Building Healthier Communities: Response to an Aging Community A North Kansas City Demonstration Project Tina Uridge, Clay County Senior Services Michelle Peterson, Cerner Corporation Dr. James Stewart, MD, North Kansas City Hospital Katy Dodd, LifeWise Renovations

© 2012 Cerner Corporation. All rights reserved. This document contains Cerner confidential and/or proprietary information which may not be reproduced or transmitted without the express written consent of Cerner. 2 There’s No Place Like Home

© 2012 Cerner Corporation. All rights reserved. This document contains Cerner confidential and/or proprietary information which may not be reproduced or transmitted without the express written consent of Cerner. 3 Older Populations Want to Live Independently 86% Want to stay in their current residence for as long as possible 85% Want to remain in their local community for as long as possible 65% Want to stay in their home because they like what the community has to offer

© 2012 Cerner Corporation. All rights reserved. This document contains Cerner confidential and/or proprietary information which may not be reproduced or transmitted without the express written consent of Cerner. 4 What is the Scope of the Issue? According to the Robert Wood Johnson Foundation, one in five elderly patients wind up back in the hospital within 30 days of leaving, creating a “revolving- door” affect.

© 2012 Cerner Corporation. All rights reserved. This document contains Cerner confidential and/or proprietary information which may not be reproduced or transmitted without the express written consent of Cerner. 5 What are the Causes? Inadequate discharge planning Persons living alone without a sufficient social support system Having unmet functional need Inadequate follow-up or self-management skills Noncompliance with medications and diet Failure to seek medical attention promptly when symptoms recur Social, Environmental and Behavioral Contributing Factors

© 2012 Cerner Corporation. All rights reserved. This document contains Cerner confidential and/or proprietary information which may not be reproduced or transmitted without the express written consent of Cerner. 6 What Do We Know About North Kansas City? 20% of the population is 62 years or older and this is growing 24% of households have individuals 65 years or older 73% housing units are renter-occupied vs. owned 14% of patients aged 65+ are readmitted*

© 2012 Cerner Corporation. All rights reserved. This document contains Cerner confidential and/or proprietary information which may not be reproduced or transmitted without the express written consent of Cerner. 7 Enable a Livable Community and Aging in Place Studies have shown that: Older adults who receive home modifications and specialized home-based healthcare services demonstrate reduced disability and improved clinical outcomes Supportive housing services are more cost-effective than assisted-living facility care Home-based rehabilitation services can reduce the occurrence of readmissions

© 2012 Cerner Corporation. All rights reserved. This document contains Cerner confidential and/or proprietary information which may not be reproduced or transmitted without the express written consent of Cerner. 8 Successful Partnerships in the Community They are possible! Require: Committed, strong leadership Buy-in from all the partners Regular communication Involvement! Look beyond costs Studies show Improved health for community participants Real cost savings from prevention benefits

© 2012 Cerner Corporation. All rights reserved. This document contains Cerner confidential and/or proprietary information which may not be reproduced or transmitted without the express written consent of Cerner. 9 North Kansas City Aging In Place Northland Shepard’s Center NKC Community Center City of North Kansas City Clay County Senior Services Public/Private Partnership

© 2012 Cerner Corporation. All rights reserved. This document contains Cerner confidential and/or proprietary information which may not be reproduced or transmitted without the express written consent of Cerner. 10 What this looks like in NKC Cost of readmissions and impact of preventative health North Kansas City Hospital Coordination of wellness planning at NKC Community Center, transportation City of North Kansas City Thought leaders around best practices for universal design for aging populations LifeWise Renovations Health Monitoring technology, local corporate partner, real time lab for new advances in population health Cerner Corporation Service provider for target population Northland Shepard Center Funder/partner in serving target population Clay County Senior Services Thought leader around the intersection of housing and health K2 Consulting Solutions

© 2012 Cerner Corporation. All rights reserved. This document contains Cerner confidential and/or proprietary information which may not be reproduced or transmitted without the express written consent of Cerner. 11 Whole community approach to working with aging populations: Multidisciplinary Patient-centered Home supported Caregiver valued Cross continuum Intervention focused Community-based Coordinated Aging Programs and Services

© 2012 Cerner Corporation. All rights reserved. This document contains Cerner confidential and/or proprietary information which may not be reproduced or transmitted without the express written consent of Cerner. 12 Clinics and Community “Stay well” - Wellness Workshops, Exercise, Groceries, Education, Home Modification “Manage Well” - Caregivers, Care Manager, Condition Management, Benefit Check-ups “Get Well” - Follow-up Visits, Transitions to Primary Care, Falls Prevention, Transportation STAY WELLSTAY WELL CONTINUUM Benefits/Condition Mgmt. HEALTH CARE MANAGE WELL GET WELL Coordinated Aging Programs and Services Wellness/Nutrition

© 2012 Cerner Corporation. All rights reserved. This document contains Cerner confidential and/or proprietary information which may not be reproduced or transmitted without the express written consent of Cerner. 13 Aging in Place Demonstration Project Identify a cohort of ~50 Clay and Platte County residents aged 65+ hospitalized and at high risk of readmission Care management Community engagement Service enriched housing Demonstration of participation and patient outcomes

© 2012 Cerner Corporation. All rights reserved. This document contains Cerner confidential and/or proprietary information which may not be reproduced or transmitted without the express written consent of Cerner. 14 Roles within the Demonstration Project Community Engagement Care Management Service Enriched Housing

© 2012 Cerner Corporation. All rights reserved. This document contains Cerner confidential and/or proprietary information which may not be reproduced or transmitted without the express written consent of Cerner. 15 Program Case Manager Recruitment and consent Coordinate with Primary Care Physician and other health services Assisting with transition of care from the hospital to home Post-discharge home visit and subsequent follow-up phone calls Ensuring educational modules are available Coordinating patient wellness plan and home health monitoring

© 2012 Cerner Corporation. All rights reserved. This document contains Cerner confidential and/or proprietary information which may not be reproduced or transmitted without the express written consent of Cerner. 16 Home Assessment Specialist Perform a full home safety assessment Create prioritized list of suggested modifications Work with participants to make low cost and simple modifications Assist in determining appropriate home modifications Schedule and oversee home modifications

© 2012 Cerner Corporation. All rights reserved. This document contains Cerner confidential and/or proprietary information which may not be reproduced or transmitted without the express written consent of Cerner. 17 Community Programs Specialist Coordinate with Program Case Manager to identify all participants Conduct an assessment of individual community-based needs upon discharge Conduct an assessment of current state community resources available on an individual basis Connect participants to services for which they qualify Identify barriers to patient engagement and receptivity

© 2012 Cerner Corporation. All rights reserved. This document contains Cerner confidential and/or proprietary information which may not be reproduced or transmitted without the express written consent of Cerner. 18 Coordinated Aging Programs and Services Community engagement Community Programs Specialist Care calls, daily check-ins, home visits & health checks Benefits counseling Aging workshops Exercise programs Social support programs for individual and caregiver Groceries and food Transportation services Care management Program Case Manager Readmission risk score Transition of care Cerner Wellness Assessment & condition management Patient education: wellness and nutrition Remote health monitoring: wellness home device kit Service enriched housing Home Assessment Specialist Home safety assessments Home retrofitting Handyman minor repairs Light housekeeping Home maintenance Yard care

© 2012 Cerner Corporation. All rights reserved. This document contains Cerner confidential and/or proprietary information which may not be reproduced or transmitted without the express written consent of Cerner. 19 Coordinated Aging Programs and Services Aging Population Health Management Step 1: Identify Stakeholders Funding opportunities Project goals Step 2: Design Tailor programs to aging Coalition objectives and expectations Step 3: Implement Enroll participants Provide services Communicate Coordinate Step 4: Demonstration Participation Patient outcomes

© 2012 Cerner Corporation. All rights reserved. This document contains Cerner confidential and/or proprietary information which may not be reproduced or transmitted without the express written consent of Cerner. 20 Evaluation Process Measures Number participants enrolled Number home assessments conducted Number of home modifications made Number of wellness kits distributed Number and type of community programs for which participants qualify and enroll in Number of meals delivered Outcome Measures Knowledge and satisfaction Functional independence Quality of Life Depression Rate of falls Rate of hospital readmission Return on investment

“We need to keep people in their homes, but we need builders to renovate them and care givers to come to their homes. We need the medical community to think more about delivery of care at the home level and use hospitals only as the last option.” Eugene Wilson, a volunteer concerned with aging issues Quoted in Stafford, D. “Living out your years at home can be challenging,” Kansas City Star, 4/16/11. LIVE WELL WELL AND AND INDEPENDENT INDEPENDENT