A Collaborative Community-Based

Model

CarePartners in

A CSSD Project, State of Minnesota, Dept. of Human Services

© 2008 Normandale Center for Healing & Wholeness, Edina, MN 55436

Today’s Agenda • Describe the Partners in Care approach• Identify/describe results/impact • Identify “promising practices” that have

emerged • Discuss how to make the “business

case”• Identify potential next

steps/sustainability • Discuss new e-technology component

ProjectTo “walk with” 100+ older

adults and their family members (caregivers) on their journey for at least

one year.

Through a collaborative of organizations--coordinate

assistance such as volunteer support,

resource information, education & prevention.

Desired Impact

More aware, informed choices

Better connections

Help seniors and family members understand their own needs, connect to resources (including volunteers), plan

ahead, prevent functional decline where possible, and make informed decisions.

Willingness to use additional supports

Two Areas of Focus

People• Seniors • Family caregivers

Systems• Partners in

Care organizations working together in a neighborhood-based approach

Profile of Older Edina Residents

• Nearly 1 in 4 Edina residents are over age 65• 36% of all households have a person who is

over age 65• 49% of senior households have seniors who

have lived in the same house for 30 years or longer

• 3% of Individuals over age 65 live below poverty level

Sources: Supporting Edina’s Seniors: Opportunities for Strengthening Informal Networks, Report to the Edina Human Relations Commission, January 2003; U.S. Census Bureau, 4600 Silver Hill Road, Washington, DC 20233 www.census.gov/main/www/contacts.html

People Participating

• 168 Seniors & Family members – primarily live in Edina/Bloomington

• Live in the community, not a nursing home• Informed consent to participate

(cognitively able to participate)• Seniors: 73% women, 27% men, average

age 81• Seniors: About 60% live alone; single

family home or townhome/condo

Example of issues/needs• Transportation • Home repair, maintenance & yardwork• Help with exploring and making a move• Information/education on prevention or wellness• In-home services or home delivered services, support

(e.g., housekeeping, meals, personal care)• Help with legal or financial planning issues• Grief support• Isolation• Family caregiver role: stress, need for information

Partner Organizations

Normandale Center forHealing & Wholeness

“Walking With” Approach to

Community-based Support

Parish Nurse

Support

Older Adult & family members

Resource Coordination

(I&R)

Organized Volunteer Support

(includes rides)

Prevention Pgrms/Scrning

Cgvr Ed/Trng

Education

Partners in Care Approach

For Persons• Enroll/Informed

consent• Assess• Team• Listen, Respond • Inform/Invite (All)• Target (High Risk)• Maintain contact• Encourage

For Organizations• Outline areas of

responsibility for each organization

• Group planning meetings 3-4x year, plus one-on-one around events/services

• Evaluate response• Report back &

modify

Project Components

• A year of “walking with” – Tailored personal assessments & home

visits– Volunteer support– Resource coordination and information– Screening, clinics, health education– Wellness, fitness– Caregiver training & workshops & resource

materials– Quarterly newsletters

Parish Nurse Home Assessments

• Senior Self-Assessment gives a baseline and periodic updates of each senior’s situation

• Helps them think about what they need now and what they need need in the future

• Opportunity to ask questions about wellness and “aging successfully”

Normandale Center forHealing & Wholeness

Coordinating Community Resources

• One-on-one resource coordination support with staff (Normandale or Edina Resource Center)

• Calls or visits (at request) from Resource Coordinator staff, tailored to informational needs (make use of Senior Linkage Line and www.minnesotahelp.info )

15

Volunteer Care Team Support

• Care Team Model – We help organize a group of volunteers to address non-medical supportive needs (e.g., grocery shopping, rides to medical appointments, friendly visiting, exercise buddy, reader, paperwork support, etc.)

• OLG or Normandale coordinates the volunteers Normandale Center for

Healing & Wholeness

Health Education, Screening & Fitness

• Falls Prevention• Stroke Prevention & Stroke

Awareness • Diabetes Prevention • Tai Chi • Flu Shots

All PIC participants

provided with Resource Toolkit (including west metro Resource

Directory)

Caregiver Support

• Caregiver training and support co-facilitated and hosted by ElderCare Rights Alliance, using the “Share the Care” model and components of the PIC Resource Toolkit (including the “Family Resources” and “Resource Directory” sections)

Results: Senior Participants

• High participation rate in services/programs

• Many weathered changes in conditions or new events

• Fewer hospitalizations/falls

• Several moved to assisted living or senior housing; many accessed new services in the community or through the program

• 3 permanent nursing home placements since 2006

• 15 deaths over 2.5 years

9%11%

35%35% 35%

41%

17%

9%

3%5%

0%

5%

10%

15%20%

25%

30%35%

40%

45%

1 =Exllnt 2=V. Good 3=Good 4=Fair 5=Poor

Health Status in Last Year - 1st Cohort

Assmnt. #1 Assmnt. #2

Selected Index: Health Status

Selected Index: Living Arrangement

0.0%

20.0%

40.0%

60.0%

80.0%

100.0%

No Yes

Assessment

Changed Living Arrangements, Cohort 1

Assmnt.#1

Assmnt. #2

Selected Index: ER Visits

1413

8

2

5

1

0

5

10

15

1 Visit 2 Visits 3 + Visits

Number Reporting One or More E.R. Visits in Last Year, Cohort 1

Assmnt. #1 Assmnt. #2

Selected Index: Hospital Visits

12

18

9

35

3

0

5

10

15

20

1 Visit 2 Visits 3 + Visits

Number reporting one or more Hospital Visits in Last Year - 1st Cohort

Assmnt. #1 Assmnt. #2

Selected Index: Falls

66%75%

34%25%

0%

20%

40%

60%

80%

No Yes

Fallen in Last Year, 1st Cohort

Assmnt #1 Assmnt #2

Results: Organizations

• Increased service capacity, increased persons served

• Increased number of volunteers• Improved programs on health education,

screening (more, better)• Created new methods of “walking with”

older persons and family members• Increased connections between

organizations and improved efficiency

Promising Practices:

• Actively recruit/define the population upfront • Make 1st access point clear (Normandale &

OLG)• Actively facilitate connections, encourage

participation, ensure follow-up• Maintain relationship-based, “informed

friend” approach• Take into account both older person and

family situation• Be sure roles, duties of each organization are

clear

Promising Practices• Conduct a baseline assessment in home• Identify family member or key contact upfront• Use a team approach to each person/family• Periodically check in (on radar screen) • Be proactive on health ed/screening; we

contact each person to encourage participation

• Encourage families to be aware of resources & contact us when needed—keep trying

Promising Practices

• Build in “person contact” opportunities • Keep updated records that the whole

team can access• Ask permission to let others know—

then follow-up• Keep inviting them and encouraging

them• Be there during times of transition

Important “Transition Points”

• When spouse dies• When fall occurs (with injury)• When person decides to stop driving• When person decides to make a move• When health declines (precipitously)• When family member(s) decide the

situation is unsafe (e.g., during a holiday visit)

Promising Practices: Organizations

• Goals, expectations, accountability clear for each organization (MOUs, workplan, roster of key contact person, reporting req’s)

• Regular e-mail & phone contact to individuals, as well as project-wide planning meetings (3-4x yr)

• Structured, coordinated programming (health education, screening, workshops) with defined goals--extend use of resources across organizations

Success FactorsSuccess Factor #1 – Common

Goals/CommitmentSuccess Factor #2 –

“Champions” within each organization who respect collaboration

Success Factor #3 – Ongoing relationships“neighbor to neighbor”

Lessons Learned• It’s about relationships and trust• Be proactive with participants, but not

pushy• Build on what is there• Collaborative efforts take work; focus on

goals, facilitate individual and group communication, build sense of organizational community

• Need a champion/lead at the organizational level who is committed to the effort & sees the value

Strengths & Challenges

Strengths• We know each other

(contacts) on a face-to-face basis

• We can move faster and put things in motion that make sense (greater flexibility, fewer layers)

• Strong personal relationships lead to better follow up and fewer “failing through the cracks”

Challenges• We are stretched with

many obligations• We have very small

staffs, and fewer hands to do the work. Loss of one person can be significant

• Limited capacity to expand to meet additional need

• We are financially vulnerable

Benefits

•To seniors and family members

•To organizations participating

•To community

Making the “Business Case”

• What is the economic value of keeping people in their community?

• What is the value of reducing family caregiver burden?

• What is the value of having organizations coordinating resources to avoid duplication or extend the reach of services?

Older Citizens as Resources

• Civic engagement & community awareness

• Volunteerism• Stability in neighborhoods• Economic contributions • Wisdom and relationships imparted

to the next generation

Family Caregivers

• 1 out of 4 are family caregivers• Economic value of informal support is well

documented• “Cost” of caregiving is real: lost days of

work, diminished health status, increased stress

• Sustaining caregiving role (avoiding or reducing caregiver burnout) has economic value—to person, to family, to community, to society

Community

• More people served• New sites of service• More coordination across organizations• Seeing value of tying together different

access points• Greater awareness of needs and of

service options• City support for replicating model

Making the “Business Case”

• How can we demonstrate our prevention efforts are effective?

• How can we determine how/whether we have delayed nursing home admissions?

• What evidence do we have that people are more willing or able to successfully use community resources?

Costs Avoided

Benefits/Costs: Overview

Benefits Costs

Person Services rec’d; help with

health, transportation, service access, IADLs

Time to participate 

Caregiver Time, stress reduction, incr awareness of options

Time (minimal)

Organization

Greater service capacity, intensity and breadth of

service, more people served 

Unfunded service costs, planning, coordination

across orgs.

Community

Delayed nursing home admission (potential)

Greater service capacity to community 

Funding of program (compare to costs of

potential earlier admission to nursing

home)

Sustainability• Imbedding some of the practices, methods

and tools into our service(s)• Continuing health education & screening

activities through partners’ community health/outreach efforts (will require some out of pocket payment)

• Replicating the approach in other organizations

• Building electronic capacity to function as a “virtual Partners in Care”

New: Technological Component

Goal: To create an electronic resource that simulates the “walking with” Partners in Care approach (as much as possible) to allow a family member or older adult to assess need, identify an action plan, select resources and make changes as necessary to maximize independence and meet personal goals.

“Personal Care Resource”

With seniors and family members, we are developing the content and format for a personalized database resource tool (Internet-based) to assist in:– Self-assessment of need– Organization of key information– Building awareness about options and resources – Education about prevention and wellness– Planning ahead

Personal Profile, Organizer & Action Planner

Create/access your own personal profile built from your Senior Self-

Assessment. Identify your personal action plan around goals & needs

Education and Resource Directory

Display, read, or download resources,

handouts, educational material to improve

health, nutrition, exercise (includes Partners in Care

Resource Directory &Toolkit)

Calendar, reminders, registration

View and add appointments, see upcoming events,

register for programs

Community organization and volunteer “portal”

Allow selected community programs to access your web site and help them understand your

needs

Personal Care Resource Proposed Features

Personal Care Resource Hosted by: Normandale Center for Healing & Wholeness

Our Lady of GraceOther community agency [enter name]

Log-inPasscode

Welcome! ToYour Personal Care

Resource

My Profile Cover Sheet: Jane Doe123 Maple Street Ph: 952-123-0000Anytown, MN 55555

My life/health goals: Stay in my homeCurrent health status is: Very GoodLiving: Alone in own home; everything on one levelExercising: 3 x a week; walking and gardeningNutrition: Making own meals; nutrition goodStill driving? Sometimes (during daytime hours, not highway)Services receiving: Yardwork (mowing & shoveling);Home repair & maintenance; Laundry service; Occasional rides to medical appointments [click here for Service names and numbers]

Key contacts: Daughter & Son in town; neighbors; close friends[click here to view key contact info]

Starting Point for Personal Care

ResourcePersonal Organizer & Action Planner• Personal self-profile of goals and status

built from each senior’s Self-Assessment to present a picture

• Senior Self-Assessment Instrument was created from a review of several existing senior-focused assessment instruments and includes items on: exercise, nutrition, sleep, emotional health, physical health, functional issues, pain, current living arrangements, etc.

My Personal Assessment

• [click here] to view last assessment (date: _____)

• [click here] for composite over all assessments

Decision Support based on Triggers we are

programming• Red – Take

action soon• Yellow – Some

signs to indicate follow-up or changes needed

• Green – Doing well, keep it up.

Action Plan

Summary Action Plan : Fred JonesBased on Assessment done on: 8/19/2008

This Plan is for the next 90 days

Fred’s Goal: “To get healthier and have a better attitude.”

Area(s) for Follow-Up

Triggers that were activated

 Next Steps Resources

Another PCR component: Education & Resource Directory• Repository of programs, resources, groups, workshops, handouts, educational materials and other information that can be searched, viewed, and downloaded by the senior or family member

• Would include information from the Partners in Care Resource Toolkit (currently in hard copy, 3-ring binder) with hotlinks to the organizations’ web sites and contacts numbers through the www.minnesotahelp.info web site

Resource Repository

[click on any topic below to link to an information sheet or report]

• Exercise & Nutrition Tips for Seniors• Falls Prevention materials• Stroke & Diabetes Awareness• Family Member Caregiver Support Tips • Handouts from local workshops [click

here for searchable list]

PCR Component: Calendars & Reminders

Monday Tuesday Wednesday

Thursday

Friday Saturday

Sunday

H&W Falls Prevention Program @ 10 -11:30

Foot Care

Tai Chi 2-3

Walk w/ Marge

Ride to Worship

Dr. Appnt 2:30

Tai Chi 2-3

Walk w/ Marge

Ride to Worship

Dental Appnt 9:30

H&W Flu Shot 11-1

Tai Chi 2-3

Walk w/ Marge

Ride to Worship

Tai Chi 2-3

Walk w/ Marge

Ride to Worship

Case Story: Susan & Anne

• Susan lives alone, single family home, 80+ health problems, isolation

• Anne lives nearby, primary caregiver (evidence of caregiver stress/burden)

• Rides, health screening, home visit, falls prevention main activities

• PIC program is seen as supportive resource; relief to both

Steps on PCR Development

1. Conducted focus groups with seniors and family members; reviewed survey findings

2. Goals and features desired prioritized

3. Working with information technology software developer, designed a “prototype” (screens only, not “live” on the Internet) in 2008

4. Having Partners in Care participants “test out” prototype

5. Selecting developer to create a production version by June 2009

Review the PIC Approach

• This is a strengths-based model• Takes an inclusive view—senior and

their “support systems”• Tailors response to needs and situations

—respecting persons’ wishes & goals• Draws upon volunteers from their own

social network• Teaches them how to find, connect and

advocate on their own, using all types of resources

More InformationCall Deborah Paone,

Normandale Center for Healing & Wholeness, at 952-929-1697, ext. 45 or

visit www.healing.normluth.org