1. A Center for Healthy Aging Population Health Management Model
Nancy Becker, Resource Coordinator
Monica Leone, RN Transitional Care RN
Wendy Martinson, MSN, RN Program Director
Patty O’Brian, Alzheimer's Dementia Specialist
Social & Economic
Medical
Person
Cognitive

2. Center for Healthy Aging
The Center is a starting point for people seeking help and/or information
A free resource and assessment center for individuals and their families
It is a community based model that sits in an acute care setting
Referrals received from case managers, hospitals, ACO, community providers, neighbors, concerned citizens
Our goal is to provide the right level of care at the right time in the right place to maximize an individuals quality of life

3. The Center for Healthy Aging Helps to Meet Basic and Advanced Needs
Resource Coordinators
Transitional Care RN
Geriatric Care Manager
Alzheimer’s/Dementia Specialists

4. Center for Healthy Aging Case Example
Mary, a 91 y/o with multiple health problems, including dementia, was referred to the Center for Healthy Aging by the Hospital of Central CT New Britain Campus Emergency Department staff for safety and health concerns
We have changed the names to protect privacy Mary (Mother) and Donna (daughter).
*Names have been changed to protect the privacy of Mary and Donna

5. Resource Coordinator Provide home, telephonic, or office assessments
Strong focus on socioeconomic and psychosocial needs
Work with community agencies to assist with resource allocation
Food, housing, care funding, medication support, clarification for eligibility for CT Homecare Program and VA benefits, Adult Day Care, transportation, elder law attorneys
Telephonic follow-up
Community outreach
Education
Lunch and Learn
Health Screenings

6. Alzheimer’s/Dementia Specialist
Provides: Assistance for Formal Caregivers
Coaching
Virtual Dementia Rounds
Staff Training
On the Fly Reference Guide Tips for
Working Well With Individuals With Memory Loss
Dementia Symposium offering CEUs (SW, Nursing, PT)

7. Alzheimer’s/Dementia Specialist
Provides: Assistance for the Informal Caregiver
Dementia Coaching
Communication strategies
Behavior challenges
Future planning
Continued support through all stages
Support
Link to community resources
Facilitate support groups
Dementia Education
5 Week Dementia Education Series
Dementia Resource Guide

8. Transitional Care Nurse
Provides free home visits for high risk
individuals in the community who are
not receiving homecare services
Do not need to meet homebound criteria
Home safety evaluation and physical assessment
Disease specific teaching and medication review
Preventing readmissions and ER visits
30 day follow up calls and support

9. Transitional Care Nurse-Why Refer?
Unsure if the individual meets criteria for homecare
No longer meeting medical necessity for homecare but concerned he/she still needs help or education
Limited support at home
Clinical concerns
Needs additional disease specific education
Still appears high risk
Concerned patient will be readmitted

10. What Did the Center for Healthy Aging do for Mary?
The Center for Healthy Aging facilitated and coordinated Mary's care across the care continuum. We were able to care for her immediate needs as well as help her daughter Donna plan for her Mom’s future needs. All in all the Center enlisted 10 different entities to meet Mary’s needs.

11. We ask the Question…..
What would have happened to Mary if the Hospital Emergency Department didn’t have the Hartford Healthcare Center for Healthy Aging to refer to?

12. Contact Information
Hartford Healthcare Center for Healthy Aging At
Hospital of Central Connecticut New Britain
Hospital of Central Connecticut at Bradley memorial
MidState Medical Center
Windham Hospital
Hartford Healthcare at Home TCN Program
1-800-HOMECARE
For a free copy of the Dementia Caregiver Guide