Texas Aging and Disability Provider Network

Project coordination provided by:

Texas Aging and Disability Provider Network (TADPN)

Partnering to better meet the needsof United’s high-risk Medicaid and Medicare beneficiaries

Who we areMembers of Texas Aging and Disability Provider Network (TADPN), a voluntary, interagency collaboration representing:

• 10 Aging and Disability Resource Centers• 24 Area Agencies on Aging• 12 Local Authorities• Texas Department of Aging and Disability

Services

Provider agencies (1)

• Area Agencies on Aging (AAAs): network of 28 agencies, serving persons age 60 and over, their family caregivers, nursing home residents of all ages, and Medicare beneficiaries of all ages• Bexar market: Bexar and Alamo AAAs• Central market: Alamo, Brazos Valley, Central, Heart of

Texas, North Central, and West Central AAAs• Dallas market: Dallas and North Central AAAs• El Paso market: Rio Grande AAA• Harris market: Harris and Houston-Galveston AAAs

Provider agencies (2)

Area Agencies on Aging (cont.)• Hidalgo market: Lower Rio, Middle Rio, and South Texas

AAAs• Jefferson market: Deep East, Houston-Galveston, and

South East AAAs• Northeast market: Ark-Tex, Deep East, and East Texas

AAAs• Nueces market: Alamo, Coastal Bend, and Golden

Crescent AAAs • Tarrant market: Tarrant and North Central AAAs• Travis market: Capital AAA

Provider agencies (3)

• Aging and Disability Resource Centers (ADRCs): 14 community-based interagency collaboratives serving people of all ages, with all types of disabilities, with all income levels• Bexar market: Alamo Connection• Central market: Central Texas ADRC• Dallas market: Connect to Care (Dallas) and North

Central Texas ADRC• El Paso market: El Paso and Far West Texas ADRC

Provider agencies (4)

• ADRCs (cont.)• Harris market: Care Connection, the Gulf Coast ADRC• Hidalgo market: Rio-NET• Northeast market: East Texas ADRC• Nueces market: Brazos Valley ADRC, Coastal Bend

ADRC, and Alamo Service Connection• Tarrant market: Tarrant County ADRC and North

Central ADRC• Other United markets: will be served by ADRCs in 2014

Provider strengths (1)

• Local visibility • Expertise working with high-risk individuals• Ability to navigate complex systems of care• Knowledge of federal, state and local services, including non-Medicaid services• Ability to serve consumers and caregivers, regardless of payer source

Provider strengths (2)

• Knowledge of nursing home regulations and resident advocacy•Well-developed network of down-stream providers• Experience administering evidence-based programs• Ability to provide intensive health education/peer support

Core services: Nutrition/Transportation

• Congregate Meals: 3,633,468 during FY 12•Home-Delivered Meals: 4,886,825 during FY 12• Transportation: 772,515 one-way trips during FY 12

Core services: Benefits/Options Counseling• Helps consumers understand and access public and private benefits (e.g., veterans’ programs), protect consumer rights, plan for future needs• Staff Benefits Counselors have completed extensive training and are certified by state agencies• 21,062 persons received legal assistance during FY 12• Expertise in Medicare Part D, Medicare Savings Programs,

nursing home Medicaid, and alternatives to nursing home care

Core services: Care Coordination• Targets persons at greatest risk of premature institutionalization• Consists of:• Assessment: functional, psychosocial, financial• Planning: development/implementation of person-

centered plan• Implementation: service authorization and at least

monthly contact to monitor delivery • 18,111 received care coordination during FY12

Core services: Caregiver support• Targets caregivers who are experiencing adverse effects relative to their caregiving responsibilities• Services include:• Caregiver support coordination• Caregiver support groups• Caregiver education• Caregiver respite• Evidence-based programs including Stress Busting for

Family Caregivers and REACH II

Core services: Long-Term Care Ombudsman•Helps prospective residents and families make informed choice of facilities, understand financing, resolve complaints, and have access to relocation services• Provides training to staff on resident-centered care and residents’ rights• Supported by statewide network of 996 certified ombudsmen

Services to support strategic priorities1.Reduce risk of hospitalization2.Reduce incidence of potentially preventable

re-hospitalizations3.Promote medication adherence4.Avoid nursing home placement/ assist nursing

home residents in returning to community5.Educate and empower consumers to take

charge of their health

1. Services to reduce risk of hospitalization (1)

•Nutrition• Congregate meals • Home-delivered meals• Available statewide

1. Services to reduce risk of hospitalization (2)

• Fall Prevention: A Matter of Balance• Series of eight peer-led, small group sessions that

counteract fears, improve balance, and mitigate environmental risks• Outcomes: increased activity levels, mobility, social

function• Available in United’s Bexar, Capital, Central, Dallas,

Harris, Jefferson, Nueces, Tarrant markets

1. Services to reduce risk of hospitalization (3)

• Stanford Chronic Disease Self-Management Program (CDSMP)• Series of six peer-led small group sessions that focus

on managing symptoms, dealing with stress, talking to health care providers, evaluating treatments• Outcomes include reduced hospital lengths of stay,

outpatient visits, and hospitalizations• Services available in United’s Central, Dallas, Bexar,

Harris, Jefferson, Nueces, and Tarrant markets

1. Local services to reduce risk of hospitalization (4)

• Tai Chi (Harris County)• Prevention and Management of Alcohol Problems (Harris County)• Exerstart (Harris County)•Diabetes Screening and Management (Tarrant County)

Spotlight on Dallas AAA’s Diabetes Self-Management

• 300 participants completed series of six workshops•More than 80% of participants reported:• Greater ability to care for diabetes• Greater ability to rely on informal support for dz.

mgmt. • Greater ability to make healthy choices• Lesser disease-related impact on daily activities

2. Strategies to reduce preventable re-hospitalizations (1)

•Dr. Eric Coleman’s Care Transitions Program (CTP)• Transitions coach conducts follow-up in home and by

phone at least three times during first month post-discharge, focusing on medication compliance, follow-up with primary care provider and understanding of “red flags”• Outcomes include reduction of all cause readmissions• Available in United’s Bexar, Central, Dallas, El Paso,

Harris, Hidalgo, Jefferson, and Tarrant markets

1. Spotlight on Harris County’sCare Transitions Programs(2)

• Partnership with CHRISTUS St. Catherine Hospital and Memorial Hermann Katy Hospital• Reduction in participants’ 30-day all-cause readmission rates from 20% to 10%

3. Services to increase medication adherence•HomeMeds• In-home medication reconciliation, including all

prescription and over-the-counter meds, with intervention by pharmacist as needed• Outcomes: reduced incidence of drug-drug

interactions, greater compliance with medication regimen• Available in United’s Central, Dallas, Jefferson,

Tarrant, and Travis markets

4. Services to avoid nursing home placement (1)

• Stress-Busting for Family Caregivers: Provides education and support to small groups of family members who care for loved ones with Alzheimer’s• Outcomes include decreased caregiver stress,

depression, and anxiety, in addition to decreased rates of nursing home placement• Available in United’s Bexar, Hidalgo, Jefferson,

Nueces, Tarrant, and Travis markets

4. Services to avoid nursing home placement (2 )

• ADRC Options Counseling: helps identify and access community-based services that serve as alternatives to institutionalization• Available in United’s Bexar, Central, Dallas, El Paso, Hidalgo, Northeast, Nueces, and Tarrant markets•Will be available statewide in 2014

4. Services to help nursing home residents return to community•Home by Choice: intense case management for Medicaid residents to remove barriers to relocation such as lack of housing, need for assistance with 5+ ADLs, severe mental illness, lack of family support•Options Counseling: information, referral and assistance for non-Medicaid residents

5. Services to promote patient activation

• Chronic Disease Self-Management Program•Diabetes Self-Management Program• Care Transitions Program

Selected Challenges/Opportunities (1)

• Carve-in of nursing home care in September 2014• Pre-placement counseling regarding community-

based alternatives, paying for care, and quality considerations• Resident advocacy• Relocation counseling and assistance

Selected Challenges/Opportunities (2)

• Members with multiple, complex psychosocial needs that jeopardize disease management/independent living• Benefits/Options Counseling• Care Coordination• Members with caregivers on verge of burnout•Caregiver consultation, case management, evidence-based programs

Selected challenges/opportunities (3)

• Capitated payments for Medicaid-only inpatient care• Care Transitions• Chronic Disease Self-Management

Why pay for services that are already funded?•Make proven interventions available to United members who don’t qualify on the basis of providers’ age-eligibility or screening criteria• Provide priority access to United members

Provider contactsAging and Disability Resource Centers• Doni Green: dgreen@nctcog.org

Area Agencies on Aging• Millie DeAnda: mdeanda@ccgd.org• Jennifer Scott: jscott@capcog.org• Curtis Cooper: curtis.cooper@h-gac.com• Deborah Moore: deboraha.moore@houstontx.gov

General Questions• Doni Green: dgreen@nctcog.org