1. Partnering to Reduce Hospital Readmissions for Seniors NYS Senior Nutrition Conference October 16, 2015 Gretchen Moore Simmons, MA gmoore@seniorservicesofalbany.com

2. Meals on Wheels Transportation Services Friendly Home Visits & Grocery Shopping Assistance Community Case Management Social Adult Day Care Services (3 locations) Community Dining and Senior Activities HIICAP (Health Insurance Counseling) Support Services for seniors and their caregivers SSA’s mission is to foster independence and enhance the quality of life of older adults by providing innovative services and caregiver support. For over 60 years, SSA has developed and delivered an array of valuable, relevant and cost effective services to seniors of the Capital Region. Senior Services of Albany

3. Quiz  Approximately how many Americans are 65 or over? a) 12 million b) 22 million c) 35 million d) 46 million  What percentage of America’s seniors live in isolation? a) 10% b) 25% c) 50% d) 75%  What percentage of hospitalized Medicare beneficiaries are readmitted within 30 days? a) 5% b) 10% c) 20% d) 50% 4. Noncompliance with medications and diet, as well as inadequate social support accounts for what percentage of hospital readmissions ? a) 10-15% b) 20-25% c) 30-40% d) 45-50%  One in every three Medicare patients discharged from hospitals is readmitted within 90 days. True False

4. Statistics One in every five Medicare patients discharged from hospitals is readmitted within 30 days (20%) One in three is readmitted in 90 days (33%) These costs account for one sixth the total Medicare budget According to the American Journal of Geriatric Cardiology, “noncompliance with medications and diet, as well as inadequate social support are among the most common reasons for early re-hospitalization…, accounting for up to 50% of such re-admissions.” Studies show that persons who live alone have a 50% higher risk of hospital readmission compared to those living with others.

5. Why is this important?

6. United Way grant Senior Services of Albany applied for a Community Investment grant through United Way of the Greater Capital Region to do the following: Provide seniors discharged from the hospital with vital nutrition, transportation services, shopping and friendly home visits, and case assistance which would improve healing time, reduce the number of hospital readmissions, and decrease admission rates to nursing homes. 21-month grant (October 2014 – June 2016) applied for $72,495 (to serve approx. 250) received $52,500 (to serve approx. 175)

7. The PASST Program Providing Assistance and Support to Seniors in Transition Within 2 weeks of discharge from a hospital/rehabilitation facility, based on referrals from healthcare agencies, eligible patients will be provided with: Home-delivered meals (through Meals on Wheels) for an average of 30 days  Senior caregiver is eligible for 2 weeks of meals Transportation to doctor’s appointments for 30 days Grocery Shopping Assistance/Friendly Home Visits Community Case Assistance

8. How to get participants? Identify Partner organizations Hospitals Visiting Nurse Agencies Rehabs/Nursing Homes Home Health Care Agencies Physician groups Establish Memorandum of Agreement (started with 6) Provide referrals Notify SSA of patient rehospitalization Conduct PASST in-service Discharge planners Nurses Social workers Provide information and necessary forms Referral Form Program Process Form Eligibility Checklist PASST Brochure

9. Referral Process Receive referral from Partner Agency (or through Meals on Wheels) Complete Assessment (by phone or in person) Determine if the person is eligible and what services the person needs/wants Participant signs off on Participation Agreement Program is short-term (30 days) Participant will notify SSA of any changes, including rehospitalization Participant will actively participate in follow up assessments and program evaluation Set the person up for appropriate services within SSA* (determine start and end dates) for themselves and caregiver (if eligible) *can begin as soon as next day in most cases

10. Follow Up Process Follow-up with referring agency Person was deemed eligible Authorized services, Start/End dates (MOW; Transportation; Grocery Shopping/Friendly Home Visits; Case Assistance) Person was deemed ineligible Reason (out of catchment area, didn’t meet eligibility criteria; person didn’t want services; unable to contact patient) Follow-up with participant  30-Days; 60 Days, 90 Days Was patient readmitted to hospital? Is participant still receiving any services (which ones)? Participant Satisfaction Survey (phone or mail) Assist participant in accessing long-term services

11. Challenges Difficult to get Partners on board  Especially difficult to develop and maintain relationships with hospitals  Need to establish champions within the organization (frequent flyer referrers) Takes longer than anticipated to receive referrals Higher than expected number of referrals declined to participate (didn’t think they needed the services) Ability to provide services outside of a relatively small catchment area (rural and remote are too costly) Moving people onto long-term services

12. Successes

13. “PASST program provides a necessary link for isolated seniors after their hospitalizations. Staffed by caring and knowledgeable professionals, the program contains tangible supports, psychosocial assessment, education, and reassurance that often lacks during one’s chaotic discharge process. PASST is often the very first phone call or a home visit for older adults returning home and finding themselves overwhelmed after their hospitalization. I highly recommend and support this program!” – Tatyana Schwartz, LCSW, C-ASWCM Elder Care Consultant CHOICES Program at St. Peter’s Hospital Successes

14. Results to date 2/15 – 10/15: PASST has received 77 referrals (average of 7-10/month) 28 deemed ineligible or declined to participate (35%) 49 participated in program for an average of 30 days 6 reported a hospital readmission within 30 days (12%) 12 satisfaction surveys were returned (25% return rate) 9 months remaining on grant (grant ends June 30, 2016) anticipate serving another 90 – 100 referrals 7 primary referral sources (St. Peter’s Hospital; Eddy VNA Coaches; OrthoNY; Capital Care Physicians; Sunnyview Nursing & Rehab; Whitney Young Health Center)

15. Future of PASST  Grant ends in June 2016 o How to fund continuation of services  Look to healthcare organizations/insurance companies Reducing hospital readmissions affects their bottom line  Try to integrate into DSRIP program (9 PPS’s in NYS) Adirondack Health Institute, Inc. Advocate Community Providers, Inc. Albany Medical Center Hospital Alliance for Better Health Care, LLC Bassett Medical Center Bronx-Lebanon Hospital Center Central New York Care Collaborative, Inc. Finger Lakes Performing Provide System, Inc. NYU Lutheran Medical Center

16. Questions