Healthy-in-Place (HIP)-Seniors: A Durham Health Innovations Project

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Healthy-in-Place (HIP)-SeniorsA Durham Health
Innovations Project

• Eleanor S. McConnell, RN, PhD, GCNS, BC
• Duke School of Nursing Durham VA Geriatric
  Research, Education and Clinical Center
• On behalf of the HIP-Seniors Team

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The Cost of a Long Life
U.S.
UC Project for Global Inequality
Slide Courtesy of Rob Califf, Durham Health
Summit, 2009
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Durham County Health Status

• The US is approximately equal to Cuba (and worse
  than several dozen other countries) in terms of
  the health of its citizens
• North Carolina is in the bottom half of US states
  in survival and functional status
• Durham County is average for North Carolina in
  almost every health statistic
• except significantly more doctors and dentists
  per population

Slide Courtesy of Rob Califf, Durham Health
Summit, 2009
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• Opportunity to partner with community as never
  before to improve important public health
  outcomes in Durham

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CDC Definition of Community Engagement

• the process of working collaboratively
• with and through groups of people affiliated by
• geographic proximity,
• special interest, or
• similar situations
• to address issues affecting the wellbeing of
  those people.

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DHI Planning Grants 100K each

• Life stage
• Maternal/Fetal Health
• Adolescent Health
• Seniors Health
• Hard medical
• Cardiovascular
• Cancer screening/survivors
• Asthma/COPD

• Behaviors
• Substance abuse/pain management
• Medical/behavioral
• Obesity
• Diabetes
• STDs

Slide modified from Rob Califf, Durham Health
Summit, 2009
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Unique Features of DHI Projects

• Access to
• GIS mapping
• Data Support Repository
• Durham stakeholders
• Agency heads
• Senior leaders at Duke
• Intention to change systems of care

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Timeline for The Process

• Sept Nov 2008 Stage 1 proposals
• Jan Mar 2009 Stage 2 planning
• April Dec 2009 Stage 3 planning
• Monthly Team Meetings with gt75 stakeholders from
  DUHS and Durham Community
• Work Groups Meeting regularly to gather data,
  summarize explicate evidence-based models
• Ongoing Focus Groups Social Marketing to
• Define the problems with seniors their health
  care
• Develop an innovative model of care for seniors

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Process

• Propose an evidence-based concept responsive to
  public health need of Durham County
• Build a team
• Community University co-leadership
• Think big
• Collaborate across teams
• Focus quickly

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Aging in Place with Dignity
Where is the sweet spot?
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A protypical scenario.

• I would get scared
• I didnt even realize I had been to the ER 19
  times
• Themes
• Doctors are too busy
• Misses
• Diagnosis
• Medications
• Information on phone
• Family caregiver frustrated

Courtesy AARP http//www.aarp.org/research/ppi
/articles/faces_of_chronic_care.html
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Expanded Chronic Care Model
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VISION
By 2020, Durham County will be the community
where seniors safely age in place supported by
collaborative efforts of a community-university
health system that empowers them with the
information and resources to make choices on the
quality of their own lives.
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MISSION

• HIP Seniors is a collaborative, community-based
• planning process bringing stakeholders from the
• community and university health systems
• together to design a streamlined, comprehensive
• and innovative model of care for seniors.
• Thismodel will provide seniors a person-centered,
  
• evidence-based, cost-effective, responsive
• system of care by building upon existing
• services and offering seamless transitions, no
• wrong door access, and full coordination of care.

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Model Outcomes

• Decrease return visits to hospital/ED
• Decrease EMS calls, ED visits hospital
  admissions due to falls or med-related issues
• Increase in seniors who report at least
  30-minutes of physical activity per day
• Increase in seniors receiving immunizations

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Core Components

• USA Universal Senior Assessment
• Tool to identify risks and strengths, shared
  information
• Navigation
• Various strategies
• Self-management,
• Family-caregiver support,
• Lay navigators in community agencies or
  neighborhoods, or
• Senior Support Nurse
• Link Support to Key Interventions
• Specific programs or services that address
  identified risk
• Coordination of Services HUB
• Information, access, follow-up, follow-through
  and linkage to existing community and health
  system services

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Coordination Navigation HUB
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Community Resource Connection as a Hub?
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HIP Seniors Model Navigation Process
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Next Steps
Time Step
Now.. Durham Health Innovations Oversight Team reviews reports, and finds commonalities to create a Close-Connected-Care model
Now.. Limited support for ongoing project management to coordinate team activities Publish articles on our experience, ideas, findings
Ongoing Uniform Senior Assessment (USA) Pilot recently funded to support development of transitional care module Medication Reconciliation Therapy Management Pilot seeking funding Improved Discharge Processes Pilot GEC funded Lay navigator Coordination hub preparing CRC proposal
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