good afternoon everybody and welcome it is my pleasure to let you folks know that the pace program which means program of all inclusive care for the elderly which is the national name for the program the local name here is elda service plan of the cambridge health alliance where a separate program under the umbrella of the cambridge health alliance and belmont has been waiting for us to come here for the chen years that i've worked with the program and finally october for us we're launching the program and belmont now pace is a health care program we are both the ensure and the provider state funded in regulated which means the feds medicaid excuse me medicare and the state medicaid amassed health same thing we use the terms interchangeably just to confuse everybody give us so much money at the beginning of the month and it's up to us to make that money go around fortunately we're still revenue producing and we're doing just fine we provide all health and health related services there isn't anything with respect to health that people would need that we would not be able to get them we have a whole team which team driven we have a network if you will change is made up of geriatric providers nurse practitioner nursing occupational physical speech therapy mental health nutrition social work and recreation that's the whole primary health care team and they all sit around a chaebol under one roof and speak to each other every single person every discipline around the table advocates for every single person on our program when people enroll in our program they get assigned their own doctor nurse practitioner nurse and social worker wanted welcome welcome come on in i did welcome come on back you were just talking about this wonderful well so nursing social work and rehab work with people in our clinic which is currently the closest clinic here is one sixty three gore street in cambridge it's east cambridge for any of you that know that area and  in their own homes or their own apartments we also we can talk about assisted living supportive housing and even nursing home placement down the line but let me just say that the mission of this program the entire mission of this program is to keep people home and out of hospitals and out of nursing homes and home meaning any type of a community setting where whether their own home their private home a subsidized apartment an elderly and disabled housing or an assisted living that is still considered community the only facility that is not considered community is nursing home level of care so we provide all primary care primary health care story if people need hospitalization we provide that under the umbrella of the cambridge health alliance the cambridge health alliance today cambridge go to the beth israel and they overlap that way so all primary care they get if they need hospitalization we provide that if they need short term rehab we provide that and if they should need nursing home a level of care so we never say to people sorry you're too sick you too old you have to get off the program we take care of people right through to the end of their lives even to do the palliative care should they at the end of their lives when they need if they need eyeglasses hearing aids dentures walkers wilcher is canes and shore depends all of their meds we provide podiatry dentistry vision care appointment they certainly may take it they we would make the referral and you could call and make the appointment according to your own schedule if we're going to take a person however all they have to do is show up where they are we pick them up we take them to the appointment we pay for everything at the appointment and then we bring them back home nursing rehab and social work work with people in our clinic as well as in their own homes nursing will visit once a month unless nursing is needed more than once a month and revaluate the meds if the meds have been being utilized appropriately then nursing will reorder and the meds get delivered right to the home so that team that i told you about the team of the doctor the nurse practitioner nurse and social worker they share the kids with the particular we call them participants the people on our program because we want them to participate at whatever level they are able to participate and the caregivers that they may have on board children family member is a family whoever that might be or even any friends that they might have on board so that everybody shares the same information everybody is always on the same book and page it takes a great burden off not only the participant but on the kid give as well and archie this program is a coordinated comprehensive program which means that we do every single thing with respect to health care for someone we would take care of their primary care their referrals if they need hospitalization or if they need a rehab or if they need whatever they need we provide death for people and we have a team they can keep track of all this even the transportation the beauty of a program like this is that we have the transportation department as part of our whole team so that if transportation goes to someone's home and rings the doorbell and no one is there then they don't just say it's a no show and then they go back to their office or on to the next  where is this person is this person you know maybe making some phone calls to an relative hopefully it would be that that that person whoever it was just went out to lunch with a member of the family and forgot about the appointment but we would like to make sure that  you know might be the case rather than have someone lying in their apartment for several days and that happens we've heard of those stories so we provide it's a very tight knit program it's otitis program out here quite honestly we enroll it we begin and rolling it fifty five which is looking younger and younger every day and but we enroll right up to people that hundred one hundred five so she stayed in a community setting until she was one hundred five so that's and we have many many success stories on this program some people that don't have any given as we then sometimes even become the extended family for someone at core st we also have a day center so people can come in if they can come in of course for medical appointments but they can also come in for a social day we have a lot of activities that happen some of the same activities it probably happened here at the belmont council on aging we have help there are pretty we have entertainment they do current events and trivia and of course they do do being because it's always a popular thing being go so we provide all over the activities that are going on right there and for anyone coming in their whole medical team is there so if there is anything that happens they should need anything while they're on board we can provide it we can also provide showers there now speaking of that we do so in home kids services as well we provide the government doesn't set us up to do twenty four seven kids we cannot do any overnight care that's not the way we're set up however a family wants to warn is to supplement with an overnight then that's entirely up to the family what we can do is provide depending and i love this program because everything is done on an individual basis so you might need one thing you might need another thing it's not that we say this is what you get where you need to the not everyone gets what they need on the program so it's individualized and that we call a care plan and that care plan evolves with the person it's a living document so we devolves with the person as a person's needs increase and it almost always is the needs increase somehow they  seems to decrease today as we walk this highway of life then the care plan will change that and the services will be right there so if for instance rehab went to go out to do some therapy with someone and maybe they just found out they were sad they were depressed rehabs determine that maybe they loved one and now they're not feeling like working in doing rehab rehab would come back and excuse me welcome sir we have would come back and and let social work you know so then social work with then get involved and provide any assistance that the might need or if it might be medication then they would let the clinical team know the beauty met there are many beautiful things about this program but one of the best things about this program is that there's only one number to call and that number is the main number which is six one seven five seven five five eight five zero and you can reach anyone on the program any member that i've talked about even me who is the outlier on the program through that may number we are available twenty four seven three sixty five so even if it would be friday night sunday morning christmas day something someone might need something then you would call that number a real live medical person would return the call find out what's going on if it was something like a sore throat or maybe some flu which type symptoms they might make some suggestions and ask if if it could wait till morning if it could wait till morning then a nurse would call in the morning if it's a day that were open typically monday through friday a nurse would ask if they were fell felt well enough to come to the center if they did we send transportation for them unless a family member wanted to bring them in and was available to do that if they didn't the nursing would go right out to visit them and find out what's going on whether nursing would be in touch with their doctor and give the people the support that they would need if however they felt that it could not wait until the morning then the medical person would just batch an ambulance and get that person right to the hospital no we we that team that i told you about is that responsible for every single aspect of someone's health care wherever they are they are allowed to be out of the area for up to thirty days at a time but it's always a good idea especially if you're going out for an extended period definitely a good idea but even if you're going for a trip to the white mountains for a day it's always a good thing to left the team no because if anything should happen say up in new hampshire then that team medical team is going to have to get in touch with sorry then you better go team will have to get in touch with us because we are responsible for every single aspect of someone's health care so when people get enrolled we enroll by the way on the first day of every month so right now even though september one is not too far behind us we're getting ready to enroll on october first only day one that's the way the government sets us up basically the government tells us what to do when we do it with a simple thing we're strictly monitored and regulated by the government which is great for that for you folks because the government comes in and does a report card a survey on every chair year i'm happy to say the last two have been excellent we get a little reprieve this year but next year they'll be back in again making sure that we do everything that was that that i am here saying we're doing and that's the beautiful thing for me because i can trust and feel comfortable that what i'm telling you is actually happening back at the center so people enroll one day one of every month and even if they pass away or move away they just en at the last there are not a census until the last day of the month i guess it just makes it easier for the government to keep track of so that's the way that works now for other any questions this far but that's far peach to qualify for the program people need they don't have to be home and they don't have to be bedridden they can maybe have arthritis and  cannot there are a lot of things today that go right over our heads that people don't haft about maybe they have hip and knee problems and they cannot bend down to tie shoes or put shoes and socks on well we have a lot of shoes that we can slip fall on and we can go without doing that but those are qualifies maybe they have hip knee problems and getting their foot up and getting it into the tub becomes a challenge for them just standing up balance over and most bathrooms  ballroom type bathrooms most most bathrooms if someone falls they're going to their head or their hip on one immovable object or another so the name is the name of the game is to stay upright whether you stay upright on your own power whether you need a system where the you need a walker or a cane or however it is to stay upright if by the way and i think i did already mention that we do provide wheelchairs we would provide anything and everything if someone needed a hospital bed and then we would provide that if someone needed a scooter and they were safe to drive it we would prefer that the cab the out there then we would provide that so what ever it is that someone needs with respect to how we so someone could go into the home in the morning or if someone is a late sleeper maybe midday and a system with showers if they did not need the assistance with the showers then they it would be good to have them right in their apartment or home while they took a shower in case anything happened and they slipped and they fell we call that supervision so that's also a qualifier if they need help there if they need help with medication management if they need a light meal prep laundry house clay house cleaning we provide all that so those are the services that we promote provide in home and all the primary care happens at one sixty or street in cambridge it's a clinic both the clinic as well as the day center so people need to require assistance with two of those things like bathing dressing grooming where they need help colm meaney here maybe they have shoulder i'm finding there are a lot of shoulder issues out here and so that makes it cumbersome for people to be able to get dressed sometimes to be able to groom to cut their hair comb their hair to wash their hair all of that is a qualifier if they needed assist or even even supervision or if they actually needed to be put into a shower and scrubbed up that's from one extreme to the other from the lightest care to the heaviest care those are qualified and a skilled need like if they had a wound that needed to be taken care of if they had blood pressure that kept hopping up and down if they were diabetic and needed blood sugar monitored all that time diabetes is a it's a very prevalent disease out here i'm sorry to say and it's a very tricky disease out here my civi show that i'm doing this month in cambridge is actually on diabetes and management of it because it is all about education all about education so we have that whole team and the clinical team that would help someone manage that monitor that blood sugars in even a nutritionist on board to help with the appropriate foods to be eating because that's where a bigot education piece comes into so that's the clinical qualification they have to live in catchment area and now we are going we currently have eleven october one belmont is coming on board with us and reviere at the other end of the world will be coming on board with us so those will be all of our areas however people do not have to reside in the area to to begin the intake process if they say appropriate for an assisted living situation then we could do all of the intake from wherever they are and unless they're of course out of state the further this when i get in role meant that the person that i move the furthest away was from hawaii so he came from hawaii he had his daughter his daughter was very beneficial in helping ork orchestrate that whole move and we got him a supportive housing apartment and we're able to move in he had stage four cancer and we were able to give him the best quality of life that we could give him in a supportive apartment with his independence and with his dignity for as long as we could for as long as we could and that team that i told you about they get to know people get to know that they're comfortable that team takes them right through to the end of their lives so that's not switching off to any other team which is also a great benefit for the people now and the questions yet ok i must be doing ok so the financial qualifications people can earn up to almost twenty two hundred dollars two thousand one hundred ninety nine gross monthly income have two thousand dollars or less in the bank and we'll talk about that that's actually the quick fix of the sticky wicket can be the income if they meet those financial qualifications they do not pay a red cent for anything that i have told you there is not a co payment for doctor hospital or medication for nothing however if people are over the twenty two hundred then they can enter into a what we call a spend down situation and that means that mass health figures out the calculation but essentially it would be the difference between their actual gross monthly income and approximately five hundred dollars a month five hundred dollars which would be the money that they would pay to watch us and that we funnel back to math help it's basically a buy in to math help now if people have lots and lots and lots of money they can still we don't we're not exclusive we can still in a role most people because maybe those people would like to need some support and stay in their community or their own home instead of going off when they need extra care off to a nursing home so if they have lots and lots of money if they have medicare they we would only charge them the medicaid reimbursement amount plus the medication we call it people are pretty familiar with medicare a b c d these days so mehndi is the prescription and then we would provide all with that with that faith up lament that they would give us that we would give back to methe oh that includes everything else there is not any money exchanged for anything else even if they should need nursing home placement takes care of everything all inclusive if they do not have medicare then the fee is a little bit more so if they have medicare it's roughly around four thousand dollars with mid day which were about the third of the cost of a nursing home so it's a way for people to stretch out the assets that they have and stay in their community longer if they begin to feel and end up with having incidents and end up in the hospital and then off to rehab sometimes if this happens to people in close proximity like they come home and then a month later they have an incident they fall they go back to the hospital they go to the rehab we kind of call them frequent flyers if they have that happen to many times in a close proximity then the hospital case manager is going to say this person is no longer safe to be living alone at home and they go often to a nursing home when they might have been able to be supported in their own home so in a nutshell that's the pace program if people are not in that catchment area and there and they need the program our interest in the program might qualify for assistance living might sometimes if they can be stubborn my own mother and i never want to leave the home so we get that people want people want to stay in their homes for as long as they can we understand that but if it's not safe to be in your own home and you need extra support then maybe an assisted living situation might work there are no assisted living is that we contract with in the belmont area ye i heard talk of maybe one being developed down the line and if that happens maybe we'll approach or maybe but it will be something out but we have assisted living in the cambridge area which is only a few miles away and the some a villa area as well that people we could have those people in role with us they pay their room and board out the assisted living and then we supplement this stay there our money goes toward we what we call a care package and allows people the extra support so when you think of it if someone has to go to an assisted living then they have themselves at whatever level they're able they have any a family members or friends or whomever is in their life if they have and then if they have the team at the assisted living there are four levels of support watching out for one person that's a lot of support for one person but the whole idea is to be able to to support them and keep them functioning as independently as possible for as long as possible like a little mis to we have any questions comments concerns can i ask some questions does your mother live in the catchment area she's in new jersey well they're  c we thinking of relocating her we are ok well in that case i did i give you my card ok so e mail and cell phone of the best ways to reach me i can walk you through the process and help you so it doesn't matter mom's not to attach to any docs in this area and by the way that can sometimes be the biggest barrier to this program that you would have to leave your own doctor and come on board with us people look at that as a restriction i'm going to tell you it's a great benefit because you have one team knowing every three single thing about you what all your meds and everything else that you're taking so it's crucial for that for your primary care provider in this case a whole team to be able to have that information and be able to send that information for whatever specialists you need to go to and by the way if we are as i said part of the cambridge health alliance network and be i d m see beth israel is in our network if someone needs a specialist we will first look to the umbrella of cambridge health alliance or if we don't have a specialist there we would look to beth israel medical center if however if the person needed a specialist that hard to believe that neither the cambridge health alliance nor b i g mc we would look to contract out to whatever specialist that that person needed everyone gets what they need on this program another thing i love about this program i took care of my own so i have passion for this program because i could have used a whole team to help me and there was no one doctor she had doctor a doc to be in dr c and they didn't talk to each other that was me keeping track of her medications and her appointments and i was the chauffeur by the way and i was doing everything plus i was working full time and my daughter was up in new hampshire and her marriage process and so we had all that going on honestly my stress level was so high i thought i would pass before my mother but that was seventeen years ago so if i sound like i have passion for this program i do because i could have used that whole to him to help me while i was continuing wife to the best of my ability so the barrier can sometimes be in your instance there is no barrier mom's going to have to find a new doc when she comes on board anyway but for someone that's in this area maybe they've gone to their doctor for twenty years and they do not want to let that doctor go sometimes when people realize a lot of times when they realize that how much more they get in that they get all of these services and this whole team to guide them through every situation every health concern that they might get or have then they will they knuckle under because they know that they need all that and i've only had two men in my whole career choose a nursing home over staying in a community setting most people don't want to stay don't want to go to a nursing home most people want to stay in a community setting and we also do contract with some dementia units in assisted living facilities for those folks who might have all the time as our dementia so a little something for everybody everything with respect to health and health related services and and even housing because that is a big piece of how people stay independent with dignity so but you know what it never hurts to have the information because if it doesn't work today there in you know in the wood blink of an eye life can change and if something happens another health episode then sometimes that's what makes people say i need that program i need that program and you know there are so many ways to financially to be able to enroll in the program so people right right well that always now so if someone has a medically complex mistake then i would always recommend seeking the advice of an elder law attorney for that but i can basically walk people through and let them know what the it whether they will need to do that or not but every single person every single person all of us included should have at the very minimal health care proxy power in a czerny because if someone should be incapacitated cognitive or if they should have an accident be rendered unconscious a power over tourney is is essential to how it doesn't really get evoked until it needs to be because if we don't do that and then people are not able to speak for themselves then it's a guardianship and you have a couple hundred dollars as opposed to five thousand dollars so those documents are essential for each one because you know none of us ever know what the next moment is going to bring in the blink of an eye life can change for any one of us right so we want to be prepared so those things of the very least well if you don't have any questions or any