April 29 - May 1, 2015

Community and Home-Based Solutions for All Ages- Community Health Navigator Program

Agenda

• Introduction to LIVE WELL Initiative

• Strategic Partnerships

• About Our Program

• Goals And Results

• Benefits To The Community

• Lessons Learned And Challenges

United Way of Tarrant County’s LIVE WELL Initiative

OUR BOLD GOAL: We will have improved the lives of 17,000 adults with ongoing health concerns by the year 2020.3 Core Values:

Care for Caregivers - Provides support for the people who take care of loved ones with ongoing health concerns

A Healthier Me - Provides services to adults in our community with ongoing health concerns

A Healthier Community -  Helps to educate and provide information for a healthier Tarrant County community

Strategic PartnershipsA Healthier Me- Community Health Navigation Program’s partners and

key stakeholders

Insignia Health

Texas Christian

University

Area Agency on Aging of Tarrant

County

Federally Qualified Health

Centers (FQHC)

Managed Care

OrganizationsDepartment of

Aging and Disability Services

Other Community

Based Organizations

About Our Program

Goals And Results Total clients served since 2012: 807 Homebound older adults

A low cost high impact program

Primary Outcome: To improve consumer’s capacity for disease self management.

Participants will:

Decrease hospital and emergency care admissions

Improved health status

Patient Activation Measure (PAM) level advancement

Goals

24% ↓in hospitalizations or emergency department visits for 6 months following the intervention

81 % of clients showed positive changes in at least one outcome variable

75 % of clients advanced at least 1 level of health activation after 6 months of CHN Intervention using the PAM Model

Results

Benefits To The Community

Source: Is Patient Activation Associated with Future Health Outcomes and Healthcare Utilization Among Patients with Diabetes? Journal of Ambulatory Care Management, Oct/Dec 2009

Texas Department of State Health Services calculated that from 2008-2013, adult residents (18+) of Texas received $49,010,136,451 in charges for hospitalizations that were potentially preventable.https://www.dshs.state.tx.us/ph/state.shtm

Lessons Learned

Use of neighbor to neighbor module

Person-centered philosophy- Community Health Navigators (CHN)

Hybrid program

Challenges

Unique needs of older population

New use of technology

Establishing boundaries

Lessons Learned And Challenges

CHNs-students/retired individuals

PAM-a supported coaching tool