Hartford HealthCare – Hartford HealthCare Center for Healthy Aging

Overview

The goal of Hartford HealthCare’s Center for Healthy Aging (the Center) is to connect seniors with the right care, in the right place, at the right time. The Center achieves this goal through resource coordination, geriatric care management, transitional care nursing, and specialized dementia services. With the exception of geriatric care management, all of these services are free. The Center serves as a destination of choice for seniors and their families to receive accurate, customized referrals and resources to better age in place. The Center is a source of customized information for seniors with four physical acute care-based locations and the ability to provide in-home and telephonic counsel for seniors and their families.

Some of the unique elements of this program are the composition of its staff and its promise to never let a senior leave its watch. The staff is predominantly non-clinical but is trained in a wide array of counseling services and is extremely well versed in the intricacies of obtaining care for all types of people regardless of socioeconomic or psychosocial status. In conjunction with the staff’s expertise is their promise to follow up with their clients in 30 days, 6 months, or 1 year. Follow-up is key.

Impact

From July 2015 to June 2016, there were 2,146 new clients for the Center. For the clients served during this period, the Center made 4,785 referrals to system and area services. Referrals given to clients include recommendations for home care, legal counsel, meal delivery, transportation, physicians, and support groups. During this period, the Center had more than 3,250 attendees at community outreach events, which included Dementia Support Groups, Educational Series on Dementia and Brain Health, Blood Pressure Screenings, and Lunch & Learn events. The Center also distributed more than 25,000 self-produced resource materials for seniors and their families, including a Dementia Caregiver Resource Guide, Community Specific Resource Guides, and Dementia Memory Loss Cards. In addition, from November 2015 to September 2016, the Center provided Resource Coordination services for 3,576 low-income, Medicaid-eligible seniors.

Lessons Learned

The success of this model of care depends on the team staffed to implement the program. When choosing a team of this caliber, it is imperative that they have the knowledge, compassion, work ethic and ability to collaborate and respect each person and organization they interact with, as well as one another. The staff has been trained in/certified as: Motivational Interviewing, Dementia Practitioner Certifications, CHOICES Counseling, No Wrong Door Person Centered Counseling, Mental Health First Aid, Care Management Certifications, Sutter Disease Chronic Disease Management training, Live Well Facilitators, Geriatric Nursing, Habilitation Therapy (Train the Trainers), and Caregiver Support Group Leader training.

Another unique feature of the Center is the idea that people “never leave our watch.” Following the initial contact, an individual is entered into a database, allowing for streamlined follow-up when needed. The Center staff may contact an individual or family member/caregiver to see if there have been any changes or if further assistance is needed. It is common for people to wait for a crisis to reach out. The goal here is to thwart this practice and enable prevention. The Center staff may also re-assess people if there has been a status change since the last assessment. The database the Center utilizes is also used by Hartford HealthCare Senior Services, which allows for better coordination of care in the post-acute space. One big limitation is that the system does not link to medical records or any hospital database. However, the resource coordinators, geriatric care manager and dementia specialists do have access to the hospital and provider EMR systems. This allows the Center the ability see if there have been frequent emergency department visits, hospitalizations, and provider appointments. This insight helps with any interaction they may have with referrals from these sources.

Program elements that most contribute to its success are the composition of the staff, the continued monitoring of clients beyond an episode of care and ties with local and state agencies and other providers. This is a journey; HHC continues to learn from and expand the current Center model.

Future Goals

The Center has been invited to participate as an advisory council member of the State’s No Wrong Door (NWD) initiative. NWD is currently a philosophy/model to link people to needed long-term services and supports in a more coordinated and reliable manner with an anticipated rollout of 12 to 18 months from January 2017. As a council member, the Center has a voice and is able to help shape the NWD initiative to best meet the needs of the community.

The Center is also expanding to an additional acute setting, family health center, and skilled nursing environment. This expansion will incorporate a Good Life Fitness component to help seniors maintain and improve their functional mobility, helping them age in place and remain independent longer. The Center will continue to grow and change as the demands of the population served change.

Contact: Wendy Martinson
Program Director, HHC Center for Healthy Aging
Telephone: 860-929-6829
Email: wendy.martinson@hhchealth.org