Moving from Incremental Change to Systemic Change

PHASE 2 LAUNCHED

At the core of Aging-In- Place is the philosophy that older people and their families need coordinated support from multiple providers, and that health and social services must link together for smooth service. The project was successful in demonstrating interagency cooperation. The Office on Aging feels that a good foundation has been laid for future collaborative efforts.

Phyllis Madachy Director Howard County Office on Aging

Since the inception of the Aging-In-Place Initiative, a combination of implementation experience, data gathering and research have intersected to generate the vision of a second stage of Howard County’s effort to ensure the quality of life of its current and future senior citizens.

The experience from the Initiative has contributed to highly productive community partnerships among a range of public and private entities as well as a clearer anecdotal and statistical profile of the county’s senior citizens. Howard County’s ability to track both the current status and future needs of its citizens has been enhanced by the Initiative’s data collection component, which resulted in three reports: the “2000 Older Adult Status and Needs Assessment Survey,” a second survey on the types of services residents who are 60 or older would need in the future and formulation of benchmarks by which to measure success.

Increasingly, the literature of scientific research is pointing toward new and promising approaches to disease prevention and toward improved health care services for seniors.

Denmark’s National Model

In 2002, through research conducted by Mary Stuart, Director of the University of Maryland’s Health Administration and Policy Program, the Foundation and its partners became aware of Denmark’s highly regarded system of integrated care for older adults. In her writings about the system, Stuart explained that starting in the l980s, Denmark stopped building nursing homes and concentrated instead on developing 24-hour, community- and home-based services for older adults in a variety of settings, including nursing homes, congregate housing and private homes. Among the results of the shift, she reported, have been reductions in the rate of hospitalization and in medical and long-term care costs.

In 2003, a team including The Horizon Foundation, governmental, hospital, long-term care, academic representatives and other partners visited Denmark to study its model service delivery system and analyze the implications for improving long-term care in Howard County. The visit was noteworthy in terms of meetings held across that country with leaders in system operation and development. While Denmark’s governmental and social systems vary considerably from our own, many usable concepts were identified that are applicable to geriatric care in the United States.

PHASE 2 DEFINED

Our current “system” of long-term care is based on a medical model of caring for people when they are ill or at a high point of need. This inflexible system channels services into specific settings, creating barriers as people are moved back and forth between hospitals, nursing homes, personal homes and the homes of family members. Traditional funding streams do not recognize the interrelationship between health and community- based services, nor do they recognize the potential of self-management of their diseases by persons with chronic conditions.

Denmark’s integrated care system “has been widely recognized in Europe and Japan as an international best practice in managing care for the frail elderly efficiently—and it’s a model that the citizens have embraced as improving their quality of life as well as reducing costs.”

Mary Stuart Director University of Maryland Health Administration and Policy Program

In contrast to these persistent problems, there is promising news, with potential for solutions, from many fields of scientific research. The investment of time and money over many years has generated a body of knowledge about relevant topics including disease-prevention strategies, disease-management techniques and patient behavior. As the aging population swells with baby boomers, it makes eminent sense to draw on these scientific, evidence-based findings to relieve the additional pressures on the flawed long-term care system.

Following a multi-year planning period, the Foundation, the Office on Aging and other partners decided to focus their joint efforts on increasing the period of functional health of older adults with chronic conditions, with the potential dual benefits of improving health care utilization systems and the quality of life of the county’s seniors. Together, the program elements of this phase offer potential for linking adults with chronic conditions with the services they need to enable them to remain in their homes as long as they want to do so, as well as to reduce the costs of their care.

In its entirety, the model is intended to retread the service delivery system in order to maximize the functional independence of older adults. This requires a heavy emphasis on efficient information and referral; continuity of care across providers; the projection of services into the home setting; vast improvement in the ability of medical group practices to effectively handle older adult health needs; and, importantly, the ability of older adults to self-manage chronic diseases.

This phase consists of the following components:

• Maryland Access Point, a state-of-the-art information, referral and assistance system,
  
• A chronic disease self-management program, and
  
• A guided care nurse model.

Each of these components, which complement, articulate with and extend the original Phase 1 components, is described below.

Maryland Access Point (MAP)

Linking consumers to a reliable source of information and assistance enhances the possibility that their problems may be addressed successfully. For the elderly consumer who may be living with a chronic disease and one or more disabilities, timely access to information and help may reduce the likelihood of a health crisis and the necessity for acute care.

The Aging-In-Place Initiative demonstrated and the results of the Denmark experience confirm the importance of creating a central information point through which older adults can access services offered by a variety of public and private providers.

To respond to this need, in 2002 the Foundation funded and with community partners created HorizonHelp (www.Horizonhelp.org), a searchable, web-based information and referral service to assist the community at large, as well as local health, human and social service providers, in finding programs and services to fit their needs or the needs of their constituents. HorizonHelp is the information system backbone of Maryland Access Point.

In 2003, the Federal Department of Health and Human Services (HHS) announced the creation of a program of Aging and Disability Resource Centers (ADRC) with goals and strategies similar to those of HorizonHelp. According to HHS, “the goal of the ADRC Program is to empower individuals to make informed choices and to streamline access to longterm support. Long-term support refers to a wide range of in-home, community-based and institutional services and programs that are designed to help individuals with disabilities.” One of the requirements for receiving federal ADRC funding is to create a system that would serve both the elderly and one other target population.

In October 2004, Howard County received a federal grant to create an ADRC to serve persons age 50 years and older, and also disabled persons age 18 and older. Under the name Maryland Access Point (MAP), the funding is enabling the partners to substantially expand the HorizonHelp database and streamline the information and assistance offered by adding several trained information specialists to guide clients to appropriate community resources. Consumers access MAP through the Internet or a toll-free phone number, which is receiving an average of 2,400 phone calls per month.

Based on the philosophy that there should be “no wrong door” to enter the support system, as the development of MAP unfolds, it will provide consumers with a seamless system of access and services, individual assessment of their needs, integrated access to services and streamlined eligibility.

How MAP Can Help

A 73-year-old former teacher sold her home because she could not afford it. Since she could not get into senior subsidized housing immediately, she moved into an apartment that was too expensive for her. A fall prevented her from working in a part-time job and, consequently, she went into arrears in her rent. Her husband was three months behind in alimony. At the point that she accessed the MAP system, she was scheduled to be evicted the next day. Steps were quickly taken to provide her with financial relief that, along with her own minimal funds, stopped the eviction.

Self-Management of Chronic Disease

According to federal statistics, 48 percent of Americans age 65 or older suffer from diabetes, 37 percent from hypertension and 32 percent from hearing impairments. Substantial numbers of people in this age group also are living with arthritis, heart disease and major depression. These diseases are not necessarily curable. But, in recent years scientific research has demonstrated both that in many cases they are preventable and that, with appropriate health care and lifestyle changes such as more physical activity and smoking cessation, people who have chronic diseases can lead a healthier life and reduce their need for acute care.

Thus, in addition to systemic planning and the concept of a central access point, another theme that permeates the Foundation’s work is employing evidencebased approaches to address older adults’ chronic health issues. This approach is consistent with the Federal Administration on Aging’s efforts to “demonstrate how the results of research” by the National Institute on Aging and other scientific agencies can be translated into “evidence-based prevention programs at the community level.”

The Horizon Foundation, in tandem with the Howard County Office on Aging, has been recognized and welcomed by the Administration on Aging as a member of this public-private partnership to offer older adults access to programs that have been proven successful “ in reducing the risk of disease, disability and injury.” Through its Evidence-based Disease Prevention Grants, the federal government has funded initiatives in the areas of fall prevention, physical activity, sound nutrition, medication management, depression and disease self-management.

Only about half of persons 50 and older with disabilities report receiving any regular help with daily activities.... Because there is no organized “system” for delivering services, many individuals do not know about sources of support or how to find them, or if they are eligible for any publicly funded services.

Beyond 50 | 2003: A Report to the Nation on Independent Living and Disability, AARP, 2003

The Foundation and its partners have identified disease self-management as a promising strategy for Howard County, and are implementing it by creating the Living Well Program. The program is predicated on workshops based on the Chronic Disease Self- Management Program developed at Stanford University. The philosophy underlying the Stanford model is that participants who become actively engaged in managing their own diseases can improve their health outcomes. The potential benefits of this strategy for the individual are leading a healthier, more productive life in a setting—typically their own home—of their own choice. The potential benefits for Howard County include reducing the economic and social burden of acute health care and institutionalization as the large baby boomer cohort ages and makes its presence felt in local delivery systems.

With the active involvement of Stanford University trainers, Living Well workshops are providing individuals with chronic diseases with the tools to set goals and learn the skills they need to manage their own health. These include skills to reduce frustration, fatigue, pain and isolation; appropriate exercises; appropriate use of medications; communication techniques to deal with family, friends and health professionals, nutrition and healthy eating, and how to evaluate new treatments. The Stanford experience has shown that in addition to learning new skills, the participants’ outlook on life improves as they become more empowered to become involved in their own care.

Both the workshop leaders and participants must either have a chronic condition or live with a person who has a chronic condition. The Howard County program is training lay leaders who will then conduct the workshops, which consist of four sessions of 2.5 hours each for up to 20 participants.

As experience with the program increases, the Foundation and Office on Aging intend to bring the Stanford model to scale across Howard County using master trainers, a dispersed public system of senior centers and a well-coordinated management structure.

Guided Care Nurse Model

The third component of the Foundation’s current work with the Office on Aging is an evidence-based initiative being developed with Johns Hopkins University Hospital.

The model consists of embedding a specially trained registered nurse in physicians’ primary care practices to assist in identifying patients with multiple chronic conditions and to ensure that the patients are linked to the clinical best practices they need for those conditions. In each practice, the nurse and up to three physicians will work with 40 to 60 older patients who are living with and need to manage conditions such as arthritis, asthma, diabetes and hypertension.

According to the plan for this project element, the goal is for nurses to facilitate integration of seven “successful innovations for older people with chronic conditions” into the clinical practices. The innovations, all of which have been deemed to be highly effective by researchers who have studied them, are: outpatient geriatric evaluation and management, disease management, health enhancement programs by nurse practitioners, case management, transitional care and caregiver support.

Johns Hopkins University has conducted a successful pilot of the Guided Care approach, and the Howard County component will be part of a larger federally-funded study designed to evaluate the effects of the program on patients, their caregivers and their physicians.