2. Addressing Chronic Physical and Mental Health Needs in Affordable Housing

3. Determinants of Healing & Wellbeing of Elderly Housing Residents

4. Our Plan Assess residents so that we know them well and can help them overcome barriers to aging well Stratify the residents as to need and vulnerability so that we can make best use of residents Support residents in self management of their chronic medical conditions Structure social networks within housing to create a culture of thriving and vitality

5. Progression of Service Coordination “Concierge” service coordination Meet the needs that residents present Crisis driven interventions Targeted service coordination Assessment Stratification Care Coordination Anticipate crisis Catalyst Health Council Healthy You Java Music Club Crisis prevention

6. Care Guide is a database designed to organize the information we gather from our residents

7. Resident Health Values do not total to 100% because residents may have multiple conditions.

8. Resident Health “At Risk” and “Frail” are the ADL categories defined by HUD.

9. Vulnerable Elders Survey VES-13 Developed by RAND Can be administered by phone by non-clinicians in less than 5 minutes Validated on large populations Predictive of death and/or disability Quality care reduces mortality Allows you to allocate more time to high needs/risk individuals

10. VES-13 Prediction of Death or Decline VES -13 Score Probability

11. Resident Health VES Vulnerability Categories: Low (0-2); Moderate (3-7) ; Severe (8-10)

12. Supporting Self Care Patient Engagement – “Blockbuster Drug” that has the capability of producing better outcomes and lower costs Definition – Understanding one’s own role in the care process and having the knowledge, skills, and confidence to take on that role Patient Activation Measure (PAM) – measures the degree to which people are able to participate in their own care PAM coaching is tailored to the individual to increase their ability to participate in their own care

13. PAM in Affordable Housing Activation LevelsActivation Level Description % of residents that scored Level One Does not grasp that they need to play a role in their own health. Likely understands on some level that they are dropping the ball with their health but are not focusing or thinking about their health. Does not have the basic knowledge about their condition, treatment options or self-care. Does not feel in charge of their own health. 10% Level Two Lacks basic knowledge about their condition, treatment options and/or self care. Has little experience or success with behavior change. Feels less in charge of their own health and care. 42% Level Three Has the basic facts or their conditions and treatments. Some experience and success in making behavioral changes. Some confidence in handling limited aspects of their condition. 15% Level Four Has made most of the necessary behavior changes, but may have difficulty maintaining behaviors over time or during times of stress. 34%

14. Survey Process Successfully engaged residents to complete PAM Survey (83%) and VES(77%) Residents offered option to complete independently or with assistance Scored Responses and assigned individual coaches for PAM 1 and 2 residents Pam 3 and 4 residents offered 3 group coaching sessions by Nurse Practitioner

15. Coaching Process 90-120 day coaching period based on individual need and motivation Coaching focused on PAM survey questions to begin conversation Motivational Interviewing used to establish achievable goals and action plan VES completed as part of coaching process

16. Service Coordinator Coach Baseline PAMAfter PAM Coaching

17. Stratifying the Residents

19. Value of PAM Assessment and Coaching Assessment – Predictive of Hospital Costs – 45% of Level 1s fall into the highest quartile, only 19% of Level 4s – Average Hospital Cost by Level Level 1 $7,969 Level 2 $6,675 Level 3 $796 Level 4 $325

20. Value of PAM Assessment and Coaching Coaching – Effective in raising the PAM level in many people – Higher level associated with lower cost going forward – Higher levels associated with improved clinical outcomes, preventive care adherence and healthy lifestyle change – Effective of coaching is persistent and lasting

21. Key Learning About VES and PAM Residents are very receptive to completing the assessments Personal approach works best to get them completed Service Coordinators can be effective PAM coaches Volunteers can help gather and complete assessments but not do PAM coaching Healthy You is an effective group PAM coaching model PSH residents are more difficult to coach

22. Building Social Networks

23. Java Music Club Structured weekly social intervention to relieve isolation and depression Resident meeting facilitators Mentoring program to create outreach to non participants Develops strong relationships between residents Changes the culture of the community Fosters a thriving sense of community

24. Key Learning About Java Music Club Easily engages residents Can be residents driven and facilitated Residents with dementia can be effectively engaged and it improves their behaviors Volunteers can facilitate and coordinate the weekly sessions