Ron Budynas. NAHPe, COS, CDP, SCHM, CGPM, FHS, ALA. Wesley Housing Corporation of Memphis Inc Appling Road, Cordova TN 38016

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1 Ron Budynas NAHPe, COS, CDP, SCHM, CGPM, FHS, ALA Wesley Housing Corporation of Memphis Inc Appling Road, Cordova TN (901) Enhanced Service Coordination is part of the idea that housing can act as the platform for the delivery of services (including healthcare). Provide a method for person centered holistic approaches to addressing the needs of vulnerable low and modest-income older adults (Lewin 2011). Creating a system to allow individuals to age in place. 1

2 Supportive Services Demonstration Design Populations in affordable housing often exist with little or no family support structures Many who do have family support structures lack the necessary resources to care for elderly At age 80, 50% of all people will experience some signs of Alzheimer s or Dementia. That means that half of your residents will be in your apartments with Alzheimer's or Dementia with no family support. Who s going to take care of them? 2

3 Page 6 of the Lewin Study Innovative housing providers across the country working with community agencies have, at their own initiative, developed many prototypes of affordable housing with services strategies to assist residents as they age. 3

4 Dual eligibles (those individuals who qualify for both Medicare and Medicaid) The factors for high health care expense in dual eligible patients: Poor health behaviors throughout life Poor nutritional behaviors throughout life Indifference to medical and wellness interventions Lack of following doctor s orders post treatment Lack of follow up treatment post surgery Indifference to lifestyle change Original and traditional service coordination HUD s original vision of service coordination Extended Service Coordination What service coordination can be Service Coordination on Steroids (Enhanced Service Coordination) Extending service coordination to higher levels Providing extended services on site Bring skills necessary to care for residents of all problems 4

5 Provide a structure to do assessments on residents to ensure quality of life and delivery of appropriate services Provide an environment to allow residents to change lifestyles to live healthier, longer and with higher function to improve quality of life and prevent premature institutionalization Services include: Physical fitness/fall prevention Socialization Smoking Cessation Nutrition Wellness Pastoral Services Memory and mind exercises and group support Alzheimer and dementia resident and family support groups End of Life Planning Hospitalization and healthcare planning Post surgery case management Primary care clinic Education Programs 5

6 Traditional Service Coordination: Low skill levels Higher level Service Coordination Social Workers Enhanced Service Coordination Social Workers and; Nurses and; Mental Health Professionals and; Doctors and; The Sky 6

7 Affordable and accessible senior rental complexes, purposely organized to provide health and long-term care services and supports, may enable low-income seniors to retain the autonomy they desire in an independent living setting with care available as needed. Demonstration Programs Supportive Services Demonstration for Elderly Households in HUD- Assisted Multifamily Housing Service Coordinator Grants Interest Rate Reduction Program Debt Service Savings Reserves 7

8 The need for housing with services is growing along with the size of the elderly population Medical resources are insufficient to address the needs of the growing population The expense of healthcare for the dual eligible population is unsustainable Interventions to improve quality of life in these low income populations is essential to reduce resource use. Low income housing is a perfect platform for the delivery of these services 8

9 Section 1. BEHAVIORAL HEALTH HISTORY Are you currently seeing a therapist, psychiatrist, counselor, or social worker? Yes No If Yes, why? Previous Psychiatric Treatment? Yes No If Yes, Explain Check all that apply: Agitation/Anger Status Referral Anxiety Status Referral Appetite Disturbance Status Referral Bizarre Behavior Status Referral Combative Status Referral Confused Status Referral Delusions Status Referral Disoriented Status Referral Fall History / Risk Status Referral Family Relation Problems Status Referral Forgetful Status Referral Hallucinating Status Referral Homicidal Thoughts Status Referral Insomnia/Sleep Disturbances Status Referral Isolating Status Referral Marital Relation Problems Status Referral Mental alterations multiple meds Status Mental alterations w/med change Status Referral Referral Morbid Thoughts Status Referral Poor Concentration Status Referral

10 Poor Grooming/ Hygiene Status Referral Poor Impulse Control Status Referral Post Traumatic Stress Status Referral Restless Status Referral Seizure Risk Status Referral Self Mutilation/Harm Status Referral Social Problems Status Referral Suicidal Ideation/Gesture Status Referral Suspicious/Paranoid Status Referral Threatens Status Referral Wandering Status Referral Depression Screening Conducted Yes No If yes, Date Score Current or past Alcohol &Drug issues? When thinking about drug use, include illegal drug use and the use of prescription drug use other than prescribed YES NO Have you ever felt that you ought to cut down on your drinking or drug use? Have people annoyed you by criticizing your drinking or drug use? Have you ever felt bad or guilty about your drinking or drug use? Have you ever had a drink or used drugs first thing in the morning to steady your nerves or to get rid of a hangover? Notes/Comments

11 Section 2: PHYSICAL PROBLEMS / NEED Ambulates: w / help Independent cane wheelchair other: Appetite: Good Fair Poor PEG tube Weight Loss: No Yes Amount: Bowel: Incontinent? No Yes: if yes, date of onset: Bladder: Incontinent? No Yes: if yes, date of onset: Foley Catheter Diaper Ostomy Permanent vascular catheter? No Yes Skin wounds/tears? No Yes: if yes, Location / stage Chemotherapy? No Yes Dialysis? No Yes: if Yes, Provider: Home Health: No Yes: if Yes, Provider: Notes/Comments Section 3: CURRENT MEDICATIONS: (Include Psychiatric, OTC, and PRN medications) This list is for the resident s records only and should not be used for any other purposes but than for the service coordinator s reference. This should not be used for clinical purposes or emergencies. Medication Name Dosage Frequency Reason (per resident) Date MORSIKY ADHERENCE TEST YES NO Have you ever forgotten to take your medication? At times are you not careful about taking your medication? When you feel better, do you sometimes stop taking your medication? At times, if you feel worse when you take your medicine, do you stop taking them? Notes/Comments

12 Section 4. SPIRITUAL ASSESSMENT 1. Where do you draw your spirituality? 2. Do you feel spiritually balanced? If No, explain: 3. Do you feel spiritually conflicted? If yes: 4. Do you like to talk to others about your faiths and beliefs? 5. Would you like to speak to someone about your balance/conflicts/beliefs? 6. Who could we provide you to speak about your spirituality/conflict/balance? Notes/Comments: