Community Connections: Moving Seniors Toward Wellness A MOWAA Grant Project

1. Community Connections: Moving Seniors Toward WellnessA MOWAA Grant Project Funding for this project is provided by the Administration on Aging, Department of Health and Human Services, Award #90AM2884/01 Linda Netterville 4th State Units on Aging Nutritionists & Administrators Conference August 2006

2. Overview of Session • Vision of Community Connections Project • Community Connections Team • Building Strategic Partnerships • Creating a Systems Change • Challenges for Nutrition Programs

3. Shift toward less costly and more appropriate home and community-based servicing of acute care needs. Promote health, wellness, and independence of recently hospital discharged older adults Develop non-traditional community partnerships and demonstrate that these partnerships result in improved program coordination, services and health outcomes. Transform Meals On Wheels (MOW) providers into core programs within an integrated care system Vision of the Grant

4. Project Goal To build a comprehensive approach to promoting health, wellness, and independence of older adults through partnerships with nutrition programs, hospitals, and other community-based organizations.

5. Grant Projects • Cenla AAA, Alexandria, LA • Christian Senior Services, San Antonio, TX • Hawkeye Valley AAA, Waterloo, IA • Lutheran Service Society of Western PA, Pittsburgh, PA • MOW of Stark & Wayne Counties, Massilon, OH • Onondaga County Department of Aging & Youth, Senior Nutrition Program, Syracuse, NY

6. Community Connection Teams • Design Team-Provided the design, implementation, and monitoring of the project • Corporate Advisory Board-Leaders of the food and packaging industry provided guidance and support • National Level Advisory Council-Professionals with experience and expertise in nutrition, aging, health care, and home and community-based services provided expertise.

7. What we know… Healthcare Service Utilization for Persons 65+ • Account for 39.1% of all hospital discharges. • Rate of hospitalization increased over the entire period 1970-2000. • Rate of hospitalization is 3.5 persons for every 10 • 12.5 Mil discharged from hospitals in 2002

8. What we know… Healthcare Service Utilization for Persons 65+ • The average length of stay was 5.8 days compared with 5.0 days for persons age 45-64. • The average length of stay has decreased 5 days since 1980 (discharging quicker and sicker).

9. Nutritional Care Silos Community Based Services Older Individual Acute Care Setting Nutritional Services-Social, QOL, Provision of Meal, Nutrition Support Nutritional Services-Therapeutic for Medical Condition

10. Individual Senior wellness Program Service development & delivery System / Community Community partnerships Coordinated care Sustainability Long-term measure of change in person’s state of health or functioning Effects on health (decreased morbidity and mortality) Rehospitalization rate Program identifies innovative and cost-effective services and equips the organization (staff, resources) to deliver them. Community partnerships are strengthened and the senior health and wellness system is integrated to provide seamless care for the older adult—resulting in decreased re-hospitalizations and increased use of community-based care. Levels of Evaluation

11. Logic Model: Development of an Integrated Senior Nutrition and Wellness System Inputs Outputs Outcomes Development of service delivery innovations, treatment protocols and best practices Successful Sustainable system Improved identification of Senior health needs / more referrals Staff Identify community partners Community Partners design new system Money Cost savings, continued services Partners Appropriate services delivered to target population Facilitate community meetings Consistent application of best practices Healthier older adults Research To what extent did the change result in expected outcomes? Were all relevant parties to the system involved in the design of the system? To what extent did partnership increase? What resources were invested? How effective were community meetings? To what extent did the program and system change?

12. Mechanisms Needed in the Community-Based System Key Stakeholders Who must be aligned to achieve possibility statement? Coordinationof Services Acute CareNursing Staff Meals on Wheels SeniorNutrition Program / Hospital Partnerships • Possibility Statement • Expanded, affordable services • Services are customized • Service delivery is coordinated • Seniors restored to health • Hospitalizations decreased Physicians Home Health AAAs • Education • & • Marketing • Health Prof.’s • Clients • Caregivers Discharge Planners Dietitians Corporations Hospitals • Other Institutions: • Skilled Nursing Facilities • Rehab. Facilities • Interfaith Caregivers Helpful Mechanisms What elements of the system need to be redesigned to support the desired change? Referral & Identification

13. Program and System Evaluation: What Predicts Referral Rate? • Hours spent by MOW/CC program staff • For the first six months, it took an average of 45 hours of coordination on the Meal program side to generate 1 referral. • Six months later, the ration of number of hours to referrals is 13:1. • Process is beginning to be institutionalized.

14. Program and System Evaluation: What Doesn’t Predict Referral Rate? • No connection was found between those sites which had a previous relationship with their partner hospital. • Even those sites which had a previous relationship, had to spend a large amount of time to obtain sufficient number of referrals for the project. • Referral vs. Coordination of Services?

15. System ChangePreliminary Findings • Change requires a very significant level of effort • Effort involves extensive education and marketing. • Additional resources are needed to serve the population of hospital discharged.

16. System ChangePreliminary Findings • Incentives for hospitals and other referral sources (e.g. doctors) must be embedded into the structure of the system. • By reliance solely on grant funding, without a systems/program change this population will continue to go unserved.

17. Client Close-Out Interview Analysis

18. Client Close-Out Interview Analysis

19. Client Close-Out Interview Analysis

20. Client Close-Out Interview Analysis

21. Client Close-Out Interview Analysis

22. Client Close-Out Interview Analysis

23. Client Close-Out Interview Analysis

24. Partner Close-Out Interview Analysis

25. Partner Close-Out Interview Analysis

26. Partner Close-Out Interview Analysis

27. Partner Close-Out Interview Analysis

28. Wrap Up Project Deliverables • A Blueprint Model for nationwide replication • Best Practices which provides for local autonomy in the implementation • Data to support sustainability of the project Grant project ends 2/28/2007

29. Challenges for Nutrition Programs • Service concept • Expansion of services (More than a meal) • Integration of services with existing community services/Acute care services • Staff • Expansion of knowledge and skills • Resource building • Development of broad integrated funding base

30. Challenges for Nutrition Programs • Community Partners • Health care organizations • Community-based services • Non-traditional community services • Awareness building • Urgency to implement change

31. Acknowledgements • Nadine Sahyoun, PhD, RD, University of Maryland, College Park, MD • Ucheoma Akobundu, MS, University of Maryland, College Park, MD • Kevin Coray, PhD, Coray-Gurnitz Consulting, Washington, DC • Naomi Johnson, MS, Coray-Gurnitz Consulting, Washington, DC • Jean Lloyd, MS, RD, Project Officer, AoA, Washington, DC