1. U.S. Administration on Aging Care Transitions and AoA’s Evidence-Based Health Programs Jane Tilly, DrPH February, 2011

2. U.S. Administration on Aging 2 Federal Perspective: AoA AoA Mission: To help seniors maintain health and independence in their homes and communitiesAoA Mission: To help seniors maintain health and independence in their homes and communities.Aging Network provides a variety of programs consistent with a 3-part aim: Better Health, Better Care, Lower Costs.

3. U.S. Administration on Aging 3 Federal Perspective: AoA Better Health: –OAA Title III/ medication management –2003-2011 Evidence-based Prevention Program (CDSMP, falls prevention, mental health, exercise etc.) to 24 states –Recovery Act CDSMP grants to 47 grantees –Care transitions grants Better Care: –Single point of entry ADRCs/AAAs/CILs –Care Transitions –Consumer directed programs that support community living: Money Follows the Person (MFP) and Veterans-Directed Home and Community- Based Services (VDHCBS) Lower Costs: –The Senior Medicare Patrol (SMP) –SHIP counselors and Benefit Enrollment Centers

4. U.S. Administration on Aging 4 ADRC/AAA/CIL Intake, Assessment Enrollment, Care Management I&R CDSMP DSMP AMOB Other EBPs Medicare Benefits Counseling and Enrollment Meals and Transportation Veterans Directed HCBS Care Transitions AlzDRD and Caregiver Support Person and Caregiver Person-Centered Aging Network

5. U.S. Administration on Aging 5 ADRC/AAA/CILs help partner agencies to align their goals to provide greater access to effective, quality services Access to Aging & Disability Services Community Supports Healthcare Services ADRC/AAA/ CILs Focus ADRC/AAA/CILs as an Integration Model

6. U.S. Administration on Aging Evidence-Based Change! Partners: Administration on Aging Centers for Disease Control and Prevention AHRQ, NIH, SAMHSA and other federal agencies National Council on the Aging John A. Hartford Foundation Atlantic Philanthropies Retirement Research Foundation Archstone Foundation Regional Foundations States, localities, regional and community-based organizations

7. U.S. Administration on Aging Evidence-Based Health Programs 24state grantees: Physical activity -- Enhance Fitness or Healthy Moves, which provide safe and effective low-impact aerobic exercise, strength training, and stretching. Falls management -- Matter of Balance, which addresses fear of falling, and Stepping On and Tai Chi, which build muscle strength and improve balance to prevent falls. Nutrition Programs, such as Healthy Eating, which teaches older adults the value of choosing and eating healthy foods, and maintaining an active lifestyle. Depression and/or Substance Abuse Programs, such as PEARLS and Healthy IDEAS, which teach older adults how to manage their mild to moderate depression. Stanford University Chronic Disease Self-Management Programs which are effective in helping people with chronic conditions change their behaviors, improve their health status, and reduce their use of hospital services.

8. U.S. Administration on Aging Stanford Chronic Disease Self Management Program CDSMP an integral part of Care Transitions CDSMP teaches skills for managing conditions and building self-confidence. In RCTs consumers adopted healthy behaviors, improved well-being and reduced use of hospitals and emergency rooms. 6 weekly workshops conducted in community-based settings. Facilitated by trained and certified lay leaders. Topics include: –Techniques for dealing with problems such as frustration, fatigue, pain and isolation; –Exercise for maintaining and improving strength, flexibility, and endurance; –Nutrition; –Appropriate use of medications, and –Communicating effectively with health professionals.

9. U.S. Administration on Aging 9 Recovery Act CDSMP Grant Vision $27 million to 45 states, DC and PR$27 million to 45 states, DC and PR –50,000 “completers” by March 2012 –Platform for establishing Evidence-Based Program Distribution & Delivery Systems to assure (like meds) –Platform for establishing Evidence-Based Program Distribution & Delivery Systems to assure easy access (like meds) –State level partnership among aging, public health, Medicaid –Focus on underserved

10. U.S. Administration on Aging Program Adoption Over the Years Years of Growth 20014 communities 200314 communities 200616 states 200727 states 201046 states, DC, & Puerto Rico  Programs offered via 737 host organizations and 4,070 implementation sites

11. U.S. Administration on Aging Program Reach–All Evidence-Based Programs  14 programs reaching 84,091 older adults in 46 states, DC, and Puerto Rico

12. U.S. Administration on Aging Participant Characteristics (N= 84,091) CharacteristicPercent of Total Age 70+58% Gender Female78% Living Alone48% Racial/Ethnic Minority Group31%

13. U.S. Administration on Aging Program Reach – CDSMP Only Chronic Disease Self-Management Programs reaching 52,436 older adults

14. U.S. Administration on Aging Program Adoption Organization Type700 Lead Orgs3700 Sites Aging network; senior housing 40%58% Social services, faith-based15%25% Public health, recreation20%3% Health care25%14%

15. U.S. Administration on Aging 15 Sustainable System Components (I) Leadership:Leadership: –Integrated/coordinated state vision, plan and goals –Effective partnership among Aging, Public Health, and Medicaid Effective partnerships developed to embed CDSMP in a state’s health and LTSS:Effective partnerships developed to embed CDSMP in a state’s health and LTSS: –Reach underserved populations –Have multiple implementation sites and/or capable of scaling up statewide –Coordinate/integrate programs via ADRCs/AAAs/CILs –Coordinate with Care Transitions programs and demonstrations with physician groups and hospitals

16. U.S. Administration on Aging 16 Sustainable System Components (II) Infrastructure:Infrastructure: –Sufficient workforce –Quality host organizations and implementation sites –Quality program delivery with fidelity Financial sustainabilityFinancial sustainability –Significant role for Medicare & Medicaid (e.g., care transitions, risk management program, waivers, incentives, Health Homes, etc.) –Plan for sustaining system after grant ends (e.g., governmental payers, foundations, corporations, health plans, partnerships w/ health care providers)

17. U.S. Administration on Aging 17 Key Provisions Effective 2011 Medicare Coverage for Annual Wellness Visit (Title IV, Sec 4103)Medicare Coverage for Annual Wellness Visit (Title IV, Sec 4103) –Includes personalized prevention plan based on comprehensive health risk assessment; Prevention services plan can include referrals to community-based interventions Incentives to Medicaid enrollees who complete healthy lifestyle programs (Title IV, Sec 4108)Incentives to Medicaid enrollees who complete healthy lifestyle programs (Title IV, Sec 4108)

18. U.S. Administration on Aging Conclusions Evidence-based health programs operate across the country, serving thousands ADRC/AAA/CILs & Care Transition Programs have a key role in infrastructure: –Assessment of need –Information about programs –Referral to programs –Options Counseling –Care transitions Developing seamless connections for the consumer is critical.