Panel #1: Engaging Champions and Partners

Kimberly Delp, MOW Greater Pittsburgh

1

Meals on Wheels Greater Pittsburg

Meals on Wheels Greater Pittsburgh

Collaborative

Employees & Volunteers

Majority options/waiver recipients

3500 consumers in Allegheny County

ServTracker/COC alert system/data collection

Funding Sources: AAA, United Way, Pittsburgh Foundation, Highmark Foundation, private pay

Mission

To have MOWGP/CoC be accepted as a cost effective, reimbursable component in the  delivery of healthcare services evidenced by a documented improvement in health plan member outcomes and a reduction in the utilization of more costly services. 

Healthcare Initiatives

MLTSS (conversation with 3 MCO’s)

Complete formal white paper on 30 day post acute nutritional support.

Data collection/analysis of performance against national and regional benchmarks (potentially avoidable admissions and readmissions).

Create an “Easy” contracting/working relationship with insurers.

Duplicate CoC system into other HCBS services.

Create a cohesive logic model for MOW services.

Meals on Wheels Change of Condition

Situation: Volunteers and staff of 7 agencies in the Greater Pittsburgh deliver meals 3 times a week to community-dwelling seniors and are in a privileged position to identify change in these seniors’ conditions.  Great proportion of seniors’ hospitalization can be avoided if the first signs or symptoms are early identified and properly treated.  

Target population: community dwelling seniors who are homebound and or have functional limitations

INPUTS

MOWGP Collaborative

Program Staff

Volunteers

Nurse intervention specialist

Hot prepared meals delivery service

Cell phone app

ServeTracker system

ACTIVITIES

Training on how to identify 6 changes in conditions and to use the app.

2. In every delivery, assessment of changes in seniors and house conditions.

3. Change in conditions are reported in the app.

4. Follow up on alerts may      include calls to a      physician, the power of      attorney, a caregiver, a      visiting nurse, a therapist     or a care manager.

OUTPUTS

# volunteers and staff trained

# drivers using the app

# of alerts reported

# of follow-ups

# and % of alerts with follow-up

OUTCOMES

Drivers with knowledge and skills to properly identify and report change of conditions.

Seniors with change in condition are rapidly connected to appropriate professionals and services.

Seniors receive care at home or through community-based services.

IMPACT

Decrease in seniors’ preventable hospital admissions.

Reduction on seniors’ hospital readmssions.

Reduction in seniors’ transfers to assisted living facilities.

Greater number of seniors living independently and  safe at home.

6

Community Champions

Donors: United Way, Pittsburgh Foundation and Highmark Foundation, private donors

Academic:  University of Pittsburgh (evaluator, access to grad students)

Insurers:  MLTSS Health Plans

Engaging Donors

Align with their mission

Scalability

Perceptions/Expectations (reporting)

Community Impact

Promotion (MyUnited way, billboards, press releases, hosting site, videos)

Easy donation process (Paypal, texting)

My United Way, Let’s do lunch

Allegheny, lets do lunch

Engaging Academics

Adds Validity to study

Objectivity

Utilization of Students

Non bias interviews with participants

Robust Evaluations 

Engaging Insurers

Data collection of early interventions

Reduction of unplanned hospitalizations

Reduction in Skilled Nursing Facility (SNF) admissions (short/long term)

Cost Effectiveness

Quality initiatives

Ease of ordering/contracting

Opportunities

National Recognition

Marketing strategy (billboards, MyUnited way campaign, press releases)

MCO exposure

Extension of other HCBS into CoC concept

Data collection for HCBS program to validate impact

Challenges

Fragmented service delivery system

Existing funding sources

Limited funding for data collection/analysis

Bureaucracy

Weak link between healthcare and community based services

Lessons Learned

Improve Communication

Improve Software  

Overcome fragmented delivery system 

Increase private pay sector

Improve evaluation tools

Create a bridge between healthcare and HCBS

Questions

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