Healthy-in-Place (HIP)-Seniors:A Durham Health Innovations

Project

Eleanor S. McConnell, RN, PhD, GCNS, BCDuke School of Nursing &

Durham VA Geriatric Research, Education and Clinical CenterOn behalf of the HIP-Seniors Team

UC Project for Global InequalityUC Project for Global Inequality

The Cost of a Long LifeU.S.

Slide Courtesy of Rob Califf, Durham Health Summit, 2009

Durham County Health Status• The US is approximately equal to Cuba

(and worse than several dozen other countries) in terms of the health of its citizens

• North Carolina is in the bottom half of US states in survival and functional status

• Durham County is average for North Carolina in almost every health statistic– except significantly more doctors and dentists per

population

Slide Courtesy of Rob Califf, Durham Health Summit, 2009

Opportunity to partner with community as never before to improve important public health outcomes in Durham

CDC Definition of Community Engagement

• “ the process of working collaboratively • with and through groups of people

affiliated by:– geographic proximity,– special interest, or – similar situations

• to address issues affecting the wellbeing of those people.”

DHI Planning Grants: $100K each

• Life stage

1. Maternal/Fetal Health

2. Adolescent Health

3. Seniors’ Health• “Hard medical”

4. Cardiovascular

5. Cancer screening/survivors

6. Asthma/COPD

• Behaviors

7. Substance abuse/pain management

• Medical/behavioral

8. Obesity

9. Diabetes

10.STDs

Slide modified from Rob Califf, Durham Health Summit, 2009

Unique Features of DHI Projects

Access to:• GIS mapping• Data Support

Repository• Durham stakeholders

– Agency heads– Senior leaders at Duke

Intention to change systems of care

Timeline for The Process

• Sept – Nov 2008: Stage 1 proposals• Jan – Mar 2009: Stage 2 planning• April – Dec 2009: Stage 3 planning

• Monthly Team Meetings with >75 stakeholders from DUHS and Durham Community

• Work Groups Meeting regularly to gather data, summarize & explicate evidence-based models

• Ongoing Focus Groups & Social Marketing to:– Define the problems with seniors & their health care– Develop an innovative model of care for seniors

Process

• Propose an evidence-based concept responsive to public health need of Durham County

• Build a team– Community & University co-leadership

• Think big• Collaborate across teams• Focus quickly

Aging in Place with Dignity

Falls Prevention & Physical Activity Promotion

Outreach to Socially Isolated

Medication Management

ImprovedCare Transitions

Where is the sweet spot?

Courtesy: AARP: http://www.aarp.org/research/ppi/articles/faces_of_chronic_care.html

A protypical scenario….

•“I would get scared – I didn’t even realize I had been to the ER 19 times”

Themes:•Doctors are too busy•Misses…

•Diagnosis•Medications•Information on phone

•Family caregiver frustrated

Expanded Chronic Care Model

VISION

By 2020, Durham County will be the community where seniors safely age in place supported by collaborative efforts of a community-university health system that empowers them with the information and resources to make choices on the quality of their own lives.

MISSION

HIP Seniors is a collaborative, community-based

planning process bringing stakeholders from the

community and university health systems

together to design a streamlined, comprehensive

and innovative model of care for seniors.

Thismodel will provide seniors a person-centered,

evidence-based, cost-effective, responsive

system of care by building upon existing

services and offering seamless transitions, no

wrong door access, and full coordination of care.

Model Outcomes

• Decrease return visits to hospital/ED

• Decrease EMS calls, ED visits & hospital admissions due to falls or med-related issues

• Increase in seniors who report at least 30-minutes of physical activity per day

• Increase in seniors receiving immunizations

Core Components

• USA – Universal Senior Assessment – Tool to identify risks and strengths, shared information

• Navigation – Various strategies:

• Self-management,

• Family-caregiver support,

• Lay navigators in community agencies or neighborhoods, or

• Senior Support Nurse

• Link & Support to Key Interventions– Specific programs or services that address identified risk

• Coordination of Services HUB– Information, access, follow-up, follow-through and linkage to existing

community and health system services

Coordination & Navigation HUB

Seniors Duke University Health System

Nonprofit Organizations

Durham City & County Agencies

HUB of

Coordination

Community Resource Connection as a Hub?

POINT OF CONTACT:ER, Hospital Admission, PCP, or Community Agency

Universal Senior Assessment (USA)

Completed*

Assessment includes:

•Falls risk assessment•Cognition assessment•Medication assessment•Wellness practices •Social support

PHASE 1:Assessment

PHASE 2:Identify Care Navigator Type

Self

Family/ Significant Other

Lay Care Navigator

Senior Support Nurse

**Each care navigator would consult and collaborate with discharge planner (PRM) as is current practice. New Discharge checklist to be revised/added consistent with Coleman’s Model

*Completed by RN in ER or hosp. setting

PHASE 3:Identification of Potential Interventions

Personal Electronic Health Record to be made available to the care navigator and health care providers across the care continuum.

Falls Risk Referrals & Linkages

Medication MgmtReferrals & Linkages

Wellness Practices

Referrals for vaccines, or to community or health system resources re physical activity

Social Needs

Such as transportation, meals on wheels, utility assistance, personal care service referrals

Complex Health Care Coordination

Coordination of care & assistance with multiple co-morbidities, multiple health care providers, lack of social support to assist, facilitates communication and assesses ongoing needs, both health & social

Coordination of care & assistance with multiple co-morbidities, multiple health care providers, lack of social support to assist, facilitates communication and assesses ongoing needs, both health & social

HE

AL

TH

CO

RE

HIP Seniors Model: Navigation Process

Next Steps

Time Step

Now.. Durham Health Innovations Oversight Team reviews reports, and finds commonalities to create a Close-Connected-Care model

Limited support for ongoing project management to coordinate team activitiesPublish articles on our experience, ideas, findings

Ongoing •Uniform Senior Assessment (USA): Pilot recently funded to support development of transitional care module

•Medication Reconciliation & Therapy Management Pilot: seeking funding•Improved Discharge Processes Pilot: GEC funded•Lay navigator •Coordination hub – preparing CRC proposal