1. 1 Laura Davie, Project Director Institute for Health Policy and Practice ADRC National Conference February 14, 2011 Care Transitions in New Hampshire

2. 2 Topics for today:  New Hampshire’s ADRC program  2009 Enhancement Grant  Person-centered hospital discharge planning model  2010 Option D: Evidence Based Care Transitions Grant  Decision to use Care Transitions Intervention (CTI) & Better Outcomes for Older Adults through Safe Transfers (BOOST)

3. 3 New Hampshire’s ADRC program  NH has received ADRC funding since 2003  ADRC model in NH is the ServiceLink Resource Center Network  State-wide network  Fully-functioning ADRC model

4. 4 NH ServiceLink Resource Centers 1-866-634-9412 www.servicelink.org Berlin Littleton Tamworth Lebanon Laconia Claremont Rochester Concord Portsmouth Manchester Keene Salem Nashua Belknap County Laconia Carroll County Tamworth Coos County Berlin Grafton County Lebanon Littleton Hillsborough County Manchester Nashua Merrimack County Concord Monadnock Region Keene Rockingham County Portsmouth Salem Strafford County Rochester Sullivan County Claremont

5. 5 2009 Enhancement Grant Activities Develop a person-centered hospital discharge planning model:  Formalize how hospitals refer to SLRC’s and train hospital and community providers in person- centered approach.  Two Communities: Monadnock SLRC and Cheshire Medical Center/Dartmouth Hitchcock Keene and Carroll SLRC and Memorial Hospital.

6. 6 2009 Enhancement Grant Activities continued… Established state-level workgroup: – Each community SLRC, hospital, consumer – New Hampshire Hospital Association – Home Care Association of New Hampshire – New Hampshire Bureau of Elderly and Adult Services – Institute on Disability at UNH – New Hampshire ADRC Advisory Board

7. 7 2009 Enhancement Grant Activities continued…. Developed Vision/Mission/Goals/Activities: – Vision: A coordinated, person-centered long term care system that supports individuals as they transition back into the community. – Project Mission: Partner hospitals & community providers will identify 65 and older persons at risk for institutionalization or rehospitalization and utilize person-centered transition planning to help maintain their ability to live & age in the community.

8. 8 By July 2010 we had a draft model but…. Then Option D came along…..  Mapping evidence-based Care Transitions models in the two communities  “Divine Intervention”- Belknap SLRC/Lakes Region General Hospital for BOOST

9. 9 2010 Option D:Evidence Based Care Transitions Activities 2010: implement and/or enhance evidence- based models for care transitions. – The Better Outcomes for Older Adults through Safe Transitions (BOOST) model Lakes Region General Hospital and Belknap SLRC. – The Care Transition Intervention (CTI) model Cheshire Medical Center- CMC-DHK and Monadnock SLRC; and Memorial Hospital and Carroll County SLRC.

10. 10 2009-2012: ADRC Person-Centered Care Transitions Projects The primary program goals of the project: 1) Establish and train an SLRC -CTS in three of NH’s ADRC’s to serve as the SLRC-hospital liaison for care transitions; 2) Define and evaluate the relationship of the SLRC CTS with the provider organizations in an evidence-based care transition model; and 3) Define and evaluate the role of the SLRC CTS within the scope of the evidence-based care transition model and among SLRC programs (e.g. I/R specialist, caregiver specialist).

11. 11 Care Transitions InterventionPilot SLRC Care Transitions Specialist (CTS) has a place at the hospital. CTS integrated into multidisciplinary team. Hospital visit, home visit, phone calls. Using most of the model tools. Sharing access to databases (EMR and Refer7). Enhancement- coaching on accessing social system (not just medical system).

12. 12 BOOST Pilot SLRC Care Transitions Specialist has a place at the hospital. CTS integrated into multidisciplinary team. Utilizing the Risk Assessment tool to determine referrals to SLRC. Hospital visit, home visit, phone calls. Enhancement: Connecting participants to the SLRC.

13. 13 NH Care Transitions Conference Spring 2011 Where is care transitions/care coordination occurring in NH? What are the medical models/social (community) models? What evidence-based models are being used? State Plan for Care Transitions?

14. 14 Laura Davie, Project Director NH Institute for Health Policy and Practice (603) 862-3682 laura.davie@unh.edu http://www.nhhealthpolicyinstitute.unh.edu/adrc_pchdpp.html