1. April 29 - May 1, 2015 Community and Home-Based Solutions for All Ages- Community Health Navigator Program

2. Agenda Introduction to LIVE WELL Initiative Strategic Partnerships About Our Program Goals And Results Benefits To The Community Lessons Learned And Challenges

3. United Way of Tarrant County’s LIVE WELL Initiative OUR BOLD GOAL: We will have improved the lives of 17,000 adults with ongoing health concerns by the year 2020. 3 Core Values: Care for Caregivers - Provides support for the people who take care of loved ones with ongoing health concerns A Healthier Me - Provides services to adults in our community with ongoing health concerns A Healthier Community - Helps to educate and provide information for a healthier Tarrant County community

4. Strategic Partnerships A Healthier Me- Community Health Navigation Program’s partners and key stakeholders Insignia Health Texas Christian University Area Agency on Aging of Tarrant County Federally Qualified Health Centers (FQHC) Managed Care Organizations Department of Aging and Disability Services Other Community Based Organizations

5. About Our Program

6. Goals And Results Total clients served since 2012: 807 Homebound older adults A low cost high impact program  Primary Outcome: To improve consumer’s capacity for disease self management.  Participants will:  Decrease hospital and emergency care admissions  Improved health status  Patient Activation Measure (PAM) level advancement Goals 24% ↓in hospitalizations or emergency department visits for 6 months following the intervention 81 % of clients showed positive changes in at least one outcome variable 75 % of clients advanced at least 1 level of health activation after 6 months of CHN Intervention using the PAM Model Results

7. Benefits To The Community Source: Is Patient Activation Associated with Future Health Outcomes and Healthcare Utilization Among Patients with Diabetes? Journal of Ambulatory Care Management, Oct/Dec 2009 Texas Department of State Health Services calculated that from 2008-2013, adult residents (18+) of Texas received $49,010,136,451 in charges for hospitalizations that were potentially preventable. https://www.dshs.state.tx.us/ph/state.shtm

8. Lessons Learned  Use of neighbor to neighbor module  Person-centered philosophy- Community Health Navigators (CHN)  Hybrid program Challenges  Unique needs of older population  New use of technology  Establishing boundaries Lessons Learned And Challenges CHNs-students/retired individuals PAM-a supported coaching tool