The Community Supports Navigator Program

The Community Supports Navigator Program Building a Bridge of Support: Neighbors Helping Neighbors Presented by: John Cochran, Assistant Director for Legislative Affairs and Strategic Planning Gail Koser, Assistant Director for Division of Policy, Research and Legislative Affairs Amy Snyder, Senior Long Term Care Coordinator, Bureau of Long Term Care

Workshop Purpose • Background/Context • Federal and State Policy • Overview of Community Supports Navigator Program

NYSOFA’S Mission • The core mission of the New York State Office for the Aging is to help older New Yorkers to be as independent as possible for as long as possible through advocacy, the development and delivery of person-centered, consumer-oriented, and cost-effective policies, programs and services which support and empower older New Yorkers and their families, in partnership with the network of public and private organizations which serve them: • Local network of providers • 59 AAA’s – thousands of subcontractors • Medicaid spend-down and nursing home diversion programs • Cost effective community-based services

NYSOFA Priorities • New York @Home – Comprehensive consumer program to assist older persons to continue living independently • NY Connects – Home and Community Based Services • Community Empowerment Strategies – Community Building: the process to achieve goals through the development of Sustainable/Livable Communities • Health Promotion/Wellness • Caregiving – 2.2 million caregivers in NYS • Family Caregiver Council • Title IIIE – National Family Caregiver Support • Civic Engagement, Volunteerism, Workforce

National Governors Association (NGA) Center for Best Practices Policy Academy on Civic Engagement: Engaging Seniors in Volunteering and Employment • New York State selected to participate in 2008 • New York is one of six states selected to participate in the Academy - Idaho, Illinois, Maryland, Massachusetts, and Pennsylvania • New York State Office for the Aging - selected by Governor to lead NY’s involvement

National Governors Association Center for Best Practices "Policy Academy on Civic Engagement of Older Adults" • The focus is on helping states improve the health and lives of older adults and strengthening communities statewide by developing strategies for training, retraining and retaining older adults and volunteer activities/ opportunities. • The grant will work to develop strategies to utilize more effectively the skills, knowledge and talents of older adults by enhancing access to life long learning opportunities and meaningful volunteer activities that can help address many community problems.

NGA Project - New York State Volunteer Service Goals • Raise awareness and educate the public regarding the importance of fostering a culture of service and valuing the contributions of older adults to communities and the workplace. • Strengthen the infrastructure that supports the mobilization of older New Yorkers to participate in meaningful volunteer activities and programs that address community needs – i.e. Community Support Navigator.

The Transformation of Long Term Care • There is a national movement toward a person-centered, self-directed long term care system. • This system should effectively assist consumers with identifying and accessing a whole range of home and community based resources. • It is necessary to design a system that maintains the independence of older adults and persons with disabilities while supporting transitions in care that promote quality and consumer empowerment.

Health Care Reform • The recently passed Health Reform Law contains specific directives related to providing high-need Medicare beneficiaries with primary care services in their home in order to reduce preventable hospitalizations, prevent hospital readmissions, improve health outcomes, improve the efficiency of care, reduce the cost of health care services, and achieve patient satisfaction. (Effective January 1, 2012)

The Affordable Care Act Implementation Timeline • 2011 • Improving Transitional Care for Medicare Beneficiaries. Establishes the Community Care Transitions Program to provide transition services to high-risk Medicare beneficiaries. Effective January 1, 2011 • Increasing Access to Home and Community Based Services. The new Community First Choice Option, which allows States to offer home and community based services to disabled individuals through Medicaid rather than institutional care. Effective October 1, 2011 • 2012 • Reducing Avoidable Hospital Readmissions. Directs CMS to track hospital readmission rates for certain high-cost conditions and implements a payment penalty for hospitals with the highest readmission rates .

New York State Health Care Law • Regulations to be instituted that may incorporate quality related measures pertaining to potentially preventable complications or readmissions and provide for rate adjustments or payment disallowances related to potentially preventable readmissions

Aging and Disability Resource Centers (ADRCs) • Collaborative effort of the Administration on Aging (AoA) and the Centers for Medicare & Medicaid Services (CMS) • Single points of entry into the long term care system for older adults and people with disabilities • AoA and CMS originally funded 43 states and territories to develop ADRC programs between 2003-2005

ADRC Core Functions • Raise visibility about the full range of options that are available through: • The provision of objective information, advice, counseling, and assistance • Empowering people to make informed decisions about their long term supports • Helping people to easily access public and private long term supports and services programs • The provision of support during periods of care transitions

NY Connects: Choices for Long Term Care • NY Connects is the driving force behind New York’s effort to rebalance the long term care system • Established in 2006 by NYSOFA and the Department of Health • Recognized by AoA and CMS as a formal ADRC • There are 54 local programs in NYS

NY Connects Components • Information and Assistance – provision of comprehensive, objective information on the full range of available long term care options • Public Education – ongoing education and awareness campaign • Long Term Care Councils – local advisory groups comprised of consumers, providers, advocates, government reps, and other key stakeholders that are charged with analyzing the long term care system and making recommendations for improvements • The provision of support during periods of care transitions

Federal Funding Opportunities • In September 2009, $11 million in grants were awarded to 49 states and territories to implement or expand the ADRC program • New York State was awarded $246,056 for the first year of a three year grant • Albany and Tompkins Counties were selected as pilot sites for this grant • A key component of this grant is the development of a Care Transitions program

What are Care Transitions? • The term care transitions refers to the movements that patients make between health care practitioners and settings as their condition and care needs change during the course of a chronic or acute illness. • Transitional care is based on a comprehensive plan of care involving information about the patient's goals, preferences, and clinical status. It includes logistical arrangements, education of the patient and family, and coordination among the health professionals involved in the transition. Source: American Geriatrics Society Health Care Systems Committee. Improving the Quality of Transitional Care for Persons with Complex Care Needs. Journal of the American Geriatrics Society. 2003;51(4):556-557.

Transitions Between Points of Care • Home to Hospital • Hospital to Rehab or Skilled Nursing Facility • Rehab or Skilled Nursing Facility to Home. • From Somewhere to Hospice • From Hospice to Home or Rehab

The Care Transitions Interventionfrom a fragmented approach to a person-centered approach "Care transitions is a team sport, and yet all too often we don't know who our teammates are, or how they can help." ~ Eric A. Coleman, MD, MPH

Hospital Readmission Data • A 2003-2004 study published in the New England Journal of Medicine found that: • Almost 1/5 of Medicare beneficiaries had an unplanned readmission to the hospital within 30 days of discharge • While, more than 1/3 had an unplanned readmission within 90 days of discharge • Overall, unplanned readmissions were estimated to cost Medicare $17.4 billion in 2004 • New York State readmission rate: 20.7% Source: Jencks, S.F., Williams, M.V, & Coleman, E.A., 2009. Rehospitalizations Among Patients in the Medicare-Fee-for-Service Program. New England Journal of Medicine, 360(14). 1418-1428.

Top 5 Reasons for Hospital Readmission 30 day rate • Congestive Heart Failure – 26.9% • Pneumonia – 20.1% • Cardiopulmonary Disease (COPD) – 22.6% • Psychoses – 24.6% • GI problems – 19.2% Source: Jencks, S.F., Williams, M.V, & Coleman, E.A., 2009. Rehospitalizations Among Patients in the Medicare-Fee-for-Service Program. New England Journal of Medicine, 360(14). 1418-1428.

Care Transitions Models • Eric Coleman – The Care Transitions Program – 4 Pillars: (1.) medication management, (2.) use of a Personal Health Record (PHR), (3.) primary care and specialist follow-up, and (4.) knowledge of red flags • Mary Naylor – Transitional Care Model – eligiblepatients are assigned a Transitional Care Nurse who conducts a comprehensive assessment • Project BOOST Mentoring Program (Better Outcomes for Older Adults through Safe Transitions) – aimed at reducing readmission rates for hospitals across the country, includes a toolkit, a mentoring program, and national advocacy • The Reengineered Hospital Discharge Plan (Project RED) – Boston University – utilizes a 'discharge advocate' who provides education, support, and advocacy to the patient at discharge

Care Transitions – An Evidenced-Based Practice • Coleman’s Care Transitions Program: • Patients were significantly less likely to be readmitted to the hospital • Anticipated cost savings for 350 chronically ill individuals receiving the intervention during an initial hospitalization over 12 months is $295,594 • Naylor’s Transitional Care Model: • Within 6 weeks of discharge, patients receiving the Naylor intervention had a readmission rate of 10% versus a 23% rate for a control group • Within 24 weeks, there was a $4845 savings in total health care costs per person (i.e.: physician, hospital, and home health) • Project RED: • There has been a 30% reduction in hospital readmission rates and emergency room visits • The hospital saved approximately $400 in outcome costs per patient

New York State’s Response:The Community Supports Navigator Program • An initiative that will pair willing older adults with trained Volunteer Navigators who will help them access the services and supports that they need to remain safely in the community following discharge from a hospital. • The volunteer Navigators will be matched with these older adults and will provide assistance and guidance with non-medical tasks that the person might need when they are discharged from the hospital. The Navigator will connect with the person as quickly as they can during those vulnerable first days post-discharge.

Community Supports Navigator Target Population • Older Adults, who: • Are medically complex/have multiple chronic conditions • Having one or more of these: Chronic Obstructive Pulmonary Disease (COPD), Chronic Heart Failure (CHF), Myocardial Infarction (MI or Heart Attack), Renal Failure, Asthma, Diabetes Mellitus (DM), and/or Vascular Surgery • Are aged 60+ • Are currently in the hospital or has recently been discharged • There is a presence of informal supports. If informal supports are unavailable, the individual has the capacity for self-direction • Have some characteristics that make them at-risk of rehospitalization • The individual needs assistance that is consistent with the role of the CSN

Target Population Exclusion Criteria • Individuals that are being served by Adult Protective Services • Individuals who have medically complex needs** • Individuals who have socially complex needs, i.e.:** • A significant history of or current mental health diagnosis • A significant history of or current substance abuse problems **These individuals need not be excluded if CSNs with special skills in serving these populations are available to support these consumers and/or the CSN functions in a partnership with other professionals serving the consumer who are skilled in providing appropriate care.

Consumer Support Navigator Tasks • The CSN will provide a continuum of care after discharge for a period of 30, 60, or 90 days. • Following represent a list of tasks that the Navigator may be responsible for: • Assistance with scheduling and attending follow up appointments • Encourage the use and updating of the Personal Health Diary • Assistance with accessing prescribed medication • Encouragement of the use of medication reminders (pill boxes, medication check-list, automatic dispensers, etc.) • Provide information, education, and support to consumer and caregiver • Assist with linking the consumer to necessary community services and support groups • Providing companionship and support to the consumer or caregiver

The Personal Health Record • Component of the CSN program • A tool that will be used to collect, track, and share past and current information about the consumer’s health • Provides medical professionals with insight into the consumer’s health • Allows the consumer to update and manage their health status • Contains a medication list to be routinely updated by consumer or caregiver

Establishing a Host Agency • The host agency for the Community Supports Navigator should have the following characteristics: • A recognizable presence in the community, especially in long term care • Experience working with volunteers who provide a direct service to consumers • Strong internal and external communication skills • Strong management and staff development activities and approaches • A philosophy that embeds the use of strength-based approaches with a belief in consumer empowerment and self management • An environment where volunteers are respected and supported and civic engagement is a priority • Understanding and/or experience in working with older adults

Necessary Collaborations • Hospital (HANYS) – key in identifying older adults that may be at-risk of hospital readmission • NY Connects – will provide the necessary support to the volunteer and link the consumer to appropriate services • Professional volunteer organizations (e.g.: RSVP, Senior Companion, Senior Corp) – will assist in the recruitment and retention of volunteers

Albany County – Collaborative Model • Collaboration with a professional Care Transitions Model (Northeast Health Care Transition Model) • Volunteer paired with RN – to attend initial home visit together • Volunteer works with the consumer on non-medical reinforcements – key messages, medication self-support, updating Personal Health Record • Volunteer makes linkages to NY Connects

Tompkins County – Volunteer Model • Volunteers will be recruited and trained by existing volunteer organization • Volunteers will make contact with consumer in the hospital prior to discharge • Volunteer works with the consumer on non-medical reinforcements – key messages, medication self-support, updating Personal Health Record • Volunteer makes linkages to NY Connects • Volunteers will be supported by the Office for the Aging and NY Connects

Potential for Replication – NYSOFA’s Role • NYSOFA will work with the SUNY Center for Excellence in Aging Services and Community Wellness to develop a volunteer training curriculum that will be accessible statewide. • Technical assistance will be provided as the CSN progress towards implementation. • NYSOFA will continue to convene the Think Group for discussions involving program development • NYSOFA will develop and distribute a manual that will contain the components of the CSN program for replication purposes. • A overall evaluation of the CSN programs in both counties will be conducted by the Center for Excellence that will assist in the potential growth and expansion of the program.

Questions? John Cochran – John.Cochran@ofa.state.ny.us Gail Koser – Gail.Koser@ofa.state.ny.us Amy Snyder – Amy.Snyder@ofa.state.ny.us www.aging.ny.gov www.nyconnects.org

The Community Supports Navigator Program