1. Connecticut’s ADRC Approach to Integrating the Care Transition Intervention Model & Chronic Disease Self Management Program AoA National Meeting 2011 Baltimore, Maryland

2. 2 Presentation Overview North Central CT Community Choices Care Transition Intervention Model Hospital of Central CT The “Live Well Program” – CT’s Chronic Disease Self Management Program

3. 3 North Central Connecticut Community Choices Opened – May 2010 Comprised of 3 core partners: North Central Area Agency on Aging, Independence Unlimited & Connecticut Community Care, Inc. Serving Greater Hartford area 1 st CT ADRC to pilot a Care Transition model Independence Unlimited

4. 4 Dr. Eric Coleman’s Care Transition Intervention (CTI) Model Tammy & Joyce - Care Transition Coaches

5. 5 Hospital of Central CT 2 campuses in Central Connecticut 414 beds “As affiliates of Planetree Continuing Care, a patient- centered, holistic approach to healthcare, we at HCC believe in providing access to understandable health information to empower individuals to participate in their health. Our objective to provide education and information in a collaborative community of healthcare organizations, facilitating efforts to create patient centered care in healing environments, is in sync with the Planetree philosophy.”

6. 6 NCADRC Care Transition Coach (TC) TC has received the referral and has entered a referral into the NCADRC electronic database (Cybercam). Based on cross reference from HCC's CERNER database, consumer is ineligible for CTI and referral is not taken up. TC initiates the CTI process. Hospital visit is conducted. 4 pillars are introduced. CTI information materials and tool packet, along with NCADRC brochure provided. Consumer expresses no interest in CTI program. Case documented as refusal. Available NCARDC Community Choices services reiterated. Consumer chooses to continue with CTI. TC monitors consumer's hospital stay. Consumer transitioned to ECF or another hospital. CTI does not continue. TC is aware of transition. 24-48hr phone contact made to consumer to schedule a home/community visit. TC initiates post transition follow up with consumer. Consumer expresses no interest in CTI program, or refuses home visit. TC reiterates available NCADRC Community Choices resources. CTI does not continue. During home visit, 4 pillars reviewed and consumer demonstrates ability to self- manage chronic disease and meds. NCADRC Community Choices and HCBS resources discussed and referrals made as needed. TC contacts home care or VNA agency as needed. TC prepares consumer for follow up phone contacts. 7day follow up contact made. 4 pillars reviewed. TC answers any questions consumer may have. TC reiterates availability of NCADRC Community Choices as resource options. 14day follow up contact made. 4 pillars reviewed. TC answers any questions about CTI. TC reiterates availability of NCADRC Community Choices as resource options. TC completes CTI related reports and/or surveys. TC discusses CDSMP and offers participation to CTI consumer. Consumer has completed CTI program. TC monitors census reports for 30 day HCC re- admission. NCADRC Care Transition Initiative Referral Case Finding from: 1) The Hospital of Central CT (HCC) daily emergency admission report and/or 2) Transition Coach receives referral of consumer demographic face sheet via fax from HCC's care coordination staff.

7. 7 The Live Well Program Surgeon General’s Report – July 2009 “Programs such as Stanford University School of Medicine’s “Chronic Disease Self- Management Program” significantly increase the self-confidence of older adults when it comes to their health and managing their chronic illnesses.” Source: Public Health Reports / July–August 2009 / Volume 124

8. 8 So What Does the Program Do? Introduces tools needed in day-to-day life for persons with chronic diseases. Brings people with chronic diseases and their families together in a community setting. Supports and enhances disease specific education, but does not replace it.

9. 9 Six week workshop where participants meet 1 x per wk for 2.5 hrs Trainings are led by a team of 2 leaders The State Unit on Aging is the Stanford licensed agency Chronic Disease Self Management Workshops: Program Design

10. 10 Evidence-Based Program Advantages Increases the odds the program will work as intended and public good will be enhanced. Greater efficiency in using limited resources on what has been proven to work, not what people think will work or has traditionally done. Offer well-packaged program materials, staff training and technical assistance.

11. 11 The CDSMP / ADRC Connection Realization of the State Unit on Aging vision to embed CDSMP with all CT ADRCs. Community Choices Counselors as CDSMP Leaders running workshops in the community. Next steps

12. 12 Contact Information: North Central CT Community Choices – Care Transition Intervention Model – Project Lead – Daniel Flynn, LCSW, STB, CMC Connecticut Community Care, Inc. DanielF@ctcommunitycare.organielF@ctcommunitycare.org Connecticut Statewide ADRC Coordinator – Jennifer Throwe, MSW, CIRS-A Connecticut Dept. of Social Services Aging Services Division Jennifer.Throwe@ct.gov