Community Based Services

Introduction

Shirley Weaver LOTR, MSOL
Director of Community Based Services for Seniors

Bonney Dahlgren DosSantos BSW, CMC
Director of Saint Monica Eldercare Program
Boomer Generation

In 1966, Time magazine declared that the
Generation Twenty-Five and Under would be
its Persons of the Year.


Population Trends
Population Statistics
Source: http://www.aoa.gov/Aging_Statistics/Profile/index.aspx

Population Statistics
Source: www.aoa.gov/Aging_Statistics/.../PopAge1900-2050-by-decade.xls

Living Arrangement over 65
Source: http://www.aoa.gov/Aging_Statistics/Profile/2012/docs/2012profile.pdf
Community Dwellers
2012: 11.8 million or 28% of non-institutionalized
older persons live alone
Median income in 2011 was $27,707 for males and
$15,362 for females
Households headed by persons 65+ median income
$48,538
2012: 9.1% was the poverty rate for people 65+

Source: Administration on Aging: Profile of Older Americans: 2012
https://www.census.gov/hhes/www/poverty/about/overview/
Source: http://www.aoa.gov/Aging_Statistics/Profile/2012/9.aspx
Philadelphia
2010: 45% of seniors live at or below 200% of
poverty level
2010: 36% of seniors are 75+
26% of seniors have less than high school education
45% of older adults with incomes less than 200% of
poverty level have less than high school education


Source: PCA Area Plan 2012-2016

Philadelphia
2003: Second among 23 US cities in population of
residents 65 and older
Increasing age 2025:
85+: 18% increase
75 to 84: 22% decline
65 to 74: 28% Increase

Source: PCA Philadelphia Aging Population, 2006

Trending Results
Number of older adults continues to grow
Increase age results in increased chronic disease
Management of chronic disease places increased
demands on healthcare system
Management of chronic disease places increased
financial demands on the individual


Aging in Place
Older adults express a desire to remain in their
homes and communities
Remaining in the community is less costly than
institutionalization
Seniors also desire to stay in a particular residential
setting as long as possible

Managing Chronic Disease
Impact
Re-hospitalizations
Quality of Service

30 day hospital readmission rate
Approximately 2.6 million seniors
Nearly 1 in 5 Medicare patients discharged from a hospital
Readmission cost of over $26 billion every year
2013: 2,225 hospitals penalized for Medicare
reimbursement
Acute Myocardial Infarction (AMI), Heart Failure (HF) and
Pneumonia (PN);
Source: http://innovation.cms.gov/initiatives/CCTP/index.html





Source: http://innovation.cms.gov/initiatives/CCTP/index.html
Reasons for Re-hospitalizations
Lack of physician follow up
Medication mismanagement
Lack of understanding of signs/symptoms of
exacerbation of chronic conditions
Poor transfer from one setting to another
Lack of use of home health services
Poor patient self management
Insufficient care giver support
Lack of availability or awareness of community
resources
Source: Polisher Research Institute



Remaining in the Community
Community Support
Area Agency on Aging: Various projects Federal/
State Funding
Senior Centers
Program for All Inclusive Care for the Elderly (PACE/LIFE):
Transitions Care Management Programs
Naturally Occurring Retirement Community: Public/
Private funding
Geriatric Care Management: Private and Insurance
funding

Residential Support

Independent Living
Personal Care/Assisted Living
CCRC: Continuing Care Retirement
Community
Life Care at Home

Response
Build a Network of Services

Link Medical and Social Models
Support
Provide resources
Network with existing programs
Senior
Eldercare
Helpline
Senior
Housing
Senior
Clubs
Senior
Centers
Senior
Care
Partners
Saint
Monica
Eldercare
Program
In-Home
Support
Program
Community Nurse Liaison
Provision of Nursing services where seniors gather
Goal
Self Management of Chronic disease
Omaha System
Health Promotion
Facilitate collaboration with Medical systems
General Education

Community Nurse Liaison
Ask the Nurse Day
Health Consulting
Analyze programs and develop new programs to address
the health issues
Health Education
Articles on health & wellness for seniors
Monthly presentations

Community Nurse Liaison
Evaluation Based on a Standardized tool
Develop a care plan
Reassessment upon next visit
Care Plan revision as necessary
Document all patient contact
Community Nurse Liaison
The Omaha System
Problem Categories: Environmental, Psychosocial,
Physiological, Health-related Behaviors
Consists of three, five-point scales measuring the
range of severity for the concepts:
Knowledge: Understanding and management of the
specific problem.
Behavior: Persons ability and approach towards managing
their problem.
Status: Measures signs/symptoms of the problem.
Ask the Nurse Day
Services rendered since Nov. 2013
247 Unduplicated Seniors
Reassessment on 104 unduplicated seniors
491 Total Patient Visits
234 Repeat Visits
71.2% of patients show improvement
38.2% average improvement from initial score


Senior
Eldercare
Helpline
Senior
Housing
Senior
Clubs
Senior
Centers
Senior
Care
Partners
Saint
Monica
Eldercare
Program
In-Home
Support
Program
CCOPE
(Catholic Care Options Program for the Elderly)
No-fee resource information and referral service
Managed through Senior Care Partners
Entry point for internal and external services
Resource for community, professionals, pastors
Senior
Eldercare
Helpline
Senior
Housing
Senior
Clubs
Senior
Centers
Senior
Care
Partners
Saint
Monica
Eldercare
Program
In-Home
Support
Program
In Home Support
Partnership with PCA
Evaluation and resource coordination
South Philadelphia area
Target population
Early intervention and prevention services for 60+
individuals
Temporarily homebound or require assistance or
supervision to leave home
In Home Support
Case Management Services
Short Term Services: Less than 6 months
Home care, chore service, minor home repair
Long term services:
Home-delivered meals, transportation, and senior
companions.

In Home Support
Number of Open Cases: 274
Impact:
Home delivered meals: 2,112
Transportation requests: 1,554
Light House keeping services: 888
Adaptive Equipment: 44
Senior
Eldercare
Helpline
Senior
Housing
Senior
Clubs
Senior
Centers
Senior
Care
Partners
Saint
Monica
Eldercare
Program
In-Home
Support
Program
Senior Housing
St. John Neumann Place
75 one-bedroom Independent Living apartments for
income-eligible residents at the former SJN High
School
Casa Carmen Aponte
Section 8 housing with 35 apartments
Located above Norris Square Senior Community
Center
St. Mary Residence
Former convent with supportive housing for women
over 60 years old

Senior Housing
In Process
Name Units Primary
Funding
Total
Cost
Timeline
Nativity B.V.M. Place
(Port Richmond, Philadelphia)
63 HUD 202

$12.5m

Start Construction: Jan 2015 (maybe sooner)
Ready for residents: February, 2016

St. Francis Villa
(Kensington, Philadelphia)
40 LIHTC $12m Start Construction: March, 2015
Ready for residents: April, 2015

St. John Neumann Place II
(South Philadelphia, Philadelphia)
52 LIHTC Ask John Applying for funding: January, 2015
If awarded funding, start construction: April,
2016
Ready for residents: May, 2017


Senior Housing
St. John Neumann Place
Senior Housing
St. John Neumann Place

Senior Housing
St. John Neumann Place

Community Nurse Liaison
Average monthly patient visits: 10
Active Care Management cases per month: 20
Referrals: 315 (Benefit Programs, Health Care Services,
Legal Services, Financial Services, Crisis Support)
Hospice: 2 within 12 months
Life Program: 12 residents
PCA LTC Program: 11 residents




Senior
Eldercare
Helpline
Senior
Housing
Senior
Clubs
Senior
Centers
Senior
Care
Partners
Saint
Monica
Eldercare
Program
In-Home
Support
Program
Senior Citizen Clubs
The Archdiocesan Senior Citizen Council (ASCC)
Approximately 75 senior clubs
Self-directed, independently incorporated
Approximate combined membership 7,000
Connecting
Participate in Club fairs and meetings
ASCC Newsletter: CHCS Health and Wellness
Marketing availability of services and programs





Senior Club members working on a Prayer
Square Quilt for Victims of Abuse
Senior
Eldercare
Helpline
Senior
Housing
Senior
Clubs
Senior
Centers
Senior
Care
Partners
Saint
Monica
Eldercare
Program
In-Home
Support
Program
Senior Community Centers
Funding
- Philadelphia Corporation for Aging
- Catholic Health Care Services
- United Way
Philadelphia Locations
- North Central: Norris Square: Hispanic
- Port Richmond: St. Anne: Polish
- West Philadelphia: Star Harbor: African American
- South Philadelphia: St. Charles: Chinese African
American

Senior Community Centers
Participants are 60 + and residents of Philadelphia
Total impact: 5,338
Daily attendance: 239
Unduplicated seniors: 1,965 last fiscal year
Information and Assistance: 3,373 seniors
Program Focus
Social Isolation
Health and Wellness
Food Insecurity


Menu of Programs and Services

Congregate meal (lunch)
Social programs
Recreational activities
Day Trips
Arts and Music
Consumer/Health Education
Programs

Spirituality Program
Physical exercises (yoga,
tai chi, dance, aerobics)
Computer lab and classes
Health Screenings
Nutrition Education and
Supplemental food
programs
Social Isolation
Social events
Trips
Depression Screening Program
Counseling Services
Senior Community Centers
Food Insecurity
Food Insecurity Program
Breakfast Program: 29,057 meals
Congregate Lunch: 56,393 meals
Commodities Boxes: 4,041 boxes
Produce Vouchers: 949 vouchers


Senior Community Centers
Food Insecurity
Nutritional Risk Assessment
Pa. Dept. Aging nutritional assessment tool
321 new members over 8 months
140 or (43.62%) were nutritionally at risk.
Reassessed: 90 after 6 months


Senior Community Centers
Food Insecurity
Outcomes 2
21.12% remained the same no change in risk score
44.44% improved with a decrease in risk score
34.44% were at increased risk
Plan
1.Investigate reason for the increased risk
attendance
accessibility to food suppliers/stores
financial supports/resources
2. Continue assessment program




Senior Community Centers
Health and Wellness
Enhanced Fitness:
307 classes
6,846 attendees
Health Promotions:
1,876 classes/sessions
25,355 attendees
Health Education
569 sessions/screening
10,086 attendees


Senior Community Centers
Health and Wellness
Ask the Nurse Day
Memory Screening
Other Services
Podiatry
Glaucoma screening
Falls risk screening
YOGA FOR OUR SENIORS
CHRISTMAS IN JULY AT THE CENTER
Senior
Eldercare
Helpline
Senior
Housing
Senior
Clubs
Senior
Centers
Senior
Care
Partners
Saint
Monica
Eldercare
Program
In-Home
Support
Program
Background
Funded by the Farrell Townsend Trust, initially
established in the 1940s
Serves registered parishioners and their families
in Saint Monica Parish in South Philadelphia
Started in September 2003
Provides direct service, connects to other
services, fills in gaps



SMEP Core Services
Information and Referral: 125 calls per year
Service Delivery for open cases
Care Partner
Care Management
Form completion
Connecting to organizations
Facilitating Family meetings
Spiritual Care and Guidance
Operations
Number of Employees
1 FTE, Director CGCM (Certified Geriatric Care
Manager)
3 part time Care Partners
4 occasional Care Partners
10 hour/week Pastoral Care Partner
10 hour/week Administrative Support
Budget: $194,356 per year

Focus
Overall well being
Quality of Life
Care giver support
Impact
Reduction in re-hospitalization
Reduction in nursing home placement
Fills gaps in other available services

Data Collection
July 2010,2011,2012
89 participants studied
Gathered data for all participants
Demographic
Services rendered
Health information
Diagnoses, hospitalizations
Disposition

Demographic Characteristics
for 89 sample
Mean Age all members: 84.6 years (SD 32.5) Range
44-97 years ( 2 individuals: 44 & 47)
Mean Age 85.1 years; Range 57-97 removed 44 &
47
26% Live Alone
51% Receiving a psychotropic medication
30% Display Cognitive Impairment: Observation
*MMSE test implemented in March 2013 indicate 28.5%
cognitive impairment


Demographic Characteristics
for 89 Sample
Average length of time in SMEP 3.5 years
Average total number of self-reported medical
diagnoses = 4 (range 0-12)
66% Female
Average annual documented income for 33
individuals is $12,882
10 or 11% were receiving services typical of a
nursing home population (LIFE program, Waiver
services, hospice, 24 hr. private duty aides,
family care givers)
Percent of Members Receiving Services
Percent of Members Receiving Services
Percent Receiving Other Vital Services
Red Dots = participants in the SMEP N=89
Blue Squares = services and referrals
Visualization of SMEP members connected to services
Direct Services Diagram subset from above
Visualization of SMEP members connected to direct services
Referrals to other Programs (subset of entire graph above)
Visualization of SMEP members connected to referrals
Satisfaction Survey
74 questionnaires mailed to current members
(including family if member was unable to
complete)
103 questionnaires mailed to past members
(including family if member was deceased)
N=107 Returned Questionnaire
61% response rate
Satisfaction
Information provided helps me resolve my
issues:
81 % strongly agreed, 17% agreed
How Important is to you that St. Monica
Eldercare Program is associate with your parish:
90% extremely important, 9% important, 1% not
important
Would you recommend St. Monica Eldercare
Program to neighbors, friends or family:
100% yes
Community Partners Responses
Questionnaires mailed to all businesses that
the SMEP refers clients
28 questionnaires mailed to community
business partners
68% response rate
N=19
Business Satisfaction
Being aware of the Saint Monica Eldercare
Program has increased my awareness of the needs
of the senior community
64% strongly agreed
36% agreed
My business has benefitted from the relationship
with the Saint Monica Eldercare Program
68% strongly agreed
32% agreed
Rogers Family
Adult Child of Joe & Sue called program in 2003 to
request services for Parents
Joe (age 78; services from 2003-2004)
Sue (age 78; services from 2003-2007; 2009-2011)
Son Jim (age 48;services from 2003-2005)
Daughter-in-Law Becky (age 62; services from Jan-July 2012)
Sues sister, Paula (age 89; services from 2011 present)
Rogers Family
2003
One of first Program participants 9/2003
Care Management for Sue, Joe, and Jim
Sue was caregiver for Joe and Jim
Services accessed 2003-2007
2003 - CCT for Joe and Sue, Rx assistance for
Sue, Medicaid Waiver Program for Joe
2004
Establishment of trust for Jim
All legal documents for Joe and Sue prepared
Sue: Medicare Advantage enrollment
PACE for Sue, LIHEAP, RE Tax Rebate, discount plans
w/ PGW, PECO
Jim: advocated for in home care when Jim could no
longer attend workshop
2004

Joe hospitalized, ST rehab at Methodist Nursing
Center, home w/ services
Joe passed away in August; assisted Sue and Jim in
receiving SS benefits on his record

2005
Jim: Arranged in-home assessment by
gerontologist; Primary diagnosis of dementia
Jim: Assisted with first floor set up;
recommended physician who made house calls
Jim passed away in October after short
hospitalization

2006-2007
Sue: Continued care management
Sue: Bereavement support group offered
Sue: Submitted application for VA benefits;
denied as expenses were not high
Pro bono legal work completed
Sue agreed that case could be closed in spring
2007
2009-2010
Case reopened after call from son
Sue diagnosed with dementia
Care Management services initiated
Initiated long term planning
Care Partner assigned

2011
Sue sustained stroke, hospitalization, short
term rehabilitation
Sue: Coordination of medical home care
Sons chose reverse mortgage to pay for care at
home
June: Sue passed away at home
Paula: Sues Sister Paula fell and broke hip
Becky: December diagnosed brain cancer

2012
Paula admitted to St. Monica Manor in January
Care Management initiated
Home renovations
Private pay home care
July: Becky passed away at home
2013/2014
Paula: March returned home with 24 hour live in
care
Doing Well at home with live in caregiver
Physician who makes house calls
Therapy at home PRN
Communion in her home
Prayer Partner program


Rogers Family Timeline

Joe & Sue- Husband and Wife
Jim Adult Son with Downs Syndrome
Becky Daughter-in-law
Paula Sues Sister

Visualization of Rogers Family Connected to Services.

System Impact
Reasons for Discharge N=37
Does not include those individuals still actively receiving services
System Impact
Non Institutionalization
54% or 20 individuals were discharged due to
death
11 died in their homes
4 died during short term NH stays (average 18 days)
2 during rehab stay
1 during hospice stay
1 who would have converted to Long Term care
5 died during brief hospitalizations (average 3 days)
System Impact
Nursing Home Placement
SMEP had 5% versus 11% national average for
nursing home placement of individuals age 85+
SMEP
SMEP: 4
National average projection: 10
Result: 6 fewer long term admissions


System Impact
Financial
Average length of stay in nursing home in
Pennsylvania for long term care: 183.94 days
Average cost per day in PA: $221
Savings for one individual: $ 40,651


Source: http://www.amwarnerinsurance.com/ltc-insurance/cost.php

System Impact
Hospitalization
SMEP average hospitalizations is 45% versus
national average of 58% for individuals 85+
Difference in hospitalization rate: 11%
Average cost to Medicare per hospitalization:
$7,200


Source http://www.hcup-us.ahrq.gov/reports/statbriefs/sb103.jsp
http://www.hcupus.ahrq.gov/reports/factsandfigures/2009/pdfs/FF_2009_exhibit4_3
.pdf




System Impact
Philadelphia Corporation for Aging
At the time of the study about 2,000 evaluated
individuals are on the Options waiting list for
PCA services.
16% or 14 of the 89 SMEP members were
assessed by PCA for the Options program
Three people died while waiting for services to begin
Five people waited an average of 142 days for
services to begin (Range 32-427 days)
Six people were still waiting (to date average 505
days)


System Impact
Philadelphia Corporation for Aging
SMEP
No waiting list
Services parishioners who are waiting
Provides support after PCA initiates services

Continued Growth and Development
Incorporation of Nurse Educator/Consultant
Ask the Nurse events
Telephone consultations, in home visits, assessments
Replication of Program


Continued Growth and Development
ShopRite Shop at Home
Phone in orders, same day delivery
No charge to parishioners
Call Partner Program
Requested by study participants
Allows homebound parishioners to remain active
participants in parish life
Fosters communication between members of both
churches

Senior
Eldercare
Helpline
Senior
Housing
Senior
Clubs
Senior
Centers
Senior
Care
Partners
Saint
Monica
Eldercare
Program
In-Home
Support
Program
Our Services
Transitional Care Management
SNF to Home
Traditional Care Management
Serves private paying clients and caregivers wishing
to remain at home in the community
Assessment
On-going coordination
On-going monitoring

Senior Care Partners: A Geriatric Care
Management Program
Certified Geriatric Care Managers
Programs
Skilled Nursing Transition Program
Care Management Program with Senior Bridge/Humana
Traditional Geriatric Care Management
Parish Based Programs
Preventing Hospital Readmissions
Readmission cost of over $26 billion every year
Average Cost of preventable readmission: $7,200
Most critical time frame: 72 hours post discharge
50.2% of re-hospitalized patients did not have billed
physicians office visit
Coaching chronically ill older patients and caregivers
may reduce rates of re-hospitalization




Source :Internal Medicine/vol. 166, 2006

Assessment Components
Physical Environment
Activities of Daily Living Status
Medication Management
Nutritional Support
Cognitive Status
Social and Spiritual Support
Community Medical Appointments Scheduled
Identify Additional Community Resources

Traditional Geriatric Care
Management
Assessment
Development of Care Plan
Collaboration with Client/Family
Coordination of Services
Continued monitoring
Education
Advocacy
Family caregiving coaching
Skilled Nursing Facilities
Adds a medical component to our Continuum of Care
Skilled Nursing Facility (SNF), short term rehabilitation services,
respite stays, medical care in a social environment
Understanding of Medicare and Medicaid coverage, regulations and
billing
Allows CHCS to leverage clinical resources in the community setting
Focus on ease of transitions between care settings


Skilled Nursing Facility Program
Eligibility:
ST stay at a CHCS Skilled Nursing Facility
Admitted from a participating hospital
SCP connected thru daily census report
SW informs SCP discharge planning meetings
CM attends discharge planning meeting and
schedules initial in-home assessment
Timeframes
45 day follow up services
Telephonic
Site visit if needed
Post Discharge from SNF
Day 7
Day 10
Day 14
Day 21
Day 30
Day 45
Additional unscheduled follow-ups as necessary

Skilled Nursing Facility Program
In-home assessment scheduled within 24-48 hours
of discharge
Written summary completed
submitted to hospital within 5 business days of assessment
Service provided
Discharge Completed
summary is submitted to the hospital within 5 business
days

Parish Based Program
Services
General Information and Referral
Traditional and Transitional Care Management
Volunteer Navigator/Senior Companion
Intergenerational Programing
Funding
Parish Grant
Exploration of funding models: membership, donation

Parish Based Program
Our Lady of Good Council
Partially implemented
Maria Goretti
Senior Advisory Council
Parish survey
St. Rose of Lima
Parish advisory council
Humana/SeniorBridge
Transitions Program
Hospital or SNF to home
Long-Term In-Home Program
Identified as high-risk for hospitalization
Geriatric Care Management Consults
One-time assessment and development of care plan and
appropriate resources
Traditional Care Management through Care
Management Network
Clients Served
Traditional Care Management Program
Initiated July, 2011
Clients Served: 31
SNF Transitional Program
November, 2012
Clients served: 280
Clients Served
Senior Bridge/Humana
Initiated March, 2013
Clients Served: 13
Our Lady of Good Counsel
Initiated January, 2014
Clients Served: 28

Re-Hospitalizations

Readmission following discharge from SNF
State Average: 20.6%
Senior Care Partners: 18.6%
Cost Savings: $36,000 (52 vs. 57 )


Source: Pa. Health Care Cost Containment Council 2012, 2013)
Senior
Eldercare
Helpline
Senior
Housing
Senior
Clubs
Senior
Centers
Senior
Care
Partners
Saint
Monica
Eldercare
Program
In-Home
Support
Program
Quotes

"Aging is not lost youth but a new stage
of opportunity and strength."
Betty Friedan (1921-2006)

QUESTIONS