboration. (See Attachment 10: Protective Services Training materials)

http://www.esmv.org/


MAJOR GOALS & OBJECTIVES Our recent Community Needs Assessment identified these critical needs faced by elders

in the Merrimack Valley, ranked in order of priority: Economic Security; Health Care; Housing; and Maintain Independence. Far too many of our elders are struggling to meet basic needs. We have responded in several ways to help older adults meet these “basic necessities”. We will continue to help older adults meet these “basic necessities”, building on the foundation of supports and services ESMV has created.

ESMV has identified Food Security as a major priority for Community Programs to address across the Merrimack Valley. We are joining forces with other community organizations to create a Merrimack Valley Food Collaborative to maximize all available resources to address hunger and “food insecurity” among older adults in the Merrimack Valley. We recognize the need to move beyond emergency food relief and will focus our efforts on creating connections between food production (farms, greenhouses, Community Supported Agriculture, community gardens), food recovery (local restaurants, supermarkets), and food delivery (mobile food pantries, brown bag volunteers, etc.) to promote a community-based response to elder hunger and nutrition.

Our Financial Resource Program encompasses Money Management, Financial Literacy and Representative Payee). We will continue to seek investment by a variety of community partners (banks, private foundations) to enhance our ability to deliver these services. Our recent grant from the state Treasurer’s Financial Literacy Trust Fund will target Cambodian elders in Lowell – in collaboration with community partners such as the Cambodian Mutual Assistance Association (CMAA).

The Family Caregiver Support Program will continue outreach to COAs in the Valley to re-engage with them, and enlist their help in building local PTC training capacity. Building on our collaboration with the Lawrence Senior Center/COA, Mary Immaculate ADH and Home Health VNA to design a respite program that is responsive to Latino caregivers – we will seek funding for it. We also hope to: reach out more to the local business community to educate them about what we can offer their employees as “working caregivers”; nurture our Men’s caregivers’ group and connections to Grandparents as caregivers in the Merrimack Valley; and work more closely with our own CCTP staff to offer education and support to caregivers they might encounter while they are coaching consumers and their families.

As an ADRC, we will continue to respond to opportunities to improve access to the systems of care sought by elders and adults with disabilities, including: implementation of the ADRC-SHINE grant over the next 2 years; achieving specific benchmarks around cross-training and partnership development; and hosting a joint event for legislators.

The Healthy Living Center of Excellence (HLCE) was recently awarded $1,325,000 in grants from the Tufts Health Plan Foundation and the national John A. Hartford Foundation. This major investment will enable us to: 1) develop contracts with medical providers, including primary care physicians and specialists, ACOs, SCOs and other health plans to advance better outcomes by integrating community-based organizations’ services into their practices; 2) advance the vision of an integrated health care and social service delivery system to promote Healthy Living Programs; 3) strengthen partnerships with health care providers to improve patient care, health outcomes, and lower costs; 4) increase access and consistency of evidence-based programs and other community social


services; 5) further develop the organizational infrastructure to allow six regional collaborative to disseminate evidence-based programs statewide; and 6) deliver Chronic Disease Self-Management Education (CDSME) programs statewide.

ICOs/One Care Plans: ESMV is currently working with Commonwealth Care Alliance (CCA) for the One Care Plan (formerly known as the ICO). We will provide services with the One Care Plan with Long Term Support Services Coordinators and also utilize ESMV Registered Nurses to assist the CAA RN’s in completing the Comprehensive Assessments for the enrollees.

CCTP: As with most innovative, demonstration projects, this is a dynamic, evolving process – as ESMV and CMS continue to learn more about high risk patient population, what interventions are most effective, how best to address billing issues, how best to deploy coaches and what attributes, training, experience best predicts a successful Care Transitions Coach, as well as the kind of support and infrastructure necessary to enable them to succeed. We fully expect this program to continue to evolve, as we learn from our experience, current partners and future collaborators. Our goals for this program will continue to be: to deliver high quality, cost-effective coaching and appropriate interventions in order to reduce the overall rate of admissions at our partner hospitals, empower clients to more effectively manage post-hospital recovery, and strengthen our community collaboration throughout the health care arena in order to improve access, service delivery, and client outcomes.

The statewide Senior Medicare Patrol (SMP) Program will continue its efforts to enhance and build the capacity of the program in these ways: 1) expand the capability of the existing SMP volunteer corps through ongoing training, coordination and management in compliance with the Volunteer Risk Management Program guidelines; 2) broaden the volunteer pool to increase the number of bilingual and bicultural volunteers to reach LEP elders; 3) expand outreach and education efforts to reach vulnerable communities with information about high fraud areas and other deceptive marketing; 4) strengthen ongoing partnerships and build on collaborative opportunities with OIG, CMS and CMS contractors to continue healthcare fraud awareness activities throughout the State; 5) raise awareness about the role we each have in preventing healthcare errors, fraud and abuse by using mainstream and ethnic media, through PSAs, press releases, and our custom designed multi-language website, www.masmp.org linking to the DHHS Medicare fraud website, www.stopmedicarefraud.gov.

Housing: We expect to complete construction of our HUD 202 project in Tewksbury (the Villa at MeadowView) and open for occupancy in early June, 2014. This Supportive Housing development will house 32 older adults from the greater Tewksbury area who will have access to a part-time Resident Service Coordinator through ESMV; the property will be managed by the Tewksbury Housing Authority with oversight by the nonprofit Board of the Villa at MeadowView. While the future of HUD 202 funding remains uncertain, we will continue to advocate for increased development of affordable housing for seniors and adults with disabilities in the Merrimack Valley – a huge unmet need.

Volunteer Engagement: ESMV plans to take our existing Volunteer Program to the “next level” – updating and improving volunteer training and support, increasing our volunteer capacity both in numbers and diversity (age, skills, interests), exploring intergenerational projects and events, engaging local businesses and corporations looking

http://www.masmp.org/

http://www.stopmedicarefraud.gov/


for team events/projects as part of their social responsibility, and working with ESMV’s Development department to build lasting relationships with potential sponsors and donors through direct involvement as volunteers. (See Attachment 11: Volunteer Program materials)

STRATEGIES ESMV’s overall strategy can best be described as capacity-building – whether it’s building the capacity of other community-based organizations to deliver CDSMP and other Healthy Living programs; using train-the-trainer methods to teach caregivers take better care of themselves via PTC classes; enhancing the ability of hospitals, SCOs and ACOs to reduce avoidable readmissions through CCTP and care coordination; training first responders to recognize and respond to elder abuse; training bank tellers and educating elders and caregivers to prevent or avoid financial exploitation, scams or fraud; helping Medicare beneficiaries including adults with disabilities make informed choices and decisions about health insurance coverage – we will pursue innovative opportunities to empower individuals, families, communities and partners to promote health, independence, dignity, self-determination and choice across the lifespan.

QUALITY MANAGEMENT The quality efforts at Elder Services focus on specific quality issues that need attention, but also help determine future planning, training, and program development needs for the agency. Our consumer review efforts focus on casework and include: reviewing case files on a regular basis; special reports that measure specific documentation requirements; case and clinical reviews through team meetings and supervision; and program audits and corrective action plans. Our bimonthly Ethics committee meets to discuss difficult “cases” and determine impact on policy and procedure; a formal customer satisfaction process is conducted with written surveys to consumers and caregivers; and a staff evaluation process surveys contracted providers. We evaluate community outreach and education efforts with written evaluations and verbal feedback, including presentations, trainings, and conferences. Our staff council offers critique and input on a variety of internal systems, policies, and issues of concern to our employees that leadership staff review to examine agency operations. Future plans for quality include enhancing our data management systems for accurate and comprehensive data “snapshots” to help with program management, and formalizing individual program efforts to insure consistency in measuring consumer satisfaction and program needs. (See Attachment 12: Annual Report for an overview of our accomplishments)

elder services of the merrimack valley, inc. area …...since 1974, elder services of the merrimack...

Documents