Transcript Aging in Place

Building Healthier Communities:
Response to an Aging Community
A North Kansas City Demonstration Project
Tina Uridge, Clay County Senior Services
Michelle Peterson, Cerner Corporation
Dr. James Stewart, MD, North Kansas City Hospital
Katy Dodd, LifeWise Renovations
There’s No Place Like Home
© 2012 Cerner Corporation. All rights reserved. This document contains Cerner confidential and/or proprietary information which may not be reproduced or transmitted without the express written consent of Cerner.
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Older Populations Want to Live Independently
86%
Want to stay in their current residence for as long as
possible
85%
Want to remain in their local community for as long as
possible
65%
Want to stay in their home because they like what the
community has to offer
© 2012 Cerner Corporation. All rights reserved. This document contains Cerner confidential and/or proprietary information which may not be reproduced or transmitted without the express written consent of Cerner.
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What is the Scope of the Issue?
According to the Robert Wood Johnson
Foundation, one in five elderly patients
wind up back in the hospital within 30
days of leaving, creating a “revolvingdoor” affect.
© 2012 Cerner Corporation. All rights reserved. This document contains Cerner confidential and/or proprietary information which may not be reproduced or transmitted without the express written consent of Cerner.
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What are the Causes?
Social, Environmental and Behavioral Contributing Factors
Inadequate discharge planning
Persons living alone without a sufficient social support system
Having unmet functional need
Inadequate follow-up or self-management skills
Noncompliance with medications and diet
Failure to seek medical attention promptly when symptoms recur
© 2012 Cerner Corporation. All rights reserved. This document contains Cerner confidential and/or proprietary information which may not be reproduced or transmitted without the express written consent of Cerner.
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What Do We Know About North Kansas City?
20%
of the population is 62 years or older and this is
growing
24%
of households have individuals 65 years or older
73%
housing units are renter-occupied vs. owned
14%
of patients aged 65+ are readmitted*
© 2012 Cerner Corporation. All rights reserved. This document contains Cerner confidential and/or proprietary information which may not be reproduced or transmitted without the express written consent of Cerner.
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Enable a Livable Community and Aging in Place
Studies have shown that:
Older adults who receive home
modifications and specialized
home-based healthcare services
demonstrate reduced disability
and improved clinical outcomes
Supportive housing services are
more cost-effective than
assisted-living facility care
Home-based rehabilitation
services can reduce the
occurrence of readmissions
© 2012 Cerner Corporation. All rights reserved. This document contains Cerner confidential and/or proprietary information which may not be reproduced or transmitted without the express written consent of Cerner.
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Successful Partnerships in the Community
They are possible!
Require:
Committed, strong
leadership
Buy-in from all the partners
Regular communication
Involvement!
Look beyond costs
Studies show
Improved health for
community participants
Real cost savings from
prevention benefits
© 2012 Cerner Corporation. All rights reserved. This document contains Cerner confidential and/or proprietary information which may not be reproduced or transmitted without the express written consent of Cerner.
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North Kansas City Aging In Place
Public/Private
Partnership
Northland Shepard’s Center
NKC Community Center
City of North Kansas City
Clay County Senior Services
© 2012 Cerner Corporation. All rights reserved. This document contains Cerner confidential and/or proprietary information which may not be reproduced or transmitted without the express written consent of Cerner.
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What this looks like in NKC
North Kansas City Hospital
•Cost of readmissions and impact of
preventative health
City of North Kansas City
•Coordination of wellness planning at NKC
Community Center, transportation
LifeWise Renovations
•Thought leaders around best practices
for universal design for aging populations
Cerner Corporation
Northland Shepard Center
Clay County Senior Services
K2 Consulting Solutions
•Health Monitoring technology, local corporate partner,
real time lab for new advances in population health
•Service provider for target population
•Funder/partner in serving target
population
•Thought leader around the intersection of
housing and health
© 2012 Cerner Corporation. All rights reserved. This document contains Cerner confidential and/or proprietary information which may not be reproduced or transmitted without the express written consent of Cerner.
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Coordinated Aging Programs and Services
Whole community approach to
working with aging populations:
Multidisciplinary
Patient-centered
Home supported
Caregiver valued
Cross continuum
Intervention focused
Community-based
© 2012 Cerner Corporation. All rights reserved. This document contains Cerner confidential and/or proprietary information which may not be reproduced or transmitted without the express written consent of Cerner.
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Coordinated Aging Programs and Services
CONTINUUM
HEALTH
Wellness/Nutrition
STAY WELL
Benefits/Condition Mgmt.
CARE
Clinics and Community
MANAGE WELL
GET WELL
“Stay well” - Wellness Workshops, Exercise, Groceries, Education, Home Modification
“Manage Well” - Caregivers, Care Manager, Condition Management, Benefit Check-ups
“Get Well” - Follow-up Visits, Transitions to Primary Care, Falls Prevention, Transportation
© 2012 Cerner Corporation. All rights reserved. This document contains Cerner confidential and/or proprietary information which may not be reproduced or transmitted without the express written consent of Cerner.
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Aging in Place Demonstration Project
Identify a cohort of ~50 Clay and Platte
County residents aged 65+ hospitalized and
at high risk of readmission
Care management
Community engagement
Service enriched housing
Demonstration of participation and patient
outcomes
© 2012 Cerner Corporation. All rights reserved. This document contains Cerner confidential and/or proprietary information which may not be reproduced or transmitted without the express written consent of Cerner.
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Roles within the Demonstration Project
Care
Management
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Program Case Manager
Recruitment and consent
Coordinate with Primary Care Physician and other health services
Assisting with transition of care from the hospital to home
Post-discharge home visit and subsequent follow-up phone calls
Ensuring educational modules are available
Coordinating patient wellness plan and home health monitoring
© 2012 Cerner Corporation. All rights reserved. This document contains Cerner confidential and/or proprietary information which may not be reproduced or transmitted without the express written consent of Cerner.
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Home Assessment Specialist
Perform a full home safety assessment
Create prioritized list of suggested modifications
Work with participants to make low cost and simple modifications
Assist in determining appropriate home modifications
Schedule and oversee home modifications
© 2012 Cerner Corporation. All rights reserved. This document contains Cerner confidential and/or proprietary information which may not be reproduced or transmitted without the express written consent of Cerner.
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Community Programs Specialist
Coordinate with Program Case Manager to identify all participants
Conduct an assessment of individual community-based needs upon
discharge
Conduct an assessment of current state community resources
available on an individual basis
Connect participants to services for which they qualify
Identify barriers to patient engagement and receptivity
© 2012 Cerner Corporation. All rights reserved. This document contains Cerner confidential and/or proprietary information which may not be reproduced or transmitted without the express written consent of Cerner.
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Coordinated Aging Programs and Services
Community engagement
Care management
Service enriched housing
•Community Programs
Specialist
•Program Case Manager
•Readmission risk score
•Home Assessment
Specialist
•Transition of care
•Home safety assessments
•Benefits counseling
•Cerner Wellness
•Home retrofitting
•Aging workshops
•Assessment & condition
management
•Patient education:
wellness and nutrition
•Remote health monitoring:
wellness home device kit
•Handyman minor repairs
•Care calls, daily check-ins,
home visits & health checks
•Exercise programs
•Social support programs for
individual and caregiver
•Groceries and food
•Light housekeeping
•Home maintenance
•Yard care
•Transportation services
© 2012 Cerner Corporation. All rights reserved. This document contains Cerner confidential and/or proprietary information which may not be reproduced or transmitted without the express written consent of Cerner.
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Coordinated Aging Programs and Services
Step 1: Identify
Step 2: Design
Stakeholders
Funding opportunities
Project goals
Tailor programs to aging
Coalition objectives and
expectations
Aging Population
Health Management
Step 3: Implement
Step 4: Demonstration
Participation
Patient outcomes
© 2012 Cerner Corporation. All rights reserved. This document contains Cerner confidential and/or proprietary information which may not be reproduced or transmitted without the express written consent of Cerner.
Enroll participants
Provide services
Communicate
Coordinate
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Evaluation
Process Measures
Outcome Measures
•Number participants enrolled
•Knowledge and satisfaction
•Number home assessments
conducted
•Functional independence
•Number of home modifications
made
•Depression
•Quality of Life
•Number of wellness kits distributed
•Rate of falls
•Number and type of community
programs for which participants
qualify and enroll in
•Rate of hospital readmission
•Return on investment
•Number of meals delivered
© 2012 Cerner Corporation. All rights reserved. This document contains Cerner confidential and/or proprietary information which may not be reproduced or transmitted without the express written consent of Cerner.
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“We need to keep people in their homes, but we need
builders to renovate them and care givers to come to
their homes. We need the medical community to
think more about delivery of care at the home level
and use hospitals only as the last option.”
LIVE
Eugene Wilson, a volunteer
concerned with aging issues
WELL
AND
INDEPENDENT
Quoted in Stafford, D. “Living out your years at home can be challenging,” Kansas City Star, 4/16/11.