Mae Carpenter, Commissioner Westchester County Department …€¦ · Westchester County Department of Senior Programs and Services Westchester County - Dep’t of Senior Programs

Mae Carpenter, Commissioner Westchester County Department of Senior Programs and Services

Westchester County - Dep’t of Senior Programs and Services Westchester Public/Private Partnership for Aging Services Harry and Jeanette Weinberg Foundation AARP Foundation Westchester County Government Pace University United Way of Lackawanna and Wayne Counties University of Scranton

The “Perfect Storm”

Universal Challenge: Increasing demand for care with no viable means of supply

Caregiver Shortages

Aging

Chronic Disease

Source: D Lindeman, CITRIS

New Era of Connected Health

TIPS Overview:

“High Tech Meets High Touch”

TIPS is a unique, multi-award-winning, multi-state, multi-disciplinary, multi-lingual, affinity and congregate setting, intergenerational, high-tech/high-touch, HIPAA-compliant, long-term, community-embedded remote participant health monitoring program, enhanced with multiple wrap-around aging services and workforce development funded by the Weinberg Foundation, AARP Foundation (iTIPS), Westchester County government, and community partners, targeting low-income, high health-risk seniors which has improved individual and system health care and outcomes, benefits access, and reduced health care costs.

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Simultaneously!

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7 sites in NY 5 in PA + 2 iTIPS - NY 1 iTIPS – PA 750 -900 Participants Gerontology Workforce Training and Employment

Partners: Senior Centers United Way Community Health Agencies County/Municipal Gov’t Municipal Housing Authorities Universities Aging/Community Services

POINTS OF ENTRY

Workplace

*Public Housing

*Senior Housing

Health Care, Hospitals, Home Care

Houses of Worship

*Homebound

TIPS Locations and Partners

Continuing Care

*Senior Centers & Nutrition Sites

*Libraries * “Villages”

RFD Volunteer Fire/Ambulance

* Currently operational

Telehealth vital signs monitoring for seniors

We provided the TIPS service for the sickest and neediest in our community, targeting • Over 65 • Medicaid/Medicare • 2 or more chronic conditions • Living at or below the poverty line

> Metrics collection at TIPS site > Wrap-around services assessment

Remote evaluation by RN

Secure data transfer to server

> Triage (if necessary) > Information & referral

Start

• Blood pressure • Weight • Heart rate • Blood oxygenation • Five questions about

subjective wellness

TIPS PROCESS

High Touch: Wraparound Social Services

Benefits Check Care Circles for Seniors Caregiver Coaches Chronic Disease Self Mgt Speakers Exercise FitBit tracking I & R Elder Abuse Screen Falls Prevention, etc.

TIPS Fellows

TIPS Fellows – TIPS Model

• Active Telehealth, or Planned < 9 months

• Self-sponsored sites • TIPS Model: TIPS RPM via

VitalCare Services + Care Circle Services, etc.

• TIPS Metrics and Data • Alternate Delivery models

TIPS FELLOWS TIPS Fellows –

Independent • Active Telehealth, or

Planned > 9 months • Self-sponsored sites • TIPS Model or

Independent model • TIPS Metrics & Data or Independent Metrics & Data

TIPS – Grant Sites • 7-Westchester/ 7-PA-CT-MD • Meet all TIPS Grant criteria • TIPS Model, Target clients • TIPS Metrics and Data

Increased quality of care

Expanded healthcare access

Reduced system and individual healthcare costs

Benefits

Major outcomes at first-glance

• We tracked 735 participants over an average of 300 days.

• 87.5% compliance rate to a single weekly visit.

• Average 30% reduction in ER visits across the entire cohort.

• In Medicare cohort:

» 60% reduction in hospitalizations

» 75% reduction in under-30 day readmissions

Hospitalizations ER All 735 Enrolled: 30% 31% Female 29% 31% Male: 44% 42% Medicare: 60% 57%

Hospitalizations ER Hypertension : 36% 35% COPD: 52% 47% CHF: 63% 57% Diabetes: 45% 50%

Hospitalizations ER Stroke : 49% -- CAD: 69% 59% 3 CHC: 61% 61% 4 CHC: 59% 61%

< 30-day Re-Hospitalizations COPD : 70% CAD: 100% Medicare: 75%

Hospital Community

TIPS is a community-initiated program.

We rely on self-report for all of our data.

We have no access to health information that can help us improve our program.

Hospitals have these data, but no way of securely

communicating it to us

X No Communication

Hospital Community

SES technology would allow TIPS to operate with a trusted medical record from participating

hospitals

It would dramatically improve our impact and influence in delivering better quality and more

timely services to the underserved

SES

Future Goals: 2017-2019 Continuation: Current TIPS sites in Westchester County and Scranton Expansion: New sites Baltimore area New sites Fairfield County, CT Improved Health Information Transfer

Contact: John Migliaccio, PhD: [email protected] David Sachs, PhD: [email protected] David Putrino, PhD: [email protected] www.seniorcitizens.westchestergov.com/telehealth-tips