1.  Craig Jones, MD  Molly Dugan  Kevin Loso  Nancy Eldridge Aging in Place

2. We All Want to Stay Home Home centric Consumer driven Unlicensed

3. WE BUILT AN EDUCATION SYSTEM FOR THE BABY BOOMERS IN 1953 NOW THEY NEED A LONG TERM CARE SYSTEM!

4.  150 + HUBS  All Incomes, Ages and Settings  Medicare  Dual Eligibles  Others?? A Network of Care Management HUBS

5. Housers at Health Reform Table with the State

6. The Technology Embedded Home  Central Clinical Registry  iPads  Tele-Tai Chi  Broadband for all!  Cyber Seniors

7. THANK YOU ENTERPRISE COMMUNITY PARTNERS!! THE SAVI!!

8. HEALTHY HOMES CARING COMMUNITIES POSITIVE AGING! How Will Our Residents Benefit?

9. Land Trusts CCRC’s Non-Profit Housers Public Housing Authorities Assisted Living Residential Care Facilities Housers Working Together

10. 5/1/201510 Department of Vermont Health Access Vermont Blueprint for Health Community Systems of Health Housing Assistance Council June 5, 2012

11. 5/1/201511 Department of Vermont Health Access Building A Foundation For The Future  Advanced Primary Care Practices (PCMHs)  Community Health Teams (core)  Community Health Teams extended(MCAID CCs, SASH Teams)  Multi-insurer payment reforms  Health Information Infrastructure  Evaluation & Reporting Systems  Learning Health System Activities

12. 5/1/201512 Health IT Framework Evaluation Framework Advanced Primary Care Hospitals Public Health Programs & Services Community Health Team Nurse Coordinator Social Workers Nutrition Specialists Community Health Workers Public Health Specialist Extended Community Health Team Medicaid Care Coordinators SASH Teams Specialty Care & Disease Management Programs Mental Health & Substance Abuse Programs Social, Economic, & Community Services Healthier Living Workshops 12 Advanced Primary Care Department of Vermont Health Access Multi-Insurer Payment Reform Framework

13. 5/1/201513 Department of Vermont Health Access Medicaid Medicare BlueCross MVP Cigna Self Insured Advanced Primary Care NCQA Standards Patient Centered Care Access Communication Guideline Based Care Use of Health IT Community Support Community Health Teams MCAID CCs SASH Teams Fee for Service - Volume $ PPPM (NCQA) - Quality Specialized Services Hospitals Specialty Care Mental Health Services Substance Use Services Family Services Social Services Economic Services Long Term Care Nursing Homes Payment ReformDelivery System ReformFinancing Shared Costs - Utility

14. Data warehouse Vermont Health Information Exchange (VHIE) Central Clinical Registry (Covisint-DocSite) Core data elements Hospital - hosted EMR FQHC - hosted EMR Web Access Web Access Community Health Team Central Registry Visit planners Care coordination Reporting FQHC-owned Primary Care Practices Independent Primary Care Practices Primary Care Practice No EMR Hospital-owned Primary Care Practices Core data elements Unique Patient identification information Core data elements Blueprint Information Technology Architecture EMR

15. 5/1/201515 Blueprint Expansion January 2012

16. 16 Department of Vermont Health Access

17. Gifford CME 3-2-2012 5/1/201517

18. Department of Vermont Health Access

19. Care Management Begins at Home

20. Multi-payer Advanced Primary Care Practices (MAPCP) Medicare Demonstration States  Maine  Michigan  Minnesota  New York  North Carolina  Pennsylvania  Rhode Island  Vermont

21. Integrated Care for the Dually Eligible  California  Connecticut  Colorado  Massachusetts  Michigan  Minnesota  New York  North Carolina  Oklahoma  Oregon  South Carolina  Tennessee  Vermont  Washington  Wisconsin

22. Department of Vermont Health Access Data Sources & Evaluation  Central Clinical Registry  Multi-payer Claims Database  Chart Reviews  NCQA Scoring  Public Health Registries  Patient Provider Qualitative Assessment  Patient Experience

23. Department of Vermont Health Access Early Trends – Inpatient Discharges

24. Department of Vermont Health Access Early Trends – Inpatient Discharges (Rate / 1000)

25. 5/1/201525 Department of Vermont Health Access Craig Jones, MD Lisa Dulsky Watkins, MD Jenney Samuelson Terri Price Diane Hawkins Beth Tanzman Pat Jones Julie Trottier (Milbank Fellow) Blueprint Team

26. SASH is a System, Not a Type of Housing  All settings – all ages – all incomes  Access to information for housing based staff  Population based – plus targeting  SASH as an extender to the Blueprint for Health- VT’s Medical Home Model.

27. What are the Essential Elements?  Person-centered – Population based  SASH Staff  Team Based Care Management  Information Sharing through Technology  Prevention and Wellness through Healthy Living Planning  Volunteers

28. SASH Keeps “Katie” in the Driver’s Seat

29. SASH Staff = Trusted Guides

30. Multi-Agency Team Based Care Management Nonprofit Housing Visiting Nurse Assoc. Area Agency on Aging PACE Comm. Mental Health Agency

31. The SASH Teams  Care Manager  Wellness Nurse  Acute Care Nurse  Case Manager  Mental Health Expert  PACE Intake  Assessments  Person Centered Plans  Individualized Supports  Transitions Support  Self-Management of Chronic Conditions  Care Coordination

32. Prevention and Wellness

33. Volunteers!

34. Where are we now?  Started rolling out in October 2011  Currently have 19.5 panels up and running!  1,950 people have access to SASH supports.  57 affordable housing sites are SASH sites  DocSite- Statewide Repository of Data is on-line.

35. Vermont’s SASH Goes Statewide

36. An Extension of the Community Health Team Support for Goals of the Medical Homes CHT Case Manager Representation on Functional Team SASH Representation on CHT Planning Committee SASH Representation on CHT Referral Committee SASH and the Blueprint for Health

37. Rutland Regional Medical Center (RRMC): Social Work Department RRMC: Case Management Department (Discharge Planners) RRMC: Community Wellness Programs Rutland Area VNA & Hospice – Nursing and Wellness Services Southwestern VT COA– Case Management and Programming PACE Vermont – Intake Coordination Rutland Mental Health Services – Elder Care Clinician & Case Management Southern VT Area Health Education Center – Interns Vermont Department of Health – Programming Castleton State College, School of Nursing – Interns Rutland County SASH Community Partners

38.  The Pines of Rutland (SNF) – Discharge Planning  Vermont Division of Disability & Aging Services – Choices For Care  Community Health Center of the Rutland Region (FQHC) – Medical Homes  Albany School of Pharmacology – Interns  The BUS – Transportation  Local Farmers – Nutrition Programs  Castleton Community Center – Programming  Retired Senior Volunteer Program – Volunteers  Lions Club – Vision Program  LensCrafters – Vision Program SASH and the Blueprint for Health

39.  Engages key community leaders in SASH  Provides support, guidance and general oversight  Represents interests of the SASH population  Members include leaders representing community partners, other providers, and other community stakeholders SASH Local Table

40.  General promotion of SASH to the community  Reviews strategic direction and priorities  Reviews protocols and services  Support in seeking funding sources  Reviews reports  Provides specialized experience  Reviews processes, data and outcomes  Supports overall development and sustainability SASH Local Table Roles & Responsibilities

41. Templewood Court  49 residents enrolled  39 females  10 males  Average age: 72 years old  Average # of prescription medications taken: 7  Have 3 or more medical conditions: 90%  Have 5 or more medical conditions: 55% Sheldon Towers  40 residents enrolled  17 female  23 male  Average age: 58 years old  Average # of prescription medications taken: 6  Have 3 or more medical conditions: 80%  Have 5 or more medical conditions: 55% SASH Local Table Roles & Responsibilities Profile of Residents

42. Templewood Court  Failed cognitive screening: 39%  Used ER: 43%  Have self-reported mental health concern: 33%  Have moderate to high nutritional risk: 83% Sheldon Towers  Failed cognitive screening: 12%  Used ER: 48%  Have self-reported mental health concern: 45%  Have moderate to high nutritional risk: 75% Profile of Residents

43. Templewood Court  Top 5 Medical Conditions – Vision – Arthritis – High Blood Pressure – Heart or Circulatory Problems – Chronic Pain  33% have fallen in last year Sheldon Towers  Top 5 Medical Conditions – Vision – High Blood Pressure – Arthritis – Depression – Chronic Pain  33% have fallen in last year Profile of Residents

44.  Castleton State College Nursing Programs - Internship Program  Vermont Center for Independent Living - Hunger Free Vermont Nutritional Program  Council on Aging; AmeriCorps Members – Tai Chi, Walking Program  Beauchamp & O’Rourke Pharmacy – Brown Bag Medication Review, Diabetes Education  Castleton Community Center – A Matter of Balance  RRMC – Eat Well Feel Great Community Program Support

45. Housing Staff Community Providers (VNA, AAA, Mental Health) Community Health Team Hospital Family Support Persons Primary Care Provider Nursing Homes/Rehab Facilities Information Sharing

46.  Enhanced quality of life  Decreased isolation  Increased physical activity  Improved nutritional status  Increase in primary care  Vision issues addressed  Reduction in ER and SNF utilization  Earlier treatment of health issues Enhanced aging in place Benefits to Residents

47. 1.Added supports for a changing resident population 2.Liability exposure reduced 3.Increase in on-site support staff 4.Operate without a blindfold 5.Application of evidence-based practices 6.Integral part of home & community-based services aging network 7.Part of linking non-profit assets 8.Sustainable funding for services 9.Place at the health care table 10.Benefit from a collaborative network SASH Benefits To Housers