1. Responding to the Care Transition Resource Challenges Aging Care Connections, Illinois Member of Illinois Transitional Care Consortium

2. AGING RESOURCE CENTER A Transitional Care service model provided by a Case Coordination Unit, or CCU CCU system in Illinois is a statewide network of community based providers designated by the Illinois Department on Aging and Area Agencies on Aging to provide access to information and referrals, and comprehensive assessment of needs Ongoing Care Coordination is fundamental to the work of CCUs

3. Cont’d Assessment can result in eligibility for Medicaid waiver community care programs, Older Americans Act support services, benefit assistance, local and/or grant funded programs. CCUs are responsible for completing OBRA screens for disabled and aged populations prior to placement in long term care. CCUs in Illinois are responsible for Money Follows the Person assessments.

4. BRIDGE The Aging Resource Center is a part of the Illinois Transitional Care Consortium; made up of three CCUs; one in rural Illinois, 2 suburban hospital sites and a large metropolitan hospital Bridge is interested in promoting Transitional Care using a social work model. Three of the sites are currently working with the Illinois Department on Aging and AgeOptions, our ADRC under an AOA ADRC grant. The Progress Center for Independent Living is also our partner in this grant

5. Bridge Protocols Patient is seen in the hospital prior to discharge for assessment and direct linkage to service. Patient may also be referred by discharge team for 48 hour follow up in the community. GAPs IDENTIFIED Patients are called within 48 hours to insure that services are in place and are adequate. Care plans may be adjusted, problem solving with Bridge Coordinators may be required. GAPS ARE IDENTIFIED Transition will end with stable service in place, patient requires no further assistance or patient is referred to the case management provider in their area for ongoing case management. Gap identified – HDMs that could accommodate fast transition home, special diets and weekend meals.

6. Lessons Learned from the ARC project - CHALLENGES As a CCU the feedback on client outcome was immediate; gaps in service were discovered at the 48 hour phone call and/or actually seen by the Care Coordinator at a follow up home visit. Studies show 40% - 50% of hosp. readmissions are linked to lack of resources in the community, and social problems, we found this to be true Community based services are limited by funding resulting in a “Cookie Cutter Approach” to individual need, we had to think beyond the typical services The first 48 hours are the most critical in successful transitions.

7. RESOURCE DEVELOPMENT Transitional Care can inform the community on service gaps from a unique perspective. The community is not yet fully ready to meet the needs of frail elders; this will become increasingly apparent in the coming years. Funding will continue to present obstacles to resource development ARC solution was to look for partnerships

8. PARTNERS Factors in selecting a partner: History of serviceFunding considerations Conflict of interest issuesWillingness to engage in new project Aging Care Connections selected partner before funder was identified. ARRA money became available for one year, AgeOptions – the ADRC was responsible for funding the ARRA projects. Our project was selected.

9. CHEERIOS! Secured funding for a short demo project in cooperation with AgeOptions ($28,930) Served only those clients who were not able to be served by the existing home delivered program funded under the Older Americans Act Built in project income to support the program ($9,678) In Kind contributed by ACC and our partner

10. OUTCOMES BRITISH HOME PROVIDED 4,122 MEALS to 47 PERSONS DURING THE DEMO YEAR. 31 WERE SPECIAL DIETS 4 WERE WEEKEND MEALS 3 WERE CAREGIVERS 9OTHER CIRCUMSTANCES, SHORT TERM NEED, UNCOVERED AREA, ETC.

11. Lessons learned Many providers are unable to respond to the need for expedited service provision that is essential to successful transitions for frail older adults and their families without special arrangements New community partners are interested in helping develop new community resources Anticipate the need for continuing use of resources over long periods of time even in transitional care Plan with your partner the parameters of the partnership, we did a hybrid of public and private resources for this project. Boundaries needed to be established before and re-tooled throughout the project.