Live Well At Home Project: Targeting At-Risk Older Adults August 18, 2009 Age Odyssey Conference MN Board on Aging/ MN

1. Live Well At HomeProject: Targeting At-Risk Older AdultsAugust 18, 2009Age Odyssey ConferenceMN Board on Aging/ MN Dept. Human Services

2. Presenters • Jane.Vujovich@state.mn.us • Catherine Sampson, Arrowhead AAA csampson@ardc.org • Lori Vrolson, Central MN Council on Aging, lori@cmcoa.org • Elaine Spain, MN River AAA, espain@rndc.mankato.mn.us

3. AOA-Funded Nursing Home Diversion Project (NHDP) 2007-2009 - GOALS • Develop consistent, evidence-informed process to identify and triage persons at-risk of NH use and/or spend down to Medicaid. • Further develop flexible service options for older adults and family caregivers who are private pay.

4. Project Approach • Collaborate with 3 AAAs partners and their local partners for development and service delivery • Coordinate with existing strategies and MBA programs including caregiver support, MNHelp (ADRC), memory care, and health promotion strategies • Validate screening tool and process through formalized evaluation study

5. Target Population Primary: At-risk private pay older adults with incomes at 200-250% FPGs and their family caregivers Secondary: At-risk private pay older adults with incomes >250% FPG and their family caregivers; others reluctant to use public programs

6. VISION Reduce Medical Assistance spending by helping the target group stabilize and/or mitigate risk through risk management, evidence-based, and self-directed strategies.

7. The Live Well At Home (LWAH) Model • Focus on risk factors • Design for the private pay market – lighter, softer, self-directed approach • Build on success of caregiver coaching, risk management, and self-directed support models • Empower and support vs. case manage and control to reach consumer and system outcomes

8. 1. Rapid Screen Services • Rapid Screen • 7-question tool and income question • Identify personal risks most often associated with permanent nursing home entry and/or spend down to Medical Assistance. • Scores: high-moderate-low-no risk • Easily administered (3-5 minutes) • Post-Screen Counseling • 10-15 minute session following Rapid Screen • Offers basic risk factor and initial tips information • Offers information and assisted referral to direct diversion support options

9. How Risk Is Targeted Rapid Screen risk factors: Assistance with > 2 ADLS Injurious fall No family caregiver Stressed family caregiver Lives alone Planned housing move Memory concern Additional Question About Income

10. 2. Diversion Support Services • Intense, on-going professional consultation/coaching and planning services directly tied to help person stabilize/mitigate identified risk factors • Grounded in risk management, caregiver support/coaching, memory care, consumer direction, health promotion themes, principles, and evidence-based practice • Initial (2 hours) and Extended (12 hours/year) Services • 3 Modes of Service Delivery • Web • Group Session • 1:1 • Providers (group/individual): Specially trained providers who demonstrate competence in risk factor management and outcome monitoring, and adherence to protocols; coaching; self-direction • Funded under Title III, grants, and/or private pay sliding fee

11. Consumer Impact To Date (12 months) Sustained community living for: 243 persons screened 114 high-risk persons receiving diversion support 12 targeted persons using grant-funded self-directed services with a Fiscal Support Entity

12. Components & Tools for Consumer Empowerment • On-going screening, education, counseling, planning, outcome measurement, and follow-up • www.MNLiveWellatHome.org • Rapid Screen tool • Standardized risk messaging, information, and tip sheets, up-to-date risk information • Risk Action Plan • Cost-calculator tool • Link to Senior LinkAge Line® and MNHelp.info • Link to MNHealthyAging website (enrollment in classes) • Link to consumer-directed support infrastructure • Professional tools • Direct access to start-up funds

13. Coming Soon www.mnlivewellathome.net

14. Phase II Goal: Leveraging System Capacity to Support LWAH Model On-Line Education (print education on risk factors) Multi-media Education (pod casts, video clips, recorded messages) Direct Service Providers Evidenced Based Community Programs, Aging Services, & Self Directed Supports 14 Minnesota Department of Human Services

15. What Needs to Happen: A Paradigm Shift Highly Focused Impact Aggressive identification & screening for those at highest risk Focused assessment for specific risk factors Evidenced based Interventions by risk factor Proactive Prevention Risk Management Model Topic Related Impact More Focused Assessment Coaching on topics where content is built and in use Usually Crisis Reaction Coaching Model Diffused Impact Generalized Assessment Less ability to prioritize Crisis Reaction Social Work Model Then Now -- Future 15 Minnesota Department of Human Services

16. Definition- social work Organized work intended to advance the social conditions of a community, and especially of the disadvantaged, by providing psychological counseling, guidance, and assistance Definition- Risk Management Proactively assessing, prioritizing, mitigating (to an acceptable level), and monitoring specific risk factors. Why risk management makes sense in LWAH Social Work Vs. Risk Management 16 Minnesota Department of Human Services

17. Expected System Impact • Medical Assistance savings • Less use of emergency/urgent care • Face-to-face services and Title III funds become directed to the target population • MN’s ADRC strategy, MBA programs, and local networks working to support LWAH model

18. What’s Ahead? • Broadly disseminate the Rapid Screen Tool • Integrate diversion support services and risk management protocols into the MinnesotaHelp Network™ and HCBS system • Build capacity and sustainability for high quality diversion support services • Implement Veterans-Directed HCBS option • Community Living Grant Proposal (AoA) • Implement 7 AAA regions 10.01.09 – 09.30.11 • Community Services/Service Development Grants (CSSD)

19. Catherine Sampson, Director [csampson@ardc.org] Arrowhead Area Agency on Aging LWAH Project: AAAA Experience

20. Project Partners • Senior LinkAge Line® (Arrowhead AAA staff) • Parish Nurses (Duluth area) • Hands in Service • Consumer Directions, Inc. – FSE • Benedictine Health Center*

21. Regional Approach • Rapid Screen: • Partners conduct rapid screen (in person, telephone) and provide post-screen assistance • Parish Nurses obtain informed consent and AAA Care Consultant obtains informed consent from persons screened by other partners • Partners refer to AAA Care Consultant for Diversion Support (86 rapids screens completed to date)

22. Direct Diversion Support Services • Specialized consultation and follow-up provided by AAA Care Consultant to help person manage risk factors • Consumer-Directed funds – provided to consumer via FSE to purchase self-directed community supports (currently 25 individuals/families using diversion support services; 12 persons using CDC funds)

23. Alice – 82 year old • She was failing to thrive living alone in a malodorous apartment and with an apparent need for personal care. Meals on Wheels were her only community support. • She was found to be “high” risk for nursing home diversion entry and spend down to Medical Assistance • Her income is between 200-250% FPG • She lives alone • Does not have an available family caregiver to help her with personal care and housekeeping needs • Is actively considering a move to assisted living • Has concerns about memory.

24. Alice – continued • Under LWAH she employed a friend in the building to help her with personal care and housekeeping needs. • With her private dollars she matched the $1,500 flexible service grant dollars at 100% and has continued to buy this help once the grant funds were fully spent. • A fiscal support entity helps her employ the worker. Alice and her worker were educated in ways to manage her risks. • Risk factors were stabilized and a crisis was avoided. She is now thriving and living in a clean apartment where she is happy and content.

25. Private Pay Costs for LTC Services/Support

26. Lori Vrolson, Executive Director Central MN Council on Aging Experience

27. Project Partners Title III Caregiver Coaches 1. East Central Senior Resource Center -Rapid Screen/Support Planning 2. Great River Faith in Action -Rapid Screen/Support Planning 3. Memory Care Clinic -Rapid Screen Services Senior LinkAge Line® -Rapid Screen Services 27

28. CMCOA: Rapid Screens • 166 Rapids Screens Completed 42% High Risk 12% Moderate Risk 20% Low/No Risk • 27 high-risk persons using support planning (i.e., diversion support) services 28

29. Lessons Learned • Rapid Screen is quick and easy to use • Relationships between the older adults and the provider are key to assisting the individual in developing and implementing their risk action plans 29

30. Elaine Spain, ElderCare Development Partnership Consultant[espain@rndc.org]Minnesota River Area Agency on Aging®, Inc.

31. Partners Aging Services for Communities – Le Sueur Co. Mankato Area Living at Home/Block Nurse Program – Mankato VINE Faith in Action – Blue Earth & Nicollet counties

32. Regional Approach • Rapid Screen: given at time of request for services • Each partner provides rapid screen services • 70 rapids screens completed to date