1. The Central Texas ADRC and Community Living Program H. Richard McGhee Director, Central Texas AAA and ADRC Alan B. Stevens Director, Program on Aging & Care Scott & White Healthcare

2. Central Texas ADRC Overview of Our Presentation  A Culture of Cooperation in Central Texas  Organizational Structure of Our ADRC  Key Features of Our ADRC  Community Living Program  Care Transitions Intervention  Preliminary Findings

3. A Culture of Cooperation in Central Texas Demographically diverse – includes urban, rural and semi-rural Strong military influence (Home of Ft. Hood and the Central Texas VA-MC) Accessible and high quality medical care History of partnership across health and human service agencies and local governmental entities

4. A Culture of Cooperation in Central Texas Strong existing capacity within multiple organizations dedicated to community living and formal healthcare Past successes built a foundation for enhanced private/public partnerships –Community Awareness & Relocation Grant –Designated as 2-1-1 Area Information Center –CMS Real Choice Systems Change Grant –Multiple foundation awards, including Rosalynn Carter Institute (RCI) award funded by Johnson & Johnson

5. Central Texas ADRC The Central Texas Aging And Disability Resource Center serves as a highly visible, trusted, and valued place where people of all ages and incomes can turn for information on and access to the full range of long term support options.

6. ADRC organizational structure allows leaders to align the individual goals of partner agencies to achieve greater access and new services Access to Aging & Disability Services Community Supports Healthcare Services ADRC’s Focus

7. Central Texas ADRC Partners

8. Central Texas ADRC Coordinates access to -Services Supported by the Texas Department of Aging & Disability Services - Scott & White Healthcare – Family Caregiver Program - AoA Community Living Program - Veterans Directed – Home and Community Based Services Program - Evidenced Based Programming

9. ADRC - Key Features Centralized model with the physical co-location of major regional partners Managed by a Project Leadership Team Service delivery focuses on access, intake and system navigation Employs a person/family centered approach to consumer interactions Maintains linkages with critical pathways to long- term services and supports ADRC partnerships are based upon “Employer of Record” relationships

10. Employer of Record Relationships Partners Established ADRC Community Identity - Consistent communication statement among all partner agencies - Partner agencies use consistent ADRC logos - Public image is ADRC, not programs, services or funding sources - Socially branded marketing and outreach campaign Administrative and Functional Supervision Agreements - Share funding resources through contractual agreements - Consensus on appointing someone to manage day to day business decisions - Does not alter final decision making authority regarding hiring or adverse personnel actions - Supports prompt discussion and timely management of performance issues - Requires joint input for implementing needed corrective actions

11. Employer of Record Relationships Technology Support - ADRC partner agencies use ServicePoint™ - Consumer information is shared - Assessments tailored to each partner agency or specific project need - Maintains case notes and service transactions - Ability to produce custom reports Considerations - Remain flexible due to the unique nature of communities - Experiment and take risks in organizational structure - Be responsive and timely in making changes & improvements - Seek opportunities to allow further system development

12. ADRC Staffing Examples CLP Community Long-term Support Specialist Employed by Scott & White Healthcare Access & Intake Staff Employed by Texas Dept. of Aging & Disability Services I&R Staff Employed by MHMR Authority Marketing Specialist Employed by Hill Country Community Action Association 211 Area Information Center Staff Employed by Bell County Human Services Veterans Consultant Employed by AAA

13. ADRC organizational structure allows a single point of contact for consumers.

14. The Central Texas Community Living Program Partnership among –Texas Dept of Aging and Disability Services (DADS) –Central Texas Area Agency on Aging –Scott & White Healthcare – Central Texas Veterans Health Care System Targets persons at risk of nursing home placement and spend-down to Medicaid Use of a risk assessment to enhance Person/Family Centered Planning

15. Program serves individuals identified in hospital and community settings Transitional coaching from hospital to the home Support and skills training for the family caregivers via the REACH II intervention Direct access to community-based services available through the AAA and other partner agencies of the Central Texas Aging and Disability Resource Center (ADRC).

16. Screening Ineligible or Decline Central Texas ADRC Scott & White Memorial Hospital Referrals Care Transitions Intervention Baseline Evaluation 6-Month Evaluation 10 Month Family Centered Intervention  REACH II for Caregiver  Formal Support Services  CTI (if warranted) Guided by a patient and caregiver needs assessment 12-Month Evaluation

17. Our progress to date 504 - Total referred 232 - Total Enrolled 272-Total not enrolled 185 - Currently enrolled 47-Total cancelled enrollment 18-Cancelled services 10-Deceased 16-Enrolled in VDHCBS 3-Admitted to LTCF

18. Baseline Consumer Characteristics Race White Black Other 86% 10% 4% # in Household 1-3 4+ 93 7 Income < poverty Below poverty 100-249% 5% 77% Assets $0-$10,000 $10,001-$30,000 Over $30,000 35% 38% 27% 22% Rural 55% Female 57% Married Mean Age = 82 yrs 22% Rural 55% Female 57% Married Mean Age = 82 yrs

19. Health Status of Participants Self ReportsConsumersCaregivers Average doctor visits in past 6 months 7.33 Average ER and Hospital visits in past 6 months 1.7 ER 1.4 Hospital 0.3 ER 0.2 Hospital Average number of physically unhealthy days in past month --7.5 days Average number of mentally unhealthy days in past month --4.4 days

20. Key Elements of The Care Transitions Intervention TM Transition Coach is the vehicle to build skills, develop confidence and provide tools to support self-management 4 Pillars of the Intervention –Medication reconciliation/self management –Identifying “red flag” symptoms –Follow with Primary Care Provider (PCP) –Personal health care record One home visit, three phone calls over 30 days

21. Screening Ineligible or Decline Central Texas ADRC Scott & White Memorial Hospital Referrals Care Transitions Intervention Baseline Evaluation 6-Month Evaluation 10 Month Family Centered Intervention  REACH II for Caregiver  Formal Support Services  CTI (if warranted) Guided by a patient and caregiver needs assessment 12-Month Evaluation

22. Care Transitions Intervention TM 46% of CLP participants entering from the hospital received CTI (37/81) 24% of CLP participants entering from the community received CTI (25/104) 34% of current CLP participants have received the CTI to date (62/185)

23. Preliminary Readmission Data on CLP participants Receiving CTI 59 of the 62 participants receiving CTI are 30 days post discharge –30 day readmission rate is 3.4% (2/59) 52 of the 62 participants receiving CTI are 90 days post discharge –90 day readmission rate is 17.3% (9/52)

24. MonTueWedThuFriS/Sun 123456/7 8910111213/14 151617181920/21 222324252627/28 E-MAIL REFERRAL 63YO Female COPD, heart condition Hospital Visit Enroll, PHR Discharged Home Home Visit Review PHR, Med Rec, Red Flags Primary Care Follow-Up Home Visit Introduction of new coach Home visit Baseline for CLP A Case Report

25. Challenges and Lessons Contract between ADRC to Scott & White Healthcare Contractual arrangement allowed CLP funds to pass from ADRC to Scott & White, allowing Scott & White to be the employer of record for CLP staff. CLP staff have full access to electronic medical record. Access to case managers, patients and families Engage Hospital Case Managers Multiple strategies to educate, accommodate and motivate case managers followed by feedback to build trust. Timely identification of target population

26. Challenges and Lessons Two Step Enrollment Rapid enrollment of referred patients into CTI. CLP staff complete a more comprehensive assessment to determine eligibility for full CLP program after CTI has been delivered. CLP required eligibility criteria and enrollment process Become Part of the Culture CLP, including CTI, were accepted by Post Acute Services, Quality & Patient Safety Council. Physicians involvement has been encouraged via consults. Leadership endorses efforts to reduce readmissions. Integration into hospital workflow and policies

27. Going Forward Continuing to serve CLP participants Continuing to provide CTI Conducting follow-up assessments with CLP participants Seeking new revenue to maintain CLP and to continue to reshape Title III dollars

28. THANK YOU. YOU MAY DIRECT QUESTIONS TO: H. RICHARD MCGHEE – richard.mcghee@ctcog.org ALAN B. STEVENS – astevens@swmail.sw.org