PARTNERS IN AGING: The Beginning Journey

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PARTNERS IN AGINGThe Beginning Journey
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The Beginning

• VISION
• BLUEPRINT 2010
• -- Preparing MN for the AGE WAVE
• OPPORTUNITY
• RFP to DHS

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Work Plan Focus

• Expand and coordinate services to persons with
  chronic illness and/or at risk of nursing home
  placement.
• Palliative Care Focus
• Provide seamless linkages with community programs
  and resources.
• Promote health and safety within the home of the
  Senior

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Adult Day Care
Palliative Care Preventive Medicine Chronic
Disease Management Integrative Medicine

• Faith in Action
• Transportation
• Friendly Visits
• Respite Care

Caregiver Support Groups
Physicians Health Other Care Providers

Meals On Wheels
Home Care and Hospice Fall Prevention,
Medication Management, Case Management
Caregiver Support
Private Pay HC Providers
Parish Nursing
Goodhue County Public Health

• Technology
• MyChart
• Tele-health
• Home Monitoring
• Life Line

Healthy and Safe Senior Living
Three Rivers Community Action
Goodhue County Social Services

• Red Wing
• Area Seniors
• Home
• Modification
• Senior Home Work

Driving Simulation
South County Health Alliance
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Mission, Values, Vision
Mission To improve the health of the communities
we serve. We commit our skills and resources to
the benefit of the whole person by providing the
finest in health care, while addressing the
physical, emotional and spiritual needs of
individuals and their families. We further
pledge to support the research and education
efforts of our partners, the University of
Minnesota, and its tradition of excellence.
Values Dignity Integrity Service Compassion
Who we are
Why we exist
Vision
Where we are going
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Vision
VISION We will be the integrator of care,
medical home for 1/3 of Minnesotans, and
attract patients from across the country to our
Centers of Excellence.
Emerging Definitions
Medical Home Place where populations receive
health information/education, clinical judgment
and technical skills.

• Integrator of care
• Improve the health of a population
• Leverage the continuum to provide continuity of
  care to patients over their life time
• Improve the individual experience for each
  patient
• Manage per capita costs

• Centers of Excellence
• Interdisciplinary programs recognized nationally
  for clinical and research excellence

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Our CS/SD Grant VISION
Proactively access Services that
allow Independent and safe living
Empower Seniors
Provide advocacy through a Senior Patient
Advocate to develop a plan of care that is
personalized and respects their wishes and
preferences
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GOALS

• Education and preventive measures to promote
  wellness
• Increase the use of resources to support
  independent living
• Utilize technology to track their progress toward
  their goal
• Support to the Senior to gain greater
  independence, safety, and the ability to
  self-advocate, providing respect for their life
  choices

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The PROCESS

• Job Descriptions
• Orientation
• Tools
• -Client assessment
• -Fall Risk Assessment
• -Documentation
• -Brochures
• Communication to the Community

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Role of the Senior Patient Advocate
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Another Story
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Sharing, Linkages, Education

• Palliative Care in our Outpatient Clinic
• Three Rivers Community Action, Inc.
• Faith in Action
• Stratis Health
• Living Well with Chronic Conditions
• Respecting Choices/Honoring Choices

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OUTCOMES

• Reported improved quality of life
• Reached our goal of 100 contacts by June 30,
  2009 with 50 community members enrolled and
  receiving care management
• Wellness Program/Living Well with Chronic
  Conditions
• 20 increased utilization of Community Based
  Services
• 33 receiving Palliative Care support

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CHALLENGES

• Degree of complexity of needs
• Time per client
• High needs of the referred population

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STRENGTHS

• Collaborative support
• Leadership
• Physicians
• Other service providers
• Community
• Respect

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Unexpected Outcomes

• City Council
• Communities for a Lifetime initiative
• HRA Director
• Overwhelming growth
• MDH and CDSMP project support
• Respecting Choices
• Potential for virtual contacts with clients is
  coming

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Adult Day Care
Palliative Care Preventive Medicine Chronic
Disease Management Integrative Medicine

• Faith in Action
• Transportation
• Friendly Visits
• Respite Care

Caregiver Support Groups
Physicians Health Other Care Providers
Meals On Wheels
Home Care and Hospice Fall Prevention,
Medication Management, Case Management
Caregiver Support
Parish Nursing

• Technology
• MyChart
• Tele-health
• Home Monitoring
• Life Line

Goodhue County Public Health
Partners in Aging
Three Rivers Community Action
Goodhue County Social Services

• Red Wing
• Area Seniors
• Home
• Modification
• Senior Home Work

Driving Simulation
South County Health Alliance
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Questions and/or Comments

• Thank You for your time and
• undivided attention!

Judy Treharne (jtrehar1_at_redwing.fairview.org) She
ryl Voth (svoth1_at_redwing.fairview.org) Kim
Erickson (kerick19_at_redwing.fairview.org)