1. Aging In Texas Conference Houston 2013 Sunday-June 16, 2013 Don Smith, M.A. Sherry Simon, R.D.N./L.D. Reducing Hospitalizations with Registered Dietitians Visiting Home-bound Clients

2. Presentation Objectives: Learn about the history and focus of the project Understand the tools used and how to implement them Develop a list of potential collaborators including evaluators

3. History and Focus United Way of Tarrant County Emerging Issue Increase in incidence of Diabetes $20,000 Seed Grant – 2007 Awarded to Meals On Wheels, Inc. of Tarrant County

4. History and Focus Continued Program Continues 2008 – 2010 Related program integrated into AAA Community Living Program Over 7,500 screened or counseled Administration on Aging Award – 2008 1 st Place Innovation Award from National Association of Area Agencies on Aging -2009

5. History and Focus Continued “Healthy Aging and Independent Living (HAIL)” chosen as focus by UW Strategic Planning Committee – Summer, 2009 HAIL Strategic Design Group formed – September 2009 Five Meetings – November 18, 24, December 1, 9 & January 12, 2010 Review of evidence-based interventions Prioritization of strategies Approved by UW Strategic Planning Committee (February 24, 2010) and Board (March 23, 2010)

6. History and Focus Continued 1 in 5 health care dollar is spent on diabetes 23% of older Texans and 34% of minority Texas have diabetes Average diabetes hospital stay = $25,000 Diabetes creates increased risk of Blindness Amputation Death Type II diabetes is being diagnosed at younger ages

7. History and Focus Continued Key “Healthy Aging and Independent Living (HAIL)” Strategy: Diabetes Screening and Intervention screen homebound consumers and to make referrals for those at risk of diabetes to a registered dietician for individually customized nutrition education and counseling identify at-risk individuals and helps them spend fewer nights in the hospital, with fewer visits to the emergency room

8. History and Focus Continued Formation of HAIL “Renegade” group - 2011 Identified short and intermediate outcomes Expanded strategies and target groups Developed outcome measurement tools Initiated at beginning of third year

9. History and Focus Continued HAIL funding approved through 2020 Expanded use of Registered/Licensed Dietitians (one of which is also a Certified Diabetes Educator) Hospitals Managed care

10. Wall Street Journal Article: No One Fix to Slow Hospital Readmission Epidemic Please take 5 minutes to read the article What are the highlights? What is missing from the article as a possible intervention(s)? How can Meals On Wheels organizations get involved? How are Meals On Wheels organization a business collaborator to hospitals?

11. Preventable Hospitalizations in Tarrant County 2006-2010 Source: Texas Department of State Health Services DiagnosisNumberLOSCost Angina9762.7 days$22,015 / $21,486,902 Asthma5,1744.5 days$23,933 / $123,829,834 Pneumonia16,5505.8 days$30,802 / $509,775,849 CHF17,0675.4 days$31,285 / $533,948,574 COPD9,8475.6 days$30,335 / $298,710,186 Dehydration3,2613.8 days$18,697 / $60,970,718 Diabetes-Long6,7517.1 days$37,894 / $255,821,504

12. Preventable Hospitalizations in Tarrant County 2006-2010 Source: Texas Department of State Health Services DiagnosisNumberLOSCost Diabetes-Short3,8054.0 days$24,328 / $92,567,510 Hypertension3,4163.4 days$22,732 / $77,652,260 UTI10,1754.7 days$21,753 / $221,335,638 Total to Tarrant County----$2,196,098,975

13. Why Need Evidence-Based Tools and/or Programs Efficacy of the intervention has already been demonstrated Using existing resources may save time and money Already have data to use as a benchmark You do not have to reinvent the wheel Many evidence-based interventions have developed tools that will assist you with tailoring an intervention and/or program to meet you organization’s needs

14. Why Need Evidence-Based Tools and/or Programs Efficacy of the intervention has already been demonstrated Using existing resources may save time and money Already have data to use as a benchmark You do not have to reinvent the wheel Many evidence-based interventions have developed tools that will assist you with tailoring an intervention and/or program to meet you organization’s needs

15. Meals On Wheels, Inc. of Tarrant County Wheel of Services Key: Red Tabs--- United Way Funded Programs: HAIL-Nutrition & Diabetes HomeMeds PAM Neighbor Helping Neighbor Green Tabs--- Other MOWI Programs: Friend to Friend Client Services Companion Pet Food Supplemental Groceries

16. Live Well-Healthy Aging Independent Living (HAIL) Kathie Robinson, MS, RD/LD, CDE; Lynn Vargas, R.D./L.D.; Julie Langeberg, MS, RD/LD HAIL-Diabetes and Nutrition Identification and Counseling Program--- This project aims to keep people healthy at home and reduce preventable hospitalizations and emergency room visits, ultimately saving taxpayer dollars. The clients are mostly referrals from Meals On Wheels, Inc. of Tarrant County, are aged 35 years and older, and have either a diagnosis of or are at increased risk for diabetes or increased nutrition risk. In addition to English, the project serves clients who speak Spanish and Vietnamese.

17. Project Overview  HAIL initiative started as a strategy by the United Way of Tarrant County to help people with chronic disease and their caregivers to live well in their community for a longer period of time and avoid institutional placement or hospitalization  HAIL has now has seven prongs which Meals On Wheels just implements three of the seven  July 2010, Meals On Wheels was awarded funding for implementing a HAIL initiative targeting diabetes and nutritional risk screenings and interventions strategies for the clients we serve

18. Project Details---Outputs  To screen 3000 clients annually for Diabetes Diagnosis and/or risk and Nutritional Risk using proven screening tools  To provide more in-depth services including home visits with comprehensive nutritional assessment and nutrition and/or diabetes education to 1250 clients  To make 1500 follow up calls ----All done in a effort to reduce client hospitalizations and emergency visits to ultimately save tax payer dollars

19. Project Goals---Outcomes o Reduce hospitalizations and ER visits by 10% for 6 months after interventions compared with 6 months before intervention o Enhance health status and capacity for self-care, measured using evidenced-base tools and EQ-5D and Perceived Competence Scale for Health o Improved body mass index based on self-reported height and weight at 1 year after intervention o Decrease nutritional risk score based on Nutrition Checklist for Older Adults (DETERMINE) screening tool at 1 year after intervention

20. Project Flow  MOW Case Managers complete screening tool of the DETERMINE; a Diabetes Risk Screen Tool; Risk Factors for Hospitalization and Emergent Care Assessment on all MOW clients annually.  Clients are then categorized into high, moderate, & low risk based on screening tools by project Dietitians  Dietitians calls clients to set up appointments to meet with them in their home.  Dietitian completes a full nutrition assessment; clients set behavior goals; dietitians complete documentation & formalizes education plan.  Nutrition education materials are mailed to each client’s home and based on individual needs.  Dietetics students follow-up with the initial nutrition assessment; ask about their performance on behavior goals and perform nutrition education over the phone.  Follow-up home visits are done by the Dietitians for clients most at risk  All data is maintained on our MOWI database and updated per the project requirements from the funder  An independent evaluation team involved to verify outputs; measure outcomes; look for correlations of the data; and work to prove the efficacy of the project

21. Project Tools DETERMINE Nutrition Tool Diabetes Detective Initiative Tool Risk Factors for Hospitalization and Emergent Care Assessment EQ-5D 2011 NHIS: Family Access to Health Care and Utilization 2008 NHIS: Family Health Status and Limitation Height, Weight, Body Mass Index Behavior goal tracking MOWI Database Evaluator Reporting

22. Cost Benefits Average cost of hospitalization for complications w/diabetes: $21,000-$30,000 Cost of RD visit per HAIL client to date $155 Source: txpricepoint.org

23. Marketing Your Success  Share with all your stakeholders  Quantify results into dollars  Write press releases  Ask your clients to participate and help you tell your successes  Tell client stories  Complete at least monthly reports to share with stakeholders

24. Questions and Answers Email me if you would like a copy of the presentation or if you would like any materials at: Ssimon@mealsonwheels.org