Community Connections: Moving Seniors Toward Wellness A MOWAA Grant Project

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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
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Overview of Session

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

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Vision of the Grant

• 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

• Shift toward less costly and more appropriate
  home and community-based servicing of acute care
  needs.

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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.

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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

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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.

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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

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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).

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

• Long-term measure of change in persons 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
  adultresulting in decreased re-hospitalizations
  and increased use of community-based care.

• Individual
• Senior wellness
• Program
• Service development delivery
• System / Community
• Community partnerships
• Coordinated care
• Sustainability

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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?
To what extent did partnership increase?
Were all relevant parties to the system involved
in the design of the system?
To what extent did the program and system change?
How effective were community meetings?
What resources were invested?
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Mechanisms Needed in the Community-Based System
Key Stakeholders Who must be aligned to achieve
possibility statement?
Coordination of Services
Acute Care Nursing Staff
Meals on Wheels
Senior Nutrition Program / Hospital Partnerships

• Possibility Statement
• Expanded, affordable services
• Services are customized
• Service delivery is coordinated
• Seniors restored to health
• Hospitalizations decreased

Home Health
Physicians
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
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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 131.
• Process is beginning to be institutionalized.

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Program and System Evaluation What Doesnt
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?

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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.

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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.

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Client Close-Out Interview Analysis
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Client Close-Out Interview Analysis
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Client Close-Out Interview Analysis
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Client Close-Out Interview Analysis
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Client Close-Out Interview Analysis
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Client Close-Out Interview Analysis
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Client Close-Out Interview Analysis
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Partner Close-Out Interview Analysis
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Partner Close-Out Interview Analysis
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Partner Close-Out Interview Analysis
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Partner Close-Out Interview Analysis
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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

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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

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Challenges for Nutrition Programs

• Community Partners
• Health care organizations
• Community-based services
• Non-traditional community services
• Awareness building
• Urgency to implement change

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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