Transcript Slide 1
The Aging Network Helping Older Adults Live Well at Home Today Objectives • Understand the structure, roles and funding streams for the Aging Network, including volunteer support • Explore the value of non-medical, in-home services in avoiding rehospitalization • Identify critical points in care pathways to make referrals to AAA Senior LinkAge Line® services • Learn about the infrastructure of community-based Chronic Disease SelfManagement Program (CDSMP) and Matter of Balance class offerings • Identify new resources for patients to develop the skills needed to manage their chronic conditions on a day-today basis and increase self-management skills in preventing falls • Learn about partnership opportunities with Area Agencies on Aging to develop additional capacity in selfmanagement of chronic disease and/or falls prevention Structure and roles Area Agencies on Aging created via the Older Americans Act Nation-wide home and community-based service system that develops and delivers non-medical services to help older adults maintain independence at home Minnesota’s Aging Network MN Board on Aging designates Area Agencies on Aging for statewide coverage: Six regional “AAAs” and 1 Tribal “AAA” Nonprofit corporations, quasi-governmental or tribal organizations Experts on community services, caregiving, volunteer support, housing options, Medicare and public benefits Hub organization for local vendor networks and broader regional “Aging Network” Minnesota AAAs How do AAAs have impact? Consult on-on-one with older adults and their families about services, housing choices, caregiver support, Medicare, benefits, county services Help older adults transition across settings Identify needs and distribute federal and state resources to fund services for seniors and caregivers Partner to develop new services and programs Options Counseling Person-centered consultation over the telephone via the Senior LinkAge Line®, web chat or at home to: Evaluate complex living situations Connect to housing options and services such as homemaker, meals, transportation, respite, medication management, home modifications, chronic disease self management programs Answer Medicare and insurance questions Follow-up to ensure that needs are met New statutory referral requirements in law for clinics and hospitals Addressing avoidable readmissions to the hospital Root Cause = Absent or insufficient enlistment of short or longterm services and supports Response = Community-based services provided Area Agency on Aging and local Aging Network Medication Issues: Link to Title III-funded Medication Therapy Management services and other medication management resources; enlist SHIP counselor to resolve payment issues/identify more cost-effective Part D plan; connect informal caregiver to training; address memory loss Lack of follow-up with PCP: Link to transportation provider Additional help needed at home: Provide information about and/or arrange home health care services, environmental modifications, assistive devices, meals/grocery delivery, PERS, homemaker and outdoor chore services, caregiver respite, consultation, support, training, Senior Companion, block/parish nurse, Long-Term Care Consultation/Waiver Evidence-based Health Promotion (EBHP) Programs Living Well with Chronic Conditions (CDSMP) - Increase self-confidence in the ability to control symptoms and manage the affect of multiple chronic health issues (6 weeks, 2.5 hrs./week) A Matter of Balance (MOB) - Reduce the fear of falling and increase the activity level (8 weeks, 2 hrs./week) Powerful Tools for Caregivers - Family caregivers learn skills to care for themselves while caring for others (6 weeks, 2.5 hrs/week) AAAs’ Implementation Roles – Disseminate EBHP programs through implementing partner organizations – Train leaders and provide licensing, start-up materials, and fidelity monitoring – Provide technical assistance on program implementation, marketing materials, promotion strategies to generate participants for classes, local referral partnerships – Limited funding through Older Americans Act AAAs’ experience and potential involvement integrating care systems Long-term Care Options Counseling and personcentered support coordination Care transitions and service delivery expertise Evidence-based health promotion and chronic disease management services Bridge connecting acute and clinical health care with community-based services to provide better care with follow-up; reduce health care costs; support better health Partner to develop comprehensive community approaches to care transitions that improve outcomes for patients Information and Resources For Providers: Interested in becoming leadertrained to offer classes or host a class? Contact your local Area Agency on Aging www.mn4a.org For Seniors: To get more information or to find a class in your area call: Senior LinkAge Line® 1-800-333-2433 Or visit www.mnhealthyaging.org Information and Resources Lori Vrolson, MA, Executive Director Central Minnesota Council on Aging [email protected] 320-253-9349 Dawn Simonson, MPA, Executive Director Metropolitan Area Agency on Aging [email protected] 651-641-8612 Information and Resources Minnesota Association of Area Agencies on Aging www.mn4a.org Minnesota Board on Aging/MN AAA EBHP and chronic disease management information www.mnhealthyaging.org Minnesota Board on Aging and MN Dept. of Human Services Database www.MinnesotaHelp.info Next Webinar Topic: Meaningful Use and Electronic Health Records for the RARE Campaign Date: Friday August 24, 2012 Time: 12 Noon – 1p.m. CDT Future Topics: To suggest future topics for this series, Reducing Avoidable Readmissions Effectively “RARE” Networking Webinars, contact Kathy Cummings, [email protected]