1. Healthy Homes Pilot Program with SSM Hospital

2. Healthy Homes The purpose of Healthy Homes is to give patients, recently returning home from the hospital, the opportunity to recover in a healthy environment. A healthy indoor air environment is critical for expedient recovery and to reduce avoidable hospital readmissions. Two Community Action Agencies, Community Action Agency of St. Louis County and North East Community Action Corporation (NECAC) are partnering with SSM Hospitals to improve recovery rates of recently discharged patients through education and improved home air quality. Case managers provide resources and Healthy Homes education and the Weatherization program improves air quality through installing insulation, proper ventilation, air leakage control and furnace repair or replacement. The Healthy Homes project is a pilot program involving about 30 patients with expectation that the program will be expanded.

3. Healthy Homes Selection Criteria for Targeted Patients: 30 patients falling within 200% of poverty guidelines Goal is minimum of 15 with residences in St. Louis County and 15 in St. Charles County Patients who were admitted to SSM and receive Medicare as well as Medicaid Only patients with respiratory problems including chronic obstructive pulmonary disease (COPD), pneumonia and asthma If on Medicare, patient must be “homebound” (only mobile by considerable and taxing effort, or physician order to stay indoors Patients who have had 1 readmission Using home health care removes the lack of medical attention as a variable for readmission Can be a combination of rental or homeowner Patient agrees to accept support/intervention and signs release of information form

4. Healthy Homes Method: Referral process for targeted patients SSM staff will receive training from CAA staff Hospital Case Manager assesses and selects possible Healthy Home candidates; writes order for Healthy Homes

5. Healthy Homes Home Health Care Intake Coordinator meets with patient in the hospital before discharge and presents Healthy Homes opportunities Between 24-48 hours after patient is discharged, Home Health Care Nurse makes visit and discusses Healthy Homes

6. Healthy Homes Referral will come from LPN to CAA CAA calls patient and makes an appointment for home visit

7. Healthy Homes Home Support/Intervention CAA Family Case Management: Case Manager conducts visit within the first week of patient returning home; Intake and assessment made of family issues on health needs and family goals If appropriate, referral to CAA’s Weatherization Program

8. Healthy Homes Healthy Homes education provided Case Plan developed: Action plan with timeline and Referrals to resources with CAA and externally Follow up home visits continue weekly or minimum twice per month and reports on action plan progress made at 30,60,90 days. After 90 days, visits are made monthly with reports provided at 3, 6, 9, and 1 year CAA Case Manager sends service spreadsheet to SSM Team Leader weekly to show pilot project participant level and progress with each patient.

9. Healthy Homes CAA Weatherization Program: Audit of home is with Weatherization Staff and Case Manager for: Home repair Energy use reduction and increased comfort Indoor air quality (mold, allergens, radon, CO, etc) Poisons (house cleaners, lead, etc) Safety (furnace, housing structure, living conditions, etc)

10. Healthy Homes Plan developed within program limits; accepted by head of household Plan executed within 3 months Customer satisfaction survey done after weatherization services completed

11. Healthy Homes Healthy Homes education completed in 12 months Evaluation on improved health, family goals attained 3, 6, 9 months and 1 year based on: Following medical plan Absence of hospital readmissions Savings on utility costs Family support resources utilized

12. Healthy Homes SSM responsibilities: Selects appropriate pilot project candidates Coordinates discharge planning and provides patient understanding of program Makes appropriate referrals to CAA by e-mailing completed release of information form Social Services Team Lead is available for immediate coordination needs/issues Meet monthly with CAA staff for first 3 months of pilot

13. Healthy Homes CAA responsibilities: In home case management for 12 months Home repairs to make household eligible for Weatherization services Weatherization Assistance Program Takes lead on pilot project evaluation Meet monthly with SSM staff for first 3 months of project