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

Healthy-in-Place (HIP)-Seniors: A Durham Health Innovations Project. Eleanor S. McConnell, RN, PhD, GCNS, BC Duke School of Nursing & Durham VA Geriatric Research, Education and Clinical Center On behalf of the HIP-Seniors Team. The Cost of a Long Life. U.S. UC Project for Global Inequality.

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

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  1. Healthy-in-Place (HIP)-Seniors:A Durham Health Innovations Project Eleanor S. McConnell, RN, PhD, GCNS, BC Duke School of Nursing & Durham VA Geriatric Research, Education and Clinical Center On behalf of the HIP-Seniors Team

  2. The Cost of a Long Life U.S. UC Project for Global Inequality Slide Courtesy of Rob Califf, Durham Health Summit, 2009

  3. 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

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

  5. 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.”

  6. Life stage Maternal/Fetal Health Adolescent Health Seniors’ Health “Hard medical” Cardiovascular Cancer screening/survivors Asthma/COPD Behaviors Substance abuse/pain management Medical/behavioral Obesity Diabetes STDs DHI Planning Grants: $100K each Slide modified from Rob Califf, Durham Health Summit, 2009

  7. 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

  8. 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

  9. 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

  10. Aging in Place with Dignity Where is the sweet spot?

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

  12. Expanded Chronic Care Model

  13. 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.

  14. 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.

  15. 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

  16. 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

  17. Nonprofit Organizations Durham City & County Agencies HUB of Coordination Seniors Duke University Health System Coordination & Navigation HUB

  18. Community Resource Connection as a Hub?

  19. HIP Seniors Model: Navigation Process

  20. Next Steps

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