Meals On Wheels of Sheboygan County Inc. 1 October 29, 2015

Agenda Introduction Goal of Pilot Tier Piloting Activity to Pilot Role of Meals On Wheels in the pilot Standards and Technologies Under Consideration Logistics Ecosystem Defining Success Resources/References

Introduction: Pilot Team NameRole Kelly HeynProject and IT oversight Allison ThompsonSpearheading pilot project Connie KatchkeyBookkeeper, client communication Maureen FatlaClient services and support

Introduction: Organization Since 1970 Meals On Wheels of Sheboygan County (MOW) has been an independent, non- profit agency delivering meals to the homebound, elderly, and disabled residents of Sheboygan County. MOW is a long-term accredited agency through Meals On Wheels Association. Clients come first. We recently built a new facility purposely designed to utilize fresh produce to enhance freshness, nutrition and flavor for our clients. We also manage numerous gardens and hoop houses to maintain access to fresh produce. MOW has 17 years worth of electronic client data and a tech support team willing and able to adapt as needed. MOW is at the forefront of the home-delivered meal industry. We intend to create an internal system which meshes well with CMS, to optimize client services. Our staff has complete access to our electronic data system, continually updating client information as needed to provide better service.

Pilot Introduction: Business Drivers We recognize that efficiency and integration with partnering agencies will ultimately provide better service for our clients. This pilot study aligns with our efforts to strengthen our partnerships with area healthcare providers. 5

Goal of the Pilot Because we are a community-based service provider we fall under both User Story 1 and 2 under Beneficiary System.

User Story 2 7

Pilot Workflow We deliver medically-tailored meals to the homebound, elderly and disabled. Our clients are referred to us by: family, government agencies (such as ADRC), social workers, doctors, dieticians, hospitals and nursing homes. While most referrals are verbal, others are sent via and fax. Client information is first gathered on paper and then is input into a custom-built ACCESS database. Hospitals/Doctors will fax diet restrictions. Initial client health assessments are done verbally over the phone and the information is put into the database. Ongoing assessments are done by staff and volunteers and information is updated as needed in our custom ACCESS database. 8

Which Tier are you piloting? We plan to Pilot Tier 1 and 2 with likeliness of also participating in Tier 3. We continue to modify the plan to meet changes in needs of partnering agencies, and to better service clients and understand their changing needs. Reports are shared in various ways with case workers, clients and family via phone, fax and .

What are you intending to pilot – Create Plan – Approve/Authorize Plan/Services – Access, View, Review Plan – Update Plan Identify and prioritize value-based information requirements among participating partners (hospitals, doctors, social workers). Evaluate gaps in what data elements are needed and what data elements are available. Sub-domains include: Work, Community, Relationships, Demographics, Person-Centered Profile, Medication, ADLs/IADLs, Safety, Current Behavioral Needs, Restrictions, Service, Financial/Payer Information, Service Information, Family Information, Community Connections, Access & Support Delivery, Information & Planning, Health, Dietary Needs

What role do you play in the pilot CB-LTSS Provider eLTSS plan facilitator/steward LTSS/case management info With every new client MOW gathers the previously-mentioned data and monitors the client through regularly scheduled meal deliveries. Updates are made electronically and communicated verbally, via and via fax with families/social workers/providers, as necessary.

Standards Under Consideration: Tier 1 – Non Electronic – Electronic – , ACCESS database, have access to Drop Box if needed. Tier 2 – Create documents and template methodologies to standardize the content and structure for clinical care summaries. Tier 3: – Implement revised plans and templates to share the data and information electronically with partnering agencies.

Pilot Logistics: Timeline – (April 2016 is end date for round one pilots) Kick off: November 2015 Secure partner by December 2015 Match current questionnaire with use-case activities by January 2016 Completion of RTM: March 2016 Completion of Pilots: April 2016 Challenges: – Finding healthcare agencies/government programs willing to pilot with us – Changes in technology/modifying current database – Educating staff and volunteers as to what to look for/access based on provider needs – Creating/printing additional marketing pieces to help educate the healthcare community, staff and volunteers

Pilot Ecosystem Potential partners include local hospitals, healthcare providers, dieticians, social workers, government care facilities. MOW customized ACCESS database. While most communication is verbal, there is some electronic transfer of knowledge via fax and .

How do you define success As a result of this project we hope: – that our clients will have better wrap-around care resulting in improved health outcomes. – to gain a better sense of the information that needs to be collected in order to benefit the hospitals and healthcare community. – to further relationships with hospitals and healthcare community to provide access to more meals for the homebound, elderly, disabled and those recovering from injury/surgery. – this opens electronic communications between partnering agencies. The number of clients referred by healthcare community increases. Relationships with partnering agencies grows stronger. Able to create a stronger reporting system from volunteers to MOW staff. If we are able to show growth and move into Tiers 2 and 3.

Helpful References Strengths Marketing Video of ProgramProgram Current Intake FormIntake Social Media: Facebook, Twitter, YouTube, PinterestFacebookTwitterYouTubePinterest