Community Health Needs Assessment Implementation Plan plans to focus on the following issues identified through its Community Health Needs Assessment (CHNA). These priority areas will be addressed by continuing to strengthen existing UPMC partnerships, as well as by attempting to reach more seniors in the community with these programs. Table 1. Draft Implementation Plan Addressing Chronic Disease in Chronic disease within the senior population is a priority in s community: As individuals age the incidence of cancer, dementia, and heart disease/stroke begins to increase. Many times, individuals can develop co-morbid conditions such as diabetes and heart disease - which also occur more often as people age. More than two-thirds of deaths in Allegheny County result from chronic disease, many of these deaths occurring in the senior population. is addressing this issue: has a strong set of programs to address chronic disease in seniors, from prevention and education to early detection to chronic disease management. plans to do more to focus on this priority: plans to expand their existing programs focused on addressing chronic disease in seniors by increasing the number of seniors utilizing these programs. One way plans to increase is to leverage their current relationship with area nursing homes/snfs to promote these programs, as well as establishing partnerships with area hospice organizations, senior high rises, and assisted/independent living facilities. Senior Health and Caring for Aging Populations Chronic Disease Prevention, Detection and Management s for offered through UPMC St. Margaret Prevention, Education and assistance for : Alive and Well: physicians and health care professionals speak on a variety of health-related topics at local community libraries. Topics include: skin cancer, vascular health, orthopaedics, arthritis, depression, heart disease, stroke, and diabetes. Living Healthy with Arthritis: rheumatologists and orthopedic surgeons discuss the latest treatment options for arthritis. Free Immunizations: offers free flu vaccinations to area residents age 65 and older. Free Shuttle for : Free shuttle service for seniors that provides transportation to the grocery store, doctor s offices, pharmacy, hospital, funeral homes and discount stores. The shuttle route is along Freeport Rd, and many residents of Blawnox Commons a senior high rise - use the shuttle. Detection: Skin Cancer Screening: Community members are examined by physicians at or annual free skin cancer screenings. Participants received instruction on how to identify signs and symptoms of skin cancer and will be referred for biopsies of suspicious lesions. Cardiac Risk Screenings: Registered Nurses conduct free blood pressure and BMI screenings for community members and also provide education on proper blood pressure guidelines and identify individuals with abnormal blood pressure readings. Those individuals will be encouraged to discuss their results with their family doctor. Alive & Well = 105 Living Healthy w/ Arthritis = 32 Free Immunizations = 225 Free Shuttle for = 226 seniors and 6,110 rides programs, increase average number of participants and begin to explore ways to evaluate programs Increase number of Skin Cancer Screening = 118 participants and begin Cardiac Risk Assessments = 550 to track the number of participants referred for biopsy. Management: COPD Classes = 40 Chronic Disease Classes and Support Groups: Classes and support groups focused on Diabetes Support Group =83 diabetes, COPD, weight management, Cancer (Look Good Feel Better), Alzheimer s Weight Mgmt =550 Disease/other dementias provide education based on the condition, and provide a support Look Good, Feel Better = 60 network for those affected by these chronic diseases. Alzheimer s Support= 40 Smoking Cessation: A series of 8 Smoking Cessation sessions are available for individuals who Smoking Cessation = 3 are ready to quit smoking. Attendees will receive vouchers for nicotine replacements patches. programs and maintain or increase programs, increase average number of participants and incorporate feedback from program evaluations Target Population Area residents/ seniors Low Income Continue to increase number of participants and Area residents/ track the number of seniors participants referred for biopsy. programs and maintain or increase Individuals suffering from chronic disease as well as their families/ caregivers Oakmont Carnegie Library, Cooper-Siegel Community Library, Natrona Height Community Library, Arthritis Foundation, Foundation and North Hills Community Outreach American Cancer Society, Dermatology, Area Shop N Save s Geriatric Care Center, The Alzheimer s Association, National Cosmetology Association, The Personal Care Products Council Foundation, American Lung Association
Table 2. Draft Implementation Plan Addressing the Health Needs of Low Income The health needs of low income seniors are a priority in s community: are a diverse group, but on the whole they are vulnerable relative to other age groups, particularly in terms of health and income limitations. Low income seniors are some of the most vulnerable individuals as they require specialized care and are at a higher risk for co-morbid conditions, like all seniors, but may not be able to afford care or be able to navigate the complex health care system/manage their medications or perform daily activities on their own. is addressing this issue: has programs in place to address the health needs of low income seniors specifically, which include providing free services to this population such provision of medication, medical equipment and medical supplies, family lodging, emergency housing, and transportation funded through the St. Margaret Foundation. In addition, the Family Health Centers, which are located in underserved neighborhoods, provide free medication and medication management consultations with pharmacists, home visits, outpatient behavioral health counseling, and free immunizations among other free services for low income seniors. also partners with the Aging Institute of UPMC Senior Services to provide the Living at Home and Staying at Home programs which provide care coordination for low income seniors, as well as help with daily activities such as meal delivery, grocery shopping, housekeeping and yard work. plans to do more to focus on this priority: plans to continue to offer the robust suite of programs that is currently available to low income seniors, as well as leveraging their partnership with the Aging Institute of UPMC Senior Services to expand the Living/Staying at Home programs to other locations in their service area. Addressing the Health Needs of Low Income s Initiatives to Address the Health Needs of Underserved Bed Fund: Services provided to patients of the hospital, outpatient departments, the Geriatric Care Center and to physician offices. These services range from assisting with medications, medical equipment, medical supplies, family lodging, emergency housing and transportation. Family Health Centers: Located in the underserved areas of New Kensington, Bloomfield-Garfield, and Lawrenceville these centers are committed to improving the health of the communities they serve by providing primary medical care, preventive health care, disease management, and health-related education to all patients. Specific services for the underserved/elderly include free medication program, medication management consultation with pharm D, home visits, outpatient behavioral health counseling, outpatient social work intervention, Adagio program, and free flu vaccinations to area residents age 65 and older. Baseline Goal-Year 1 Goal-Year 3 Target Population A log is maintained for all services provided by the Bed Fund. Testimonials are obtained from Patients at UPMC individuals who have received this this St Margaret, assistance on their satisfaction of the program and track program and track Geriatric Care benefits provided by the Bed Fund. number of patients that number of patients Center, outpatient 80 patients provided services for utilize it that utilize it settings and medication assistance, physician offices transportation, medical equipment, medical supplies and emergency housing. Lawrenceville FHC 13,805 Bloomfield/ Garfield FHC 8, 791 New Kensington FHC- 8,970 Total Visits 31, 566 Living at Home/Staying at Home: Living-at-Home provides care coordination for ongoing in-home care for older adults. The program makes referrals for a range of services, to help older adults live independently for as long as possible, such as home-delivered meals, grocery shopping, housekeeping and yard work. A nurse and social worker will develop a care plan for each individual and recommend services to provide any needed care. Emailed Deb Brodine waiting to The UPMC Staying-At-Home is a client-centered care coordination program hear back. offered to older adults living in their own home, in an assisted living facility, or in a retirement community. The program utilizes a proactive preventive approach to geriatric care, which provides optimal care for all clients, regardless of health or debility. The Staying-At-Home program offers two levels of care Care Coordination and Care Coordination plus Nursing. Increase the number of patients receiving services from the FHC this program in Lawrenceville and explore expanding to other parts of the service area such as New Kensington, Blawnox, and Sharpsburg as well as community high rises Continue to increase the number of patients receiving services from the FHC Patients Lacking Insurance coverage or who are underinsured Low income seniors above the age of 70 residing in Lawrenceville St Margaret Foundation Falk Clinic Adagio UPMC St. Margaret Foundation UPMC/Aging Institute of UPMC Senior Services
Table 3. Draft Implementation Plan Addressing Specialized Clinical Care and Provider Initiatives Focused on Senior Health The provision of specialized clinical care and provider education regarding the senior population is a priority in s community: often have special health needs due to factors such as increased risk for co-morbid conditions and mental health issues such as memory loss and dementia, greater vulnerability to injury and mortality due to falls, and greater vulnerability to illnesses like influenza and pneumonia. For these reasons health literacy with regard to these special needs is not only important for seniors, but their health care providers as well. is addressing this issue: is addressing this priority through specialized in hospital clinical care for geriatric populations through the Geriatric Care Center as well as through provider training and education on the health needs of the elderly and coordination with and provision of education to skilled nursing facilities. plans to do more to focus on this priority: plans to continue to offer clinical, educational and coordination programs and initiatives related to senior care, and also plans to expand these programs by increasing the number of provider participants. Specialized Clinical Care and Provider Initiatives Focused on Senior Health Specialized Clinical Care provided through UPMC St. Margaret Initiatives for care coordination and the provision of senior specific education between UPMC St. Margaret and Skilled Nursing Facilities (SNFs) Geriatric Care Center: An evaluation and treatment center designed to meet the health needs of people over age 60. Along with specialized medical and psychiatric care, geriatric professionals assist older adults and their families in making health care decisions to fulfill the patient s daily needs. The specialized geriatric team includes a physician, psychiatrist, 2,544 visits in FY12 neuropsychologist, registered nurse, clinical pharmacist, and licensed clinical social worker, who provide comprehensive evaluation and treatment. Once evaluated, patients and their families have the opportunity to discuss treatment plans and recommendations with health care professionals. Coordinating Transitions Together: All day free educational program on state of the art clinical education focusing on enhancing the care of patients, preventing unplanned readmissions to the hospital and to ensure safe transition on patients from the acute hospital setting to the SNF. is presented every year in October for Administrators, Nurses, Social Workers and other Health Professionals working in Skilled Nursing Facilities in Southwestern Pennsylvania. Consists of five, one hour lectures provided by physicians and health professionals from and the UPMC Health System. Long Term Care Initiatives: Care Management has worked collaboratively with SNFs in our community to implement a series of long term care initiatives. The focus of the long term care initiatives has been on facilitating effective sharing and communication of clinical information; developing, maintaining and enhancing relationships and interaction between the hospital and SNFs; providing ongoing educational opportunities to the skilled nursing facilities and reducing unplanned hospital readmissions. The care transitions initiative is part of the long term care initiatives at UPMC St. Margaret, and includes monthly meetings with administrators/staff of 30+ nursing homes/snfs. This meeting will be used as a communication tool to promote other programs and initiatives offered by. 112 people attended the October 3, 2012 program. surveys completed for each of the five speakers. The completed surveys are maintained in the Care Management Office. A summary of these evaluations indicates that greater than 90% of participants felt that the program increased their knowledge and provided new information relevant for their job Have reduced both seven and thirty day, begun to eliminated the culture of facilities working in isolation and enhanced the quality care for the patients 30 day unplanned readmission rate from the SNF is 12.24% Maintain or increase number of patients using the geriatric care center program and begin to evaluate and summarize results from surveys Continue this initiative and continue to maintain or decrease Maintain or increase number of patients using the geriatric care center Continue program and increase or maintain Continue this initiative and continue to maintain or decrease Patients age 60 and older Nursing Home Administrators, Nurses, Social Workers and other Health Professionals working in Skilled Nursing Facilities in Southwestern Pennsylvania SNFs within the service area of UPMC St Margaret Over 35 skilled nursing facilities within our service area
Specialized Clinical Care and Provider Initiatives Focused on Senior Health Initiatives for care coordination and the provision of senior specific education between UPMC St. Margaret and Skilled Nursing Facilities (continued) Provider Initiatives focused on specialized care for Interact II : INTERACT (Interventions to Reduce Acute Care Transfers) program is a quality improvement program that focuses on the Facility A 2011-20.66% management of acute change in a patient s condition. It includes the Facility B 2011-21.57% development of clinical and educational tools and strategies for use in Facility C 2011-27.07% every day practice in SNFs. These tools focus on early communication of Facility D 2011-14.29% changes in the patient s condition, advance care planning and care paths for specific diagnosis. Benefits are enhanced quality care for the patient Facility E 2011-16.67% and a reduction in unplanned hospital readmissions. Five facilities are currently participating in this program. Speaker s Bureau: Free educational presentations offered to local skilled nursing facilities to provide training to the nursing and health professional Verbal feedback from the staff at the facility. The topics that are offered include: Advance Care facilities has been positive. Planning, Management of COPD, Management of CHF, Diabetes, Geriatric 10 educational Fractures, Management of Dementia, DVT Prevention, Infectious Diseases presentations completed. and POLST. A health professional from the hospital provides this education at the skilled nursing facility. Geriatric Fellowship : Fellows have the opportunity to enhance and develop the knowledge and skill required to provide high-quality, evidence-based care to geriatric patients of various health care settings. Powerful Tools for Caregivers: Six week class designed to focus on developing self-care tools to: reduce personal stress, change negative selftalk, communicate their needs to family members and health care N/A providers, communicate more effectively, recognize messages in their emotions and making tough caregiving decisions regarding placement, driving and finances. program and begin to monitor hospital readmissions and collect data with a quality tool which assesses readmissions 3 fellowships each year. 1 to 2 fellows are hired in the UPMC Health System yearly upon completion of the fellowship. Facility A 2013-16.44% Facility B 2013-17.19% Facility C 2013-21.43% Facility D 2013-11.48% Facility E 2013-14.74% program and develop a program evaluation form to assess the impact of the program Develop a centralized way for reporting all speaker s bureau events and track number of events Explore partnership with senior high rises to expand these presentations to address health topics on a consumer level program and maintain or increase number of residents in the fellowship Four Social Workers will complete the two day training course to become instructors for this program and begin to offer two series of classes (six sessions each) in the community. Continue to reduce or maintain unplanned the program and continue to assess it s success Patients receiving care in skilled nursing facilities program and maintain or increase number of Residents residents in the fellowship Hold additional classes in various community settings to reach additional underserved communities. UPMC Seneca Place, HarmarVillage Care Center, The Willows of Presbyterian Senior Care, Concordia Rebecca Residence and Consulate Health Care of Cheswick Nurses, nursing aides and other health care Senior high rises professionals at local skilled nursing facilities Adult children of aging parents and well spouses functioning in the caregiving role in the community Family Medicine UPMC Health Plan, Geriatric Care Center, community agencies to be identified
Table 4. Draft Implementation Plan Addressing End of Life Care End of Life Care is a priority in s community: The majority of individuals in hospice are age 65+, and one-third are age 85+. The senior population 65+ in the service area (18.6%) is even higher than that of Allegheny County (16.8%). is addressing this issue: works with patients and their families to ensure that the patient is kept as comfortable as possible during the end of their life, eliminating symptoms of physical, spiritual, and psychosocial pain and suffering. This is achieved through palliative care services offered in the hospital to lessen pain, a palliative care consultation which aims to develop treatment goals along with an advanced directive, provide psychological and spiritual counseling, and develop discharge planning and referral, including hospice. also enlists volunteers to be with those who do not have family or friends to be around them at the end of life to provide emotional support. plans to do more to focus on this priority: plans to increase awareness of end of life issues and things that individuals and families can do to prepare for the end of life, such as creating a living will and power of attorney by increasing of their existing advance care planning program. End of Life Care End of Life Care focused on Advance Care Planning Education: Educational presentation on Advance Care Planning. This presentation focuses on the purpose and importance of having a living will and power of attorney. The 2 sessions held, 43 Five Wishes booklet is reviewed with participants and they are then participants given direction on how to complete the forms and what to do with the forms once completed. Palliative Care : Services are provided to hospitalized patients by a physician, nurse practitioner and social worker to relieve suffering, enhance communication and provide the best quality of life for both the patient and members of their family. Services include pain management, symptom management, emotional support, counseling and continuing education. Baseline FY12 Goal-Year 1 Goal-Year 3 Metrics on services provided are compiled and provided to the hospital on a quarterly basis. began in November 2011 and 159 patients have been seen program and increase number of participants Explore the development of a satisfaction survey Explore partnerships with area assisted and independent living facilities to promote the five wishes program. program and track number of patients that utilize this service Begin to summarize metrics collected on a quarterly basis? Explore leveraging partnership with Palliative and Supportive Institute (PSI) program, increase number of participants and incorporate feedback from survey if implemented program, track number of patients that utilize this service and monitor metrics collected on a quarterly basis Elderly residents of Allegheny County program Patients at UPMC St Feedback from the volunteers and begin to track number of No One Dies Alone: Trained volunteers can stay with a dying Margaret who are who participate in the patients helped (if not patient, who has no family or friends to be with them at the end of the dying and have no program and from the nursing already available) their life, in the hospital 24 hours a day. Volunteers provide support program and track family or friends to staff on the units. and comfort to the dying patient through, hand holding, comforting number of patients helped Increase awareness of be with them at the words, reading, music etc. Care provided to 10 patients program and number of end of life volunteers? Assisted and independent living facilities UPMC Palliative and Supportive Institute