Healthy-in-Place (HIP)-Seniors: A Durham Health Innovations Project
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Transcript of 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, BCDuke School of Nursing &
Durham VA Geriatric Research, Education and Clinical CenterOn behalf of the HIP-Seniors Team
UC Project for Global InequalityUC Project for Global Inequality
The Cost of a Long LifeU.S.
Slide Courtesy of Rob Califf, Durham Health Summit, 2009
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
Opportunity to partner with community as never before to improve important public health outcomes in Durham
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.”
DHI Planning Grants: $100K each
• Life stage1. Maternal/Fetal Health2. Adolescent Health3. Seniors’ Health
• “Hard medical”4. Cardiovascular5. Cancer
screening/survivors6. Asthma/COPD
• Behaviors7. Substance abuse/pain
management
• Medical/behavioral8. Obesity9. Diabetes10.STDs
Slide modified from Rob Califf, Durham Health Summit, 2009
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
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
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
Aging in Place with DignityFalls Prevention &
Physical Activity Promotion
Outreach to Socially Isolated
Medication Management
ImprovedCare Transitions
Where is the sweet spot?
Courtesy: AARP: http://www.aarp.org/research/ppi/articles/faces_of_chronic_care.html
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
Expanded Chronic Care Model
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.
MISSIONHIP Seniors is a collaborative, community-basedplanning process bringing stakeholders from thecommunity and university health systemstogether to design a streamlined, comprehensiveand innovative model of care for seniors. Thismodel will provide seniors a person-centered, evidence-based, cost-effective, responsivesystem of care by building upon existingservices and offering seamless transitions, nowrong door access, and full coordination of care.
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
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
Coordination & Navigation HUB
Seniors Duke University Health System
Nonprofit Organizations
Durham City & County Agencies
HUB of
Coordination
Community Resource Connection as a Hub?
POINT OF CONTACT:ER, Hospital Admission, PCP, or Community Agency
Universal Senior Assessment (USA)
Completed*
Assessment includes:
•Falls risk assessment•Cognition assessment•Medication assessment•Wellness practices •Social support
PHASE 1:Assessment
PHASE 2:Identify Care Navigator Type
Self
Family/ Significant Other
Lay Care Navigator
Senior Support Nurse
**Each care navigator would consult and collaborate with discharge planner (PRM) as is current practice. New Discharge checklist to be revised/added consistent with Coleman’s Model
*Completed by RN in ER or hosp. setting
PHASE 3:Identification of Potential Interventions
Personal Electronic Health Record to be made available to the care navigator and health care providers across the care continuum.
Falls Risk Referrals & Linkages
Medication MgmtReferrals & Linkages
Wellness Practices
Referrals for vaccines, or to community or health system resources re physical activity
Social NeedsSuch as transportation, meals on wheels, utility assistance, personal care service referrals
Complex Health Care Coordination
Coordination of care & assistance with multiple co-morbidities, multiple health care providers, lack of social support to assist, facilitates communication and assesses ongoing needs, both health & social
Coordination of care & assistance with multiple co-morbidities, multiple health care providers, lack of social support to assist, facilitates communication and assesses ongoing needs, both health & social
HEALTH
COR
E
HIP Seniors Model: Navigation Process
Next Steps
Time Step
Now.. Durham Health Innovations Oversight Team reviews reports, and finds commonalities to create a Close-Connected-Care model
Limited support for ongoing project management to coordinate team activitiesPublish articles on our experience, ideas, findings
Ongoing •Uniform Senior Assessment (USA): Pilot recently funded to support development of transitional care module
•Medication Reconciliation & Therapy Management Pilot: seeking funding•Improved Discharge Processes Pilot: GEC funded•Lay navigator •Coordination hub – preparing CRC proposal