Strengthening the Workforce to Support Community Living and Participation for Older Adults and Individuals with Disabilities Proceedings of a Workshop (2017) / Chapter Skim
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4 Perspectives on Coordination Across the Spectrum of Caregivers, Providers, Services, and Supports
4 Perspectives on Coordination Across the Spectrum of Caregivers, Providers, Services, and Supports
Pages 41-56
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From page 41... ...
These speakers also looked at this challenge from the perspectives of segments of the workforce that support individuals with different types of needs. COORDINATING MEDICAL AND SOCIAL MODELS TO ENHANCE CARE DELIVERY Robyn Golden Director of Health and Aging Rush University Medical Center Robyn Golden of the Rush University Medical Center began her presentation by quoting from a report from the Institute for Clinical Systems Improvement (ICSI and RWJF, 2014)
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From page 42... ...
The geriatricians at her institution have told her that they will know that the care delivery system is working effectively when they know what the direct-care worker is thinking and doing in the home of one of their patients and when the direct-care worker knows what the geriatricians are thinking and doing in their offices. She noted that the Institute of Medicine recommended developing community links to assess psychosocial issues, to deliver services in the community, and to communicate these issues with the medical team (IOM, 2013)
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From page 43... ...
It does this through several mechanisms, including providing interactive, online education for community members and professionals; developing course material; supporting faculty learning communities; promoting health education on subjects such as lesbian, gay, bisexual, and transgender older adults; and creating health ambassadors, who are similar to community health workers but are specifically older adults living in the community they are serving. The program's second aim is to transform primary care into collaborative care that places the older adult at the center of that care and includes care givers, an assessment team, the clinic or hospital intervention team, and a community intervention team.
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From page 44... ...
Success also requires innovative models of care coordination and integration as well as the community engagement and partnerships necessary to create a system where the hospital, the home health agency, and the community organizations can talk to one another and also have an understanding of the preferences and values of the older adults, the people with disabilities, and the families they serve, Golden said. COMMUNITY-LEVEL COORDINATION BY AREA AGENCIES ON AGING Sandy Markwood Chief Executive Officer National Association of Area Agencies on Aging The mission of the National Association of Area Agencies on Aging (n4a)
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From page 45... ...
More than 60 percent of Area Agencies on Aging are designated as State Health Insurance Assistance Programs, which provide direct health insurance counseling to older adults, and more than half serve as local long-term care ombudsmen to act as a resource and as an advocate for consumers living in nursing homes and other institutions. In fact, while all Area Agencies on Aging serve adults ages 60 years and older and their caregivers, an increasing percentage also serve consumers under age 60.
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From page 46... ...
They also monitor the quality of those services and test for consumer satisfaction. All Area Agencies on Aging, said Markwood, provide core services in the areas of nutrition, health and wellness, elder rights, coordinating supporting services, and supporting caregivers with information, education, and critical respite, among others (see Box 4-1)
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From page 47... ...
Today, some 90 percent of Area Agencies on Aging offer a range of evidence-based health promotion and disease prevention programs that address such key health challenges as chronic disease self-management, diabetes self-management, falls prevention, and successful care transitions; the percentage of agencies offering such programs is up from approximately 50 percent in 2007, Markwood said, adding that she expects the number to soon be 100 percent because of new requirements in the Older Americans Act. Approximately two-thirds of Area Agencies on Aging are involved in institutional transition and diversion programs that help older adults either transition from an acute care setting to home or divert them from prematurely moving to an institutional setting by setting them up with home and ommunity-based c services and supports.
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From page 48... ...
Too often, said Markwood, people do not begin to look for services and supports in the social services sector until there is a crisis, so she said she believes there is a need to do a better job of proactively providing information about community resources before people reach that crisis stage. The bottom line, said Markwood, is that millions of older adults, people with disabilities, and their caregivers are counting on the Area Agencies on Aging to help them connect to services and supports so that they can live long and independent lives where they want to live -- at home and in the community.
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From page 49... ...
In the model of independence, consumers come into the Centers on Independent Living in search of core services, such as skills management, advocacy, peer counseling, and information and referral. The independent model implies that if basic independent living core services are met, consumers will naturally participate in the community.
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From page 50... ...
Working together, these two communities can better answer questions such as who has control over hiring and firing caregivers, how much will health care workers cost and who will pay for them, and what level of certification and licensure should be required? For Americans living in rural settings and receiving care from a family member or partner, White asked how an individual deals with poor care.
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From page 51... ...
At the same time, the injury severity score has risen, resulting in more individuals alive today who have complex care needs as a result of injuries sustained in war zones. These injuries include traumatic brain injury, extremity amputations, s pinal cord injuries, chronic pain, burns, and psychological health issues.
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From page 52... ...
going to do today to get to tomorrow." Furthermore, the DoD and the VA also found that these transitions made people vulnerable to getting lost between the two health systems. The solution to this unacceptable situation, she said, was to create a different model of care that was integrated across the two departments and integrated across every transition an individual might make, whether from a military treatment facility to a civilian hospital and back again, from one military treatment facility to another military treatment facility, or from the DoD to the VA and leaving military service.
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From page 53... ...
The main challenge, Guice said in closing, lies in making sure that individuals leaving military service have what they need when they return to civilian life in their communities. Any strategy for providing care for wounded warriors must, she said, consider an individual's longterm care needs and requires a long-term, committed public–private partnership with support from communities, the DoD, and the VA.
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From page 54... ...
For the past several years, n4a has been working with the disability community and the Administration for Community Living (ACL) to pilot learning collaboratives aimed at determining how social services can be paid for by health care dollars to create a bridge between health care and social services and between the acute care world and the home.
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From page 55... ...
was still a good one and still a valuable one in bringing social services to the hospital and the health care services to the social service world and the community," said Golden. She said she believes there are easy fixes to the challenges with these types of care transition programs that would enable any of them -- not just The Bridge Model -- to be taken to scale.
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From page 56... ...
One challenge, he said, is that researchers are not running the centers and thus the centers are not equipped to do the type of research needed to generate useful outcomes data. He said that stakeholders are working together to determine what data are needed and what outcome measures will be able to produce those data.
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