1. Community Connections Heather Altman, MPH Project Director, Community Connections Carol Woods Retirement Community haltman@carolwoods.org / 918-2609

2. Why Us, Why Now?  Our Mission  Orange County Master Aging Plan  Timing & Opportunity  Results from the Planning Grant:  Crises emerge during transitions  Fragmentation of services  Poor communication among stakeholders  Organizations working in silos  Importance of utilizing technology  Importance of connections!

3. Goal To develop a model of collaborative, community-based services to increase ease of access and support available to older adults and adults with disabilities during times of transitions, specifically from hospital to home.

4. Projected Outcomes  Coordinated transitional care thru increased community collaboration & supports  Use of technology to support transitions  New health care partnerships  Health care delivered in non-traditional setting  Decrease in ER visits, hospitalization & re- hospitalization  Increase in the ability for individuals to remain in the home of their choice.

5. Community Connections Grant Initiatives SERVICE DELIVERY Connecting Community Groups Hospital Transition Teams Telehealth Programs Adult Day Expansion WORKFORCE DEVELOPMENT Partnerships & Internships POLICY & PLANNING Leadership Summits/ Advocacy

6. Community-based Approach Communities across the US are beginning to consider transitions of care as a community – based challenge that requires shared ownership and close collaboration across settings. (Institute for Healthcare Improvement)

7. Developing Strategic Partnerships  Community Organizations & Consumers  NC Department of Health & Human Service  Hospital / University Efforts (UNC & Duke)  Special Programs (Community Care & PACE)  Telehealth & Self-Management Programs

8. Linking Community Organizations  Hosted 2-Day Community Engagement Planning Meeting in Nov. 2008  County agencies, community organizations, providers, hospital, home health, mental health, university, police, consumers  Shared: experiences, data, visioning  Voted on Priorities:  Patient Advocacy in the Hospital  Education/Outreach about Available Services

9. The Power of Coming Together Results of Mid-Point Evaluation of Collaboration:  85% learned about new programs or services  80% increased connections with colleagues  40% had partnered with others for funding  34% made more referrals to other agencies  32% had begun cross training with agencies  61% increased their focus on transitions  47% serving more consumers, 39% increased programs, 22% increased consumer involvement in program design

10. Lessons Learned (so far)  Identify a Champion / Broker  Bring Stakeholders Together  Make the Case & “Build the Will”  Collaboration: Public & Private  Early Successes  Tell the Story

11. Lessons Learned (so far)  Build Synergy  Be Flexible, But Keep Focused  Different Expectations of Stakeholders  Demonstrating Impact Now vs. Future  Intervention – Outcomes – Fit  Sustainability is Critical!