Hebrew SeniorLife

Organizational Overview and

Affordable Housing with Services (R3)

HPC Board Meeting - Sept 2017

Right Care, Right Place, Right Time: Effectively Integrating Senior Care and Housing (R3)

Hebrew SeniorLife – At A Glance

113 year old organization

2,600 employees serving 3000+ seniors across 8 campuses and communities, and in-homes

– 1,500 units of senior living (independent and assisted)

– 775 beds of long term chronic care, sub-acute, and rehab care

$210+ million in annual revenue

– 4th largest nonprofit in Massachusetts (per BBJ)

Medical staff with 40 physicians and nurse practitioners

Affiliated with Harvard Medical School

– Largest aging research institute in a clinical care setting

– 700+ clinical professionals trained annually

Boston Globe Top Employer – last two years

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HEBREW SENIORLIFE OUR DNA: ONE COMMITMENT – REDEFINE THE EXPERIENCE OF AGING

… and Teaching

• Medical Students • Residents & Fellows • Nursing &Therapies • Interns

Redefine Senior Health Care • Home Care • Geriatric Primary Care • Outpatient Care • Medical Acute Care • Rehabilitative Care • Long-term Care • Hospice

Reimagine Senior Living

• NewBridge on the Charles • Orchard Cove • Center Communities of Brookline • Jack Satter House • Simon C. Fireman Community

Rediscover Every Senior’s Potential Through Research •Aging Brain Center •Syncope & Falls •Translational Research •Center for Musculoskeletal Research •Genetics & Geriomics •Quality of Care/Standards

Reach out for Philanthropic Support Recognize the Power of Partnerships

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HSL COMMUNITIES 4

HSL has developed a focused new strategy

Who? What Aims?

Dire

ct se

rvic

e an

d ca

re

Indi

rect

Impa

ct

Measurably improved quality of life

• Seniors 55+ and their families across the nation and globe

• Health care & senior care organizations, policy makers

• Geriatric professionals and researchers

HSL seeks to improve the quality of life for a growing number of seniors

and their families

• In Eastern Massachusetts

• Embracing all religions while remaining rooted in HSL’s Jewish heritage and values

• With a focus on the most vulnerable and under-served seniors, e.g.: - Age 75+ - Low and middle income - Medically complex - With Alzheimer's and other dementias

Health Cost

effective- ness

Personal satisfaction

• Mobility

• Mental health

• Cognition

• Comfort

• Autonomy

• Empowerment

• Respect

• Security

• Lower out-of-pocket costs

• Higher ROI for society

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Vitalize 360 – Key Component of Our Model

What Matters Most Coaching and assessment model supporting seniors to identify what is important to them and reach personal goals

Research Based Evidence-based assessment tool to with person-focused wellness plan

Software Supported Lifestyle survey, Health and

Social Check up, Vitalize Plan, reporting tools

Population Health Outcomes data for evaluation of individual and population health, benchmarking, and informed program design

The 360 View Health, nutrition, physical and

mental fitness, community, connections, spirituality, purpose,

learning

Innovative Solution Created by Orchard Cove,

expanded to 5 HSL communities, in partnership with Kendal,

Now in 33 communities and growing

HSL’s future approach will allow us to proactively reach more populations of seniors

Develop measures, metrics and tools to track outcomes 7

• Institute for Aging

Research

• ReAge Solutions

• Teaching Institute • Replicable model of

Affordable Housing with Supportive Services

• Brookline Master Planning

• Roslindale Campus

• Alzheimer’s Disease and Center of Excellence

• Prevention of Elder Abuse

and Neglect

• Home and Community-Based Services

• Continuing Care @

Home

• Shared Savings Initiatives

• Geriatric Care

Management Optimize our campuses

Primary and Secondary Aims

Goals Create a platform for housing and healthcare collaboration & measure effectiveness

Wellness Teams

Partners

Timing

R3: Right Care, Right Place, Right Time: Effectively Integrating Senior Care and Housing

Our vision is to create a replicable, scalable, and sustainable model of housing with supportive services to enable seniors to live independently as long as possible, receiving the right care in the right place at the right time, while reducing health care costs for this growing population.

Wellness Coordinator and Wellness Nurse

6 mo preparation period, 18 mo implementation

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Payers, hospitals, ASAPs, emergency service providers, mental health, housing

R3 Initiative: Total Funding, Scope, & Evaluation

Combined Funding Sources

of $1M

7 Senior Housing Sites

1,100 Residents 400 Enrollees

Health Policy Commission * MassHousing *

DHCD *

* Enterprise * Beacon Communities * WinnCompanies

HSL CCB Danesh * HSL CCB Cohen *

HSL CCB Goldman* Winn – TVAB *

* HSL - Fireman * MRE – Unquity House * MRE – Winter Valley

Evaluation / Research

UMass Boston * LeadingAge Collaboration *

* Pre/Post & Control Group * Impact Analysis

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Aims and Key Performance Indicators for R3 Ai

ms

Key

Perf

orm

ance

In

dica

tors

Increase utilization of wellness programs by 20%

Improve quality of life and ability to live independently by 10%

Reduce re-hospitalizations by 20%

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• Falls

• Wellness checks

• Medication adherence support

Health Cost

Effective- ness

Personal satisfaction

Increase linkages to mental health services by 20%

Reduce transfers to hospitals, emergency rooms, and long term care by 20% for target

population

• Wellness program attendance

• Health education

• Self-management/care

• Satisfaction with life and independence

• Transfers to long term care

• Transports to hospitals and emergency rooms

• Hospital readmissions within 30 days of discharge

R3 Initiative: Key Components & Current Status

Resident Engagement 400+ residents recruited across 7 sites

(210 Brookline, 190 Rand/Milt) Baseline assessments completed

Potential impact on all 1,100 residents

Wellness Teams 2 Coordinators & 2 Nurses embedded in housing

Trained in IRB and Vitalize 360 Analytics – PI team

Partnerships Emergency responders: data, training Housing: open door, recruiting

ASAPs: care managers, evidence based programs Health plans: care teams, sustainability Mental health: referrals, awareness

Programming/Health Education Targeted programs added

(brain health, med mgmt, falls prev, mindfulness) Vitalize coaching concepts utilized

Monthly newsletter Interventions

What matters most – assessments, risk groups Monthly check in calls/data gathering Supportive services teams, eyes on

Care manager collaboration and referral Transitions management

Research UMass Boston – design, ongoing

Control sites – 2 in process (baseline) Quant/Qual, Interv/Comparison

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R3 INITIATIVE: SUSTAINABLE MODEL OF HOUSING WITH SERVICES

POOLED FUNDS

ENHANCED SUPPORTIVE HOUSING WITH SERVICES

BETTER

OUTCOMES

SAVINGS

• Insurers

• Housing Providers

• State agencies

• PMPM, shared cost, or convener model

• Eyes on

• Emergency Response

• Care Coordination

• Community Services

• Assessment

• Wellness Programming

• Mental Health

• Nutrition

• Decreased hospitalizations

• Decreased Emergency Room visits

• Decreased Long Term Care Placements

• Decreased Falls

• Increased Medication Adherence

• Increased Self Care

• Increased use of Home and Community Based Services

• Pooled funds cover cost of wellness services

• Place based services result in savings to healthcare system

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HSL’S R3 INITIATIVE: IN THE NEWS

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