Presented by

The North Carolina

Association of Area Agencies on Aging

Moving Forward Together: Partnering with Your Area Agency on Aging for Effective Care Transitions Training Presentation

After today’s presentation you will:

• Understand what an Area Agency on Aging is, how they function, and their role in the North Carolina Aging Network.

• Identify services that an Area Agency on Aging offers to assist you, your agency, and consumers in the community.

• Explain how these services can aid in transitions between different levels of care and identify at least two successful best practices.

Presentation Goals

• Julie Wiggins, AAA Director, High Country Area Agency on Aging in Boone, NC

• Sarajane Melton, AAA Director, Southwest Commission Area Agency on Aging in Sylva, NC

• Linda Miller, AAA Director, Centralina Area Agency on Aging in Charlotte, NC

Panel Introduction

• Established through the Older American’s Act of 1965 which includes the Administration on Aging, State Units on Aging, and over 600 Area Agencies on Aging (AAA).

• North Carolina has 16 AAAs that serve multiple county areas housed within regional Councils of Government that promote regional issues, services, and planning.

• All 100 counties in NC are covered.

Area Agency on Aging

•Area Agencies on Aging play a key role in planning, developing, coordinating, and delivering services

•AAAs are also charged with advocating for issues pertaining to the needs of older adults

Area Agency on Aging

NC Area Agencies on Aging

• Some services are administered by our provider network:▫ Home delivered meals/congregate nutrition▫ Adult day care/adult day health▫ In home aide services▫ Family caregiver support ▫ Transportation▫ Housing and Home Improvement▫ Legal Assistance

Services Provided

•Direct Services include:▫ Long Term Care Ombudsman Program

▫ Evidence-Based Health Promotion/Disease Prevention

▫ Long Term Care Options Counseling

▫ Senior Community Services Employment Program

Services Provided

• AAA services are linked to improved health outcomes for our clients

• It is less costly to support someone in their home with services than in long term care

• Research suggests home delivered meals:▫ reduces isolation

▫ reduces loneliness

▫ increases feeling of safety residing in one’s home

▫ reduces falls

▫ reduces hospitalizations

https://news.brown.edu/articles/2015/03/meals

Outcomes

• Area Agencies on Aging assist with care transitions in various ways

▫ Facilitate county-based multi-disciplinary teams

▫ Provide information, referral and assistance

▫ Regional Care Transitions Summit (High Country Area Agency on Aging)

Care Transitions

The Transition Process

The Transition Process In The Long Term Care Setting

Why Transitions Matter

LCA – Local Contact Agency and Options Counseling

MFP and the Transition Coordination Function Transitions MatterCA – Local Contact Agency and Options CounselingMFP and the Transition Coordination Function

What We’re Talking about Today

What We’re Talking about Today

We’re talking primarily persons who have been in a long term care facility and require additional assistance to transition back into their communities.

So, when we say “transitions…”

Part of Discharge Planning Responsibilities:

Residents should be in the best environment for themselves.

Transitioning from the hospital to the nursing home and then back home requires the collaboration of many parties to assure the success of returning home.

Why do Transitions Matter?

The Local Contact Agency (LCA) is responsible for providing facility based options counseling in response to MDS-Q referral.

WHAT IS AN LCA?

Provides Person Centered Planning for the resident that allows the resident to make informed decisions about the feasibility of transitioning

Collaborates with the resident and Nursing Home Staff to incorporate independent living skills into the resident’s care plan

Shares information and assists with identifying community based resources needed for a safe and successful transition

Provides follow-up with the resident and staff on the resident’s progress leading up to the transition process

Facilitates the interested resident to transition from the Nursing Home to a community based setting

What is Options Counseling?

• Through Community Based Services

•Programs that support transitions

▫DVRIL

▫ CIL

▫MFP

WAYS PEOPLE TRANSITION

A beautifully simple concept….

An opportunity to support people to transition into their homes and communities.

What is MFP?

Money Follows the Person

• Support the transition process

• Systems change:▫ Increase Home and Community Based Services

▫ Eliminate Barriers

▫ Continued Provision of Services

▫ Quality Improvement

If we only support people to transition,

we’re only doing half our job.

MFP: 2 Primary Purposes

•Area Agencies on Aging conduct various evidence based health promotion classes that:▫ Promote wellness

▫ Reduce falls

▫ Assist with managing chronic illness

Evidence-Based Health Promotion

Growing Epidemic

Key Risks

30%:

genetics,

access to

health care,

etc.

70%: behavior

& environmental

factors

Smoking

Poor diet and nutrition

Physical inactivity

Falls

Alcohol and substance abuse

Stress

Social isolation

• Every 11 seconds, an older adult is treated in the Emergency Room for a fall

• Every 19 minutes an older adult dies from a fall

• Falls are the leading cause of fatal injury and most common cause of nonfatal trauma-related hospital admissions

• In 2013, the total cost of falls injuries was $34 billion

Older Adults and Falls

“Honest, Doc –if I’d known I was gonna

live this long, I’d have taken better care of

myself…”

EBHP are packaged and “ready to go” programs that are:

• Developed and research in controlled settings

• Proven to be effective and have a positive impact on participants

• Published

• Translated to serve a wide variety of populations

• Typically licensed and requires certifications

Evidence-based Health Programs (EBHP)

• Generally fairly scripted or controlled

• Meet for a designated period of time

• Leaders certified and receive rigorous training

• Outcomes based

• Very participatory aimed at gaining skills and self-management

• Process of enabling people to increase control over and to improve their health

What are EBHP?

• Stanford University Suite of Chronic Disease Self-Management Education (CDSME) includes Chronic Disease, Diabetes, Chronic Pain, Arthritis, Positive Self-Management, and programs in Spanish.

• Falls Prevention programs such as A Matter of Balance, Otago, etc.

• Fitness programs such as GeriFit, Walk with Ease, Tai Chi, etc.

• Caregiver Support programs such as Powerful Tools for Caregivers

• Medication management such as HomeMeds

• Approved list: https://www.ncoa.org/wp-content/uploads/Title-IIID-Highest-Tier-Evidence-FINAL-7.27.16.pdf

What are EBHP?

• Life expectancy with chronic conditions has significantly increased

• You manage over 95% of your care yourself so need to learn the right skills and self-management

• Chronic conditions are expensive and the cost savings are:

▫ Reduced utilization for Emergency Room and overnight hospital stays

▫ CMS Report to Congress (2013) cost savings report indicates over $938 savings for people who took A Matter of Balance and savings in increased compliance such as medication regime, therapy, etc.

What does that have to do with Care Transitions?

• Provide support through group-based programming

• Use peers to reinforce desired behavior

• Can result in more effective and lasting transition

• Increases communication with their healthcare providers

• Make NEW behaviors as easy to do as possible

What does that have to do with Care Transitions?

• Contact your local AAA

• EBHP are accessible and community-based so they can be at Faith-based sites, Senior Centers, YMCA, Parks and Recreation locations, Clinics and healthcare providers, ANYWHERE!

• We can bring the programs to you

• www.http://healthyagingnc.com

Where to find EBHP?

Linda Miller Sarajane Melton

Centralina AAA Southwest Commission

704-348-2712 828-586-1962

lmiller@centralina.org sarajane@regiona.org

Julie Wiggins

High County AAA

828-265-5434

jwiggins@regiond.org

Contact Information: www.nc4a.org