Changing Landscape

Senior Support Program of the Tri-Valley

Building a Village, One Outcome-Based Program at a Time

January 3, 2014 – Marlene Petersen, Executive Director, describes the approach that SSPTV uses to serve over 3,000 seniors a year as “taking care of the whole person.” The organization serves the Tri-Valley area – encompassing the cities of Pleasanton, Livermore and Dublin. It’s a unique community that is fairly isolated from the rest of Alameda County services, and because of that, SSPTV has formed an eclectic set of services in response to local needs.

One-Stop Shop

SSPTV has a fortunate location, on the site of the Pleasanton Senior Center. This allows visibility and, so seniors can find SSPTV, and helps Petersen’s staff coordinate with a host of other senior programs (among them health insurance counseling, meals, educational programs, etc.). Petersen’s staff connects seniors, assisting with applications and navigating any enrollment process. People in crisis often need more than a referral; they need an assessment to determine the right referral, an introduction, and an understanding of what help to ask for. Says Petersen, “We built ourselves on watching and listening to what seniors are really going through and making sure we don’t add to their problems.”

To connect homebound or isolated seniors with support and community, SSPTV had to develop creative programming and collaborations. “The seniors who come to the senior center and are active in the community, they’ll find us. But there are those who are never going to ask for help but when crisis comes along, they call 911.” Starting in 1981 with a Friendly Visitors program, SSPTV set out to build connections.

A Host of Programs

SSPTV’s Friendly Visitors program started with 35 clients; today the program has 250. Friendly Visitors matches the needs and interests of each senior with those of a volunteer. The program has succeeded in opening doors and lives to fulfilling experiences, and reestablished healthy social connections. Petersen notes the biggest challenge is that “once they become friends, they don’t even remember us.”

SSPTV’s In-Home Counseling Program provides one-on-one counseling and emotional support for seniors in their homes. Counseling in the seniors’ own homes is more likely to be successful because of this inherent comfort level. Says Petersen, many seniors “have lived a lifetime in hiding, from abuse, alcoholic parents, etc., so there’s a lifestyle that now reflects that. It doesn’t come out easily.”

To maintain the individual needs of independent seniors and their support structures, SSPTV provides Case Management and Family Caregiver Support services. Case Managers visit seniors at home for a comprehensive assessment, and create care plans to support seniors’ goals of living independently. Says Petersen, “Everything we do comes from the senior. We’re building trust first and foremost.” To complement this system, SSPTV’s Family Caregiver program helps caregivers with a number of resources, from planning to support groups. “We serve the whole person: body, mind and soul,” says Petersen. Additionally, SSPTV employs monthly monitoring to ensure the senior is following and succeeding with their plan’s outline.

SSPTV’s Finding Wellness is a program intent on developing each participant’s complete understanding of the benefits of nutrition, exercise, and alcohol/drug management. The program combines case management, education and a support group. Classes resemble circles of sharing. “We don’t instruct, instead we converse with seniors” says Petersen. “We get our points across” on the impact of alcohol on older bodies and brains, medication issues, falls, etc.

SSPTV’s philosophy emphasizes friendship and trust. Petersen says this allows them to “help more people because no one is afraid of us. Most people who go through the program, they’re connected and have people that care about them. That’s the biggest success.”

A Community of Partnerships

SSPTV maintains an active partnership with the local Rotary club, annually organizing over 100 volunteers to clean and repair about 100 homes. “The volunteers do gardening, they turn mattresses, sometimes they paint a house – whatever the senior needs.” SSPTV also calls on the Rotary during the year to help seniors with special needs, and has developed similar relationships with local numerous churches. Says Petersen, “It’s so amazing what the community does to make this work. It’s not Senior Support Program standing alone.”

Partnering with local Police and Fire represented a significant milestone in SSPTV’s development. Petersen described the challenge: “Emergency responders would arrive, take the senior to the hospital, but then they’re released from the hospital and sent home with no support. We wanted to make a connection when they went to the hospital, so we could visit them there and let them know services were available.”

Now in its second decade, SSPTV’s partnership with the local Fire Department includes training for first responders. They are trained to recognize dementia and other issues, assess the status of the spouse who is left at home when the caregiver is admitted to the hospital, and to make connections and warm referrals to SSPTV. “Our phone number is in their engine,” says Petersen, and “when the Fire Department says to seniors, ‘You need to work with SSPTV,’ they listen.”

Partnership with Hospitals and Managed Care?

SSPTV is working towards developing partnerships with hospitals. Though they don’t currently bill Medi-Cal or Medicare, “We know we’re the best continuum of care that any of these facilities could ever have,” says Petersen. “When seniors leave that hospital and we’re there, they aren’t readmitted because we’re providing services that prevent them from being back in the hospital.”

Return to the Changing Landscape of Aging Services page.

Alameda Alliance for Health Uses Key Principles to Inform Planning

In a proactive response to the changing managed care environment, Alameda Alliance has created a new LTSS unit that will be primarily responsible for the Long-Term Supports and Services that are moving under managed care when the Coordinated Care Initiative launches. At the January 31st SSC Panel Discussion, Alameda Alliance’s Director of Outreach and Education for LTSS, Elizabeth Edwards, outlined five guiding principles which the Alliance is operating from as they prepare for the Coordinated Care Initiative:

1. Honor consumers’ existing relationships with medical and LTSS providers.

2. Supplement medical care through a robust assessment process and by developing plan based and community based care coordination activities.

3. Engage CBOs that provide significant services to the Duals Demonstration population.

4. Enhance scarce resources but not supplant existing funding sources.

5. Define and measure success as no disruption in care.

 

To realize these principles, the Alliance will be connecting with medical providers, supportive services providers over the next several months and beyond:

● Medical Providers – The Alliance’s work will include determining which medical providers are significant to consumers, and reaching out to these providers to create contracts and continue information sharing. (Community based organizations can assist in this process by sharing medical provider contact lists with the Alliance.)

● LTSS Providers – The Alliance will contract with the MediCal LTSS providers (IHSS, MSSP, SNFs) much like they are currently contracted with CBAS/ADHC providers. These contractual relationships will allow the providers to share any recent in depth assessments of consumers upon enrollment in Alliance, allowing Alliance to be better informed about new members’ status and service needs. Elizabeth described the assessment as key to ensuring that Alliance is able to “get folks into care that need it and find the people who are not getting the services that they actually need and make that transition easy for them.”

From the CBAS transition, the Alliance learned that the expertise currently existing within the community is an incredible asset. The Alliance wants to “make it possible for those community providers to… do what they’ve been doing.” Yet Elizabeth acknowledges that resources are scarce in the county and waiting lists abound, and that the Alliance cannot provide funding to fill all these gaps.

 

To return to the Changing Landscape page, click here.

For a report on the entire January 31st SSC Panel Discussion, click here.

 

Adult Day Health Care Benefit Transitions to Managed Care


It’s
 been
 15
 months
 since
 a
 court‐mediated
 settlement
 preserved
 Medi‐Cal
 coverage
 for
 Adult
 Day
 Health
 Care
 and
 created
 a
 new
 ADHC
 benefit
 called
 Community‐Based
 Adult
 Services
 (CBAS).
 
Since
 then,
 the
 Adult
 Day
 Services
 Network
 of
 Alameda
 County
 (ADSNAC)
 has
 been
 working
 with
 its
 members
 (six
 organizations
 that
 run
 thirteen
 adult
 day
 programs
 throughout
 Alameda
 County)
 and
 with 
the 
county’s
 two 
Medi‐Cal
 Managed
 Care
 Plans 
to
 transition 
programs
 and 
patients
 into
 Medi‐Cal
 managed 
care.


Having 
experienced
 the 
transition 
of 
a
 Medi‐Cal covered 
LTSS 
into 
managed
 care,
 Anne
 Warner‐Reitz,
 ADSNAC
 Executive
 Director,
 provided
 an
 informed
 template
 for
 the
 coming 
Coordinated 
Care
 Initiative.

Ms.
 Warner‐Reitz
 acknowledged
 the
 CBAS
 implementation
 was
 complicated
 by
 the
 state’s
 flawed
 eligibility
 process.
 
 About
 35%
 of
 the
 people
 who
 had
 been
 receiving
 ADHC
 services
 in
 Alameda
 County
 were
 initially
 found
 ineligible
 for
 the
 new
 CBAS
 coverage.
 It
 took
 a
 year
 in
 a
 laborious
 and
 difficult
 fair‐hearing
 process
 to
 reinstate
 eligibility
 for 
most 
of
 those
 participants.
 During 
that 
time,
 two
 ADHC 
centers 
closed 
and
 other
 providers
 were
 severely
 stressed
 as
 they
 worked
 to
 provide
 services
 under
 the
 double 
burden
 of
 rate 
cuts
 and
 delayed
 reimbursement.

One
 of
 the
 assets
 that
 eased
 transition
 difficulties
 was
 the
 goodwill
 and
 shared
 communications
 that
 occurred
 between
 the
 plans,
 agencies
 and
 providers.
 Early,
 the
 ADHC
 centers
 invited
 medical
 directors
 and
 other
 managed
 care
 plan
 staff
 to
 the
 centers.
 The
 plans
 and
 centers
 executed
 data‐sharing
 agreements,
 then
 shared
 assessment
 and
 outcome 
information
on 
patients 
they 
had 
in 
common, 
discovering 
that
 ADHCs
 knew
 significantly
 more
 about
 patients’
 health
 and
 had
 played
 a
 clear
 role
 in
 stabilizing
 patient’s
 with
 complex
 medical
 conditions.
 These
 conversations
 allowed
 the
 plans
 to
 recognize
 ADHC’s
 value
 and
 its
 role
 in
 a
 patient’s
 care
 plan,
 and
 built
 relationships,
 good
 will
 and
 common
 understanding
 that
 proved
 helpful
 as
 they
 developed
 the
 business 
relationships,
 protocols 
and
 procedures 
to
 implement
 CBAS.

Now,
 with
 a
 few
 exceptions,
 Medi‐Cal
 CBAS
 coverage
 is
 available
 only
 through
 a
 Medi‐ Cal
 Managed
 Care
 Plan.
 There
 is
 an
 expedited
 enrollment
 process
 so
 that
 people
 who
 need
 ADHC
 services 
can 
be 
enrolled 
in 
a 
plan
 quickly.

 ADSNAC
 has
developed 
a
 guide 
to
 help
 navigate
 the
 eligibility
 and
 enrollment
 process,
 available
 at
 http://www.adsnac.org/cbas.htm.
 

To return to the Changing Landscape page, click here.

For a report on the entire January 31st SSC Panel Discussion, click here.

 

 

ValleyCare Demonstrates the Value of Home Delivered Meals


As
 part
 of
 SSC’s
 January
 31st
 Panel
 discussion
 on
 The
 Changing
 Landscape
 of
 Aging
 Services,
 Gabrielle
 Chow,
 Director
 of
 Community
 Nutrition,
 ValleyCare
 Hospital
 System,
 spoke
 about
 a
 project
 to
 prove
 the
 value
 of
 home‐delivered
 meals
 in
 reducing
 hospital
 readmissions
 among
 patients
 with
 congestive
 heart
 failure
 (CHF).
 ValleyCare
 produces
 therapeutic
 diet
 meals
 for
 Meals
 On
 Wheels
 in
 Dublin,
 Livermore
 and
 Pleasanton, 
which 
are 
then 
delivered 
by
 Spectrum 
Community Services.

The 
project
 began 
with
 a
 grant
 that
 allowed
 for 
a
 CHF 
Coordinator 
to 
work 
with 
patients
 after
 discharge,
 an
 effort
 that
 yielded
 positive
 results
 but
 did
 nothing
 to
 change
 the
 dismal
 hospital
 readmission 
rate 
of
 the 
patients.
 Recognizing
 that low 
sodium 
diet 
plays
 a
 critical
 role
 in
 managing
 CHF,
 and
 that
 patients
 were
 overloaded
 with
 information
 at
 discharge,
 Gabrielle’s 
team 
added 
home
 delivered 
meals 
as 
an 
additional
 component
 to
 the 
project.

Patients
 were
 offered
 the
 chance
 to
 enroll
 in
 the
 meal
 plan.
 ValleyCare
 and
 Spectrum
 collaborated
 to
 deliver
 two
 meals 
a
day
 for 
seven
 days 
for 
both 
the
 patient
 and
 spouse.
 ValleyCare 
pays
 for 
the 
first
 seven 
days 
and
 then 
Spectrum 
assesses patients’
 for 
Meals
 On 
Wheels
 program
 eligibility 
(so 
far,
 40%
 of 
the
 patients
 have
 stayed 
on 
beyond
 seven
 days).
 The
 initial
 results
 were
 startling:
 readmission
 rates
 for
 patients
 receiving
 meals
 decreased
 by
 40%.
 Now,
 ValleyCare
 is
 planning
 to
 add
 more
 comprehensive
 data
 collection 
and
 expand the 
project
 beyond
 patients
 with
 the 
primary
 diagnosis
 of
 CHF.

ValleyCare’s
 experience
 is
 an
 example
 of
 an
 organization
 taking
 concrete
 steps
 to
 document
 the
 measurable
 health
 outcomes
 of
 a
 LTSS
 intervention
 –
 uncovering
 a
 “bottom
line”
 outcome 
that 
hospitals 
and
 managed 
care
 plans 
will
 understand 
and
 can
 assign
 a
 value 
to.


 

For a report on the entire January 31st SSC Panel Discussion, click here.

To return to the Changing Landscape page, click here.

 

Bay Area Community Services Assesses Readiness

BACS
 Executive
 Director
 Jamie
 Almanza
 described
 how
 a
 SCAN
 Foundation
 “Linkage 
Lab” 
grant
 is 
helping
 her 
organization prepare
 for
 change.

The
 goal
 of
 the
 Linkage
 Lab
 grant
 is
 to
 provide
 BACS
 with
 the
 necessary
 training
 and
 technical
 assistance 
to 
develop
contracts
 with 
health
 care 
providers 
to 
deliver
 products
 or
 services
 that
 enable
 aging
 with
 dignity.
 BACS
 is
 one
 of
 six
 organizations
 selected
 to
 participate
 in
 Linkage 
Lab.
 This
 24
 month 
initiative
 will 
allow 
BACS
 to
 better
 coordinate
 its
 senior
 services
 with
 the
 health care
 sector,
 thus
 improving
 the
 quality
 of
 care
 for
 elders
 with
 chronic
 conditions
 and
 functional
 limitations
 while
 at
 the
 same
 time
 diversifying
 revenue 
streams 
for
 the 
organization.

BACS
 will
 begin
 by
 assessing
 their
 entire
 organization
 and
 infrastructure.
 They
 will
 identify
 both
 current
 and
 needed
 strengths
 and
 capabilities
 that
 would
 allow
 them
 to
 interface
 with
 health
 care
 partners;
 identify
 services
 and
 expertise
 that
 are
 valuable
 to
 managed
 care
 plans;
 and
 learn
 how
 to
 package
 those
 services
 and
 calculate
 their
 true
 cost.
 BACS
 will
 be
 building
 relationships
 with
 health
 care
 entities
 and
 following
 a
 practical
 path
 to
 partner
 and
 contract
 with
 local
 health
 plans
 to
 provide
 long‐term
 services
 and
 supports 
for 
dual
 eligibles.

Recognizing 
the 
role
 BACS
 will 
play
 as 
a 
change 
agent 
in 
Alameda
 County, 
Ms. 
Almanza
 will
 be
 sharing
 Linkage
 Lab
 training
 materials
 and
 tools
 with
 the
 supportive
 services
 community. 
Stay 
tuned
 as 
this
 project 
develops.

 

For a report on the entire January 31st SSC Panel Discussion, click here.

To return to the Changing Landscape page, click here.

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