4

Perspectives on Coordination Across the Spectrum of Caregivers, Providers, Services, and Supports

Although there are many services and programs throughout the United States intended to support people with disabilities and older adults, generally there is little, if any, cross-talk among these programs. The four speakers in the workshop’s second panel discussed some of the different models that already exist for developing systems that connect and integrate community services and health care programs, and they explored others that are in development. These speakers also looked at this challenge from the perspectives of segments of the workforce that support individuals with different types of needs.

COORDINATING MEDICAL AND SOCIAL MODELS TO ENHANCE CARE DELIVERY

Robyn Golden
Director of Health and Aging
Rush University Medical Center

Robyn Golden of the Rush University Medical Center began her presentation by quoting from a report from the Institute for Clinical Systems Improvement (ICSI and RWJF, 2014): “In a time of major changes to the health care delivery and payment systems, connecting clinical work to community partners and resources brings a sense of renewal and hope for the challenges ahead. Going beyond clinical walls to solve complex problems is a prescription for success.” Golden then referred to a 2011

report, Health Care’s Blind Side (RWJF, 2011), that speaks to both the trend of primary care physicians feeling that they do not have the time to attend to the social determinants of health despite knowing that those social determinants affect outcomes and costs and to the trend of physicians sometimes being reluctant to screen for social determinants due to concerns that it will “open Pandora’s box” and that they will not be able to address those needs if found.

It is well known, said Golden, that person- and family-centered coordinated care with links to the community is rare in care models, that mental health is often forgotten, and that models of care are not “bilingual” or “bicultural” with respect to bridging medical and social systems. The traditional geriatrics field, as well as primary care in general, knows little about the network of aging-related services that are available to older adults, said Golden. The geriatricians at her institution have told her that they will know that the care delivery system is working effectively when they know what the direct-care worker is thinking and doing in the home of one of their patients and when the direct-care worker knows what the geriatricians are thinking and doing in their offices. She noted that the Institute of Medicine recommended developing community links to assess psychosocial issues, to deliver services in the community, and to communicate these issues with the medical team (IOM, 2013). Golden discussed two programs at the Rush University Medical Center that are striving to integrate the medical and social systems of care for older adults and adults with disabilities: CATCH-ON and The Bridge Model of transitional care.

CATCH-ON

The Rush University Medical Center, Golden said, has been striving for the last 12 years to create the links to bridge the medical and social systems. In 2015 the institution was 1 of 44 recipients of grants awarded under the aegis of the Health Resources and Services Administration’s Geriatrics Workforce Enhancement Program (GWEP). Golden said that the program at Rush, called the Collaborative Action Team training for Community Health–Older adult Network, or CATCH-ON,¹ is focused on developing inter-professional collaborations to design and implement programs for geriatrics workforce enhancement as a means of making primary care friendlier to older adults. It does this by partnering with more than 30 educational and community partners across Illinois to create community-based outreach resource centers to address the learning and support needs of older adults, their families, and their caregivers.

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¹ For more information, see http://catch-on.org (accessed September 14, 2016).

CATCH-ON has two primary aims, said Golden. The first is to provide education about the management of chronic conditions among the diverse population of older adults. It does this through several mechanisms, including providing interactive, online education for community members and professionals; developing course material; supporting faculty learning communities; promoting health education on subjects such as lesbian, gay, bisexual, and transgender older adults; and creating health ambassadors, who are similar to community health workers but are specifically older adults living in the community they are serving. The program’s second aim is to transform primary care into collaborative care that places the older adult at the center of that care and includes caregivers, an assessment team, the clinic or hospital intervention team, and a community intervention team. One tool that CATCH-ON has developed, which Golden said other GWEP grant recipients are also planning to use, assesses the readiness of a primary care practice to change. This tool will enable programs to determine what each site needs to make it likely that a transformation will be successful. A wide range of individuals, including caregivers, representatives from chronic condition associations, geriatrics care managers, elder lawyers, and financial planners, have been involved in CATCH-ON’s efforts.

The Bridge Model

The Bridge Model,² Golden explained, is a transitional care intervention for adults with chronic conditions, older adults, and adults with disabilities, which is rooted in the principles of hospital–community collaboration and an awareness of the social determinants of health. This intervention is led by social workers who have the interdisciplinary connections to address the social, psychological, and environmental issues that can cause people to be readmitted to hospitals and nursing homes. In the program, a social worker starts by examining an individual’s electronic health record while that individual is still in the hospital and then visits the patient at the hospital bedside to make sure that post-discharge plans are in place and understood by the patient. Once the individual returns home, Golden said, the social worker facilitates connections to the appropriate community resources and coordinates subsequent home health care, primary care, and hospital care while also making sure that family caregivers have the supports they need to avoid the isolation and strains that can commonly occur for family caregivers (see presentation by Carol Levine, United Hospital Fund). The Bridge Model is an evidence-

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² For more information, see http://www.transitionalcare.org (accessed September 14, 2016).

based intervention which has been replicated in more than 50 sites around the United States.

A review of The Bridge Model (Boutwell et al., 2016) found that 30-day hospital readmission rates fell by 20 percent for program participants. Other positive outcomes included a reduction in caregiver distress, more engagement of individuals with their medical homes, greater patient self-efficacy and activation, and an increased awareness of available services among providers. This study identified three major strengths of The Bridge Model: (1) its repeated assessments to account for the fact that an individual’s needs change over time, (2) its development of interventions tailored to individuals, and (3) its ability to effectively link individuals to services. The study concluded that The Bridge Model is well suited to assess and address the transitional care needs of adults with complex medical, behavioral, and social needs and that this model may be useful with other populations, such as those served by Medicaid and those dually eligible for both Medicare and Medicaid. Because of the effectiveness of The Bridge Model, it is being incorporated into CATCH-ON. However, Illinois’s current budget crisis means that funds are not available to replicate this pilot program throughout the state at this time.

Golden concluded her presentation by saying that success requires strategies that are person- and family-centered, that focus on prevention and wellness, and that are delivered by collaborative teams that have received inter-professional education. Success also requires innovative models of care coordination and integration as well as the community engagement and partnerships necessary to create a system where the hospital, the home health agency, and the community organizations can talk to one another and also have an understanding of the preferences and values of the older adults, the people with disabilities, and the families they serve, Golden said.

COMMUNITY-LEVEL COORDINATION BY AREA AGENCIES ON AGING

Sandy Markwood
Chief Executive Officer
National Association of Area Agencies on Aging

The mission of the National Association of Area Agencies on Aging (n4a), as Sandy Markwood of the n4a described it, is to ensure that older adults can live with dignity and independence in their home of choice or in their community for as long as possible. To this end, n4a not only supports aging-in-place but also pushes more broadly to support aging-in-community. One key to enabling successful aging, Markwood said, is

the provision of a range of home and community-based services that help older adults to stay in their own home for as long as that home is safe and appropriate to support successful aging or else to ensure that these adults have the options for housing, transportation, and other needs necessary to age successfully in their community when their existing home no longer meets their needs. n4a’s vision is to build a society that values and supports people across the lifespan. To realize that vision, it focuses on building collaborative partnerships at the community level with many organizations—including several represented at this workshop, Markwood noted—to deliver community-level services that address the social determinants of health.

Area Agencies on Aging, said Markwood, were created in 1973 as part of an amendment³ to the Older Americans Act⁴ to serve as the on-the-ground coordinating bodies that would help older adults find, connect to, and receive services. Although 622 Area Agencies on Aging exist in communities across the country, where they sit in the community varies. Approximately 39 percent of the agencies are part of independent nonprofit organizations such as the United Way, 28 percent are part of county government, 26 percent are part of a council of governments or a regional planning and development area, 3 percent are part of city government, and 4 percent have other affiliations.

Area Agencies on Aging often serve functions beyond being a resource for aging-related services. For example, almost 75 percent are designated as Aging and Disability Resource Centers that help all consumers connect to services regardless of age or disability. More than 60 percent of Area Agencies on Aging are designated as State Health Insurance Assistance Programs, which provide direct health insurance counseling to older adults, and more than half serve as local long-term care ombudsmen to act as a resource and as an advocate for consumers living in nursing homes and other institutions. In fact, while all Area Agencies on Aging serve adults ages 60 years and older and their caregivers, an increasing percentage also serve consumers under age 60. Nearly three-quarters of the Area Agencies on Aging serve consumers who are under the age of 60 and have a chronic illness or disability, almost 60 percent serve caregivers of all ages, and 30 percent serve veterans of all ages.

The role of the Area Agencies on Aging is to determine how to ensure that people can live, work, play, and pray at the community level so that they can lead productive and independent lives, and then to develop the services and supports that turn that goal into reality. Fulfilling this

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³ An Act to strengthen and improve the Older Americans Act of 1965, and for other purposes, Public Law 93-29, 93rd Cong. (May 3, 1973).

⁴ Older Americans Act of 1965. Public Law 89-73, 89th Cong. (July 14, 1965).

role involves identifying the needs of individuals in the community and addressing those needs by organizing and coordinating the resource base of other community-based organizations and public and private providers. In general, Area Agencies on Aging do not deliver services directly but rather work with more than 20,000 service providers nationwide to ensure that the right services are delivered at the right time to individuals in need. They also monitor the quality of those services and test for consumer satisfaction.

All Area Agencies on Aging, said Markwood, provide core services in the areas of nutrition, health and wellness, elder rights, coordinating supporting services, and supporting caregivers with information, education, and critical respite, among others (see Box 4-1). n4a also operates the Eldercare Locator, a national 1-800 call number that helps older adults and caregivers find the resources that can help individuals stay in their homes and in their communities. Markwood said that this help line receives more than 300,000 calls annually. A typical call, for example, might come

from a caregiver looking for a nursing home for her mother but, after discussing the particulars of the situation, instead may result in connecting her mother with home meal deliveries and transportation to appointments, all of which may enable her to remain successfully in her home.

Much as CATCH-ON and The Bridge Model described by Golden do, Area Agencies on Aging look at the intersections between social services and health care to help support older adults in the maintenance of their health and to promote wellness. Today, some 90 percent of Area Agencies on Aging offer a range of evidence-based health promotion and disease prevention programs that address such key health challenges as chronic disease self-management, diabetes self-management, falls prevention, and successful care transitions; the percentage of agencies offering such programs is up from approximately 50 percent in 2007, Markwood said, adding that she expects the number to soon be 100 percent because of new requirements in the Older Americans Act. Approximately two-thirds of Area Agencies on Aging are involved in institutional transition and diversion programs that help older adults either transition from an acute care setting to home or divert them from prematurely moving to an institutional setting by setting them up with home and community-based services and supports. In addition, more than half of all of the agencies are involved in an integrated care delivery system of some kind that combines delivery, management, and organization of services related to diagnosis, treatment, care, rehabilitation, and health promotion across multiple systems. These programs take advantage of the many new opportunities for integrated care, including veteran-directed home and community-based services programs, Medicaid managed care, state demonstration programs for individuals dually eligible for Medicare and Medicaid, and the Section 1115 Medicaid demonstration waivers.

Markwood said that in Health Care’s Blind Side, the 2011 report by the Robert Wood Johnson Foundation that Golden also referred to, 85 percent of the 1,000 primary care and pediatric physicians surveyed said that unmet social needs are a direct cause of worsened health (RWJF, 2011). The same percentage of physicians said that it is just as important to address social needs as it is to address medical conditions, yet 80 percent of the physicians were not confident in their ability to address their patients’ social needs. “I think that is where the opportunity really comes in for Area Agencies on Aging and other aging and disability community-based organizations to bridge that important gap between the acute care world and the world in the home, where most health happens, to make sure there are good transitions there and to make sure that there is the opportunity to have seamless information exchange and support for older adults and their caregivers,” said Markwood.

Markwood also listed other opportunities for Area Agencies on Aging to support, enhance, and improve the care of older adults. These included

• expanding the use of evidence-based health programs in the home and the community,
• supporting care transitions from an institutional setting back into the home,
• providing assessments, care management, and care coordination,
• serving as the focal point for home and community-based services for all ages, and
• promoting livable communities that support independence across the lifespan.

Too often, said Markwood, people do not begin to look for services and supports in the social services sector until there is a crisis, so she said she believes there is a need to do a better job of proactively providing information about community resources before people reach that crisis stage. The bottom line, said Markwood, is that millions of older adults, people with disabilities, and their caregivers are counting on the Area Agencies on Aging to help them connect to services and supports so that they can live long and independent lives where they want to live—at home and in the community. “Integrating and working together is the only way that we really are going to be able to collectively meet their needs,” said Markwood.

CONTINUITY OF COMMUNITY LIVING: AN INDEPENDENT LIVING PERSPECTIVE

Glen White
Professor of Applied Behavioral Science and Director of Research and Training at the Center on Independent Living
University of Kansas

In the early 1900s, people who had disabilities or who developed disabilities as they aged lived and died in their homes, which is also today’s goal, said Glen White of University of Kansas. However, beginning in the 1960s, with the advent of Medicaid and the advancements in medicine to prolong life, the nursing home industry flourished as a growing number of people were moved into nursing homes. This trend accelerated as more women entered the workforce, diminishing at-home support for aging parents and family members with disabilities. Unfortunately, said White, nursing homes became a convenient place to house people with severe disabilities, many whom did not want to be institutionalized. In reaction

to this trend, he said, the disability community took it as a challenge to change the system so that individuals with disabilities could have the option to live at home if that was their desire.

White said that he thinks about the concepts of independent living and living in the community in terms of a continuum between a model of independence and a model of interdependence. In the model of independence, consumers come into the Centers on Independent Living in search of core services, such as skills management, advocacy, peer counseling, and information and referral. The independent model implies that if basic independent living core services are met, consumers will naturally participate in the community. However, while this model might lead to increased participation for some, others might end up living in the community as an occupant of a home rather than as a full participant. In contrast, in the model of interdependence, consumers who go into the Centers on Independent Living not only receive core independent living services but also learn how to increase their social skills to connect with others and form social networks to enhance their participation in their communities. The interdependence model assesses both the environmental and personal factors that affect that individual living and engaging in the community.

Although there are laws that protect and support people with disabilities going out into the community—e.g., the Americans with Disabilities Act and the Olmstead Decision⁵—many times there are other barriers that prevent these individuals from fully engaging and taking advantage of the opportunities these laws afford. One such barrier that concerns White, who himself has used a wheelchair since sustaining a spinal injury when he was a teenager, is the distinction between aging into a disability and aging with a disability. When someone ages into disability, that disability can be slow and progressive. These individuals tend to deny the aging process and are afraid to use the word “disability” or to rely on assistive technology. This is particularly true of the baby boomers, said White, describing them as going into the aging process kicking and screaming. He also said that there are few good role models for aging into disability and that he wished that organizations such as AARP would talk more about aging into disability.

In contrast, said White, many individuals who are aging with a disability acquired their disability when they were younger, which in some cases can make for an easier adjustment and adaptation over the lifespan. There can also be greater community inclusion and role models to encourage it, he said, and individuals aging with a disability tend to embrace the word “disability.” However, secondary health conditions such as chronic

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⁵Olmstead v. L.C., 527 U.S. 581 (1999).

urinary tract infections or severe pressure sores resulting from a primary disability can be a tipping point for independence.

White said that there is no one-size-fits-all approach when identifying policies and practices for a workforce to provide services and supports for those who are aging into disability and those who are aging with a disability. He added that in order to address these issues, there will need to be a clear conceptualization and definition of what living and participating in the community means for older adults and those with disabilities. White asked, “[Is it] just living in a house as an occupant or [is it] really truly being involved” in the community?

Building on the notion of having a clear understanding of the meaning of specific terms, White said that for the disability and aging communities to work together, they will also need to understand and respect the different words they use, such as “resident,” “sovereignty,” “caregiver” versus “personal attendant,” “consumer-directed” versus “agency-directed,” “disability with a capital D” versus “disability with a lowercase d,” “patient,” “institutionalization,” and others. This strategy would be an opportunity for the two communities to understand a common taxonomy and philosophy so that they can figure out how they can learn from each other, said White. Working together, these two communities can better answer questions such as who has control over hiring and firing caregivers, how much will health care workers cost and who will pay for them, and what level of certification and licensure should be required? For Americans living in rural settings and receiving care from a family member or partner, White asked how an individual deals with poor care. “How do you fire them and who is going to take their place?” he asked.

In conclusion, White said that there are opportunities where the disability community and the aging community could better connect with one another. “What are the common goals that can be achieved by working together?” he asked. “I think there’s a chance to learn from each other,” said White, “and I think that is one of the directions we need to consider going in.”

INTERAGENCY COORDINATION BETWEEN THE DEPARTMENT OF DEFENSE AND THE DEPARTMENT OF VETERANS AFFAIRS

Karen Guice
Acting Assistant Secretary of Defense for Health Affairs
Department of Defense

The Department of Defense’s (DoD’s) Military Health System, said Karen Guice of the DoD, provides health care to the men and women who serve in uniform and their families as well as to those who have retired

from military service, approximately 9.4 million beneficiaries. The Defense Health Program budget is approximately $50 billion for the federal fiscal year 2016. The Department of Veterans Affairs’ (VA’s) Veterans Health Administration (VHA)—a separate federal agency—provides care to qualified veterans of military service (i.e., those who served in uniform). In the federal fiscal year 2015, the VHA budget was approximately $60 billion and served some 9 million enrollees. There are approximately 1 million individuals who are eligible for care from both systems.

Guice said that she and her colleagues are proud that the case fatality rate—i.e., the number of service members dying on the battlefield—has fallen significantly over the past decade. At the same time, the injury severity score has risen, resulting in more individuals alive today who have complex care needs as a result of injuries sustained in war zones. These injuries include traumatic brain injury, extremity amputations, spinal cord injuries, chronic pain, burns, and psychological health issues. The complexity of these injuries causes challenges for both the DoD and the VA on how to provide care for these individuals, said Guice. “[We] really want them to become as good as they can be given the constellation of their injuries and their illnesses,” she said.

Although the number of disabilities among wounded warriors has risen, military health care has had some remarkable successes, Guice said. Some 20 percent of amputees return to active duty, many even deploying again to the very battlefield on which they were originally injured. That accomplishment is due to the advances that have been made in medicine and the resilience of the individuals, Guice said. Other wounded warriors successfully transition out of the military, having benefited from customized rehabilitation and reintegration strategies, and are gainfully employed and participate fully in their communities. Guice explained that the main goal of the Military Health System is to maximize this kind of recovery. “This is what we want every single time we have someone who is injured in battle,” she said.

One challenge that both the Military Health System and the VHA face is dealing with the mental health problems that members of the military and veterans can have as a result of their service. Posttraumatic stress disorder, depression, and suicidal ideation are issues that the two health systems deal with daily, said Guice. She also noted that cardiovascular disease and diabetes are more prevalent among members of the military and veterans than in the general population. In response to these and other issues, the DoD and the VA have developed more than 50 programs to serve wounded warriors. However, even with these excellent, comprehensive services, said Guice, the programs are not synchronized between the two health systems. In addition, there are no common operational procedures between the two departments; no integrated, comprehen-

sive plan for warriors in transition; and no single point of contact for an individual patient and his or her family. For example, every hospital that treats these patients has case managers, but when the patients transition from one hospital to another, they leave one set of case managers behind and acquire a new set. Patients and families have reported that they have many dozens of business cards for different case managers, said Guice. The patients and families do not know what the case managers do or how the case managers might be able to help them. “These people are just trying to figure out what new normal is,” she said. “All they are trying to figure out is what [they are] going to do today to get to tomorrow.” Furthermore, the DoD and the VA also found that these transitions made people vulnerable to getting lost between the two health systems.

The solution to this unacceptable situation, she said, was to create a different model of care that was integrated across the two departments and integrated across every transition an individual might make, whether from a military treatment facility to a civilian hospital and back again, from one military treatment facility to another military treatment facility, or from the DoD to the VA and leaving military service. To guide the creation of this new model of care, the two departments worked together to create the Interagency Care Coordination Committee. This committee has established an interagency community of practice to strengthen the care community across the two departments around common responsibilities. It created a lead coordinator position, which is a designated care management team member who coordinates all of the other care providers for a given patient and acts as the single point of contact for the wounded warrior and his or her family. In addition, the lead coordinator is also responsible for making sure that the warrior’s family’s needs are being met. While there still may be multiple lead coordinators throughout a warrior’s journey through the two health care systems, there is now transparency about who is in charge of managing that warrior’s care and what exactly is being managed.

The committee’s vision is “One mission. One policy. One plan.” The one mission is to get wounded warriors to be the best they can possibly be, regardless of where they are in their journey back from being wounded. The one policy refers to the challenge of developing a single policy for two federal departments—a challenge the two departments overcame. One plan refers to a comprehensive treatment plan that each individual takes through all of the transitions within and between the two health systems. Initially, the plan was a checklist, but it is now being implemented as an electronic record that any lead coordinator can review and use to hold the systems accountable. The transition plan includes not only medical items but also things such as the status of an individual’s Purple Heart application and retirement paperwork, where applicable.

The purpose of the plan, said Guice, is to make sure that every individual is aware of all of the resources and benefits the two departments can provide so that the individual and his or her family can focus their efforts on getting better and realizing their goals. Each individual’s plan articulates those goals and enables the lead coordinator to help these individuals and their families to achieve them, Guice explained.

Over the past few years that the committee has been operating, it has assembled a community of practice that meets quarterly. These meetings promulgate knowledge about new programs and benefits for wounded warriors. The committee has also enacted a program that has trained 2,500 personnel across the DoD and the VA to serve as lead coordinators and then sustains them by identifying champions and providing coaching and forums in which lead coordinators can interact with one another. This training program also works to increase awareness among all Military Health System and VHA care providers about the role of the lead coordinators and how to work with them.

The main challenge, Guice said in closing, lies in making sure that individuals leaving military service have what they need when they return to civilian life in their communities. Any strategy for providing care for wounded warriors must, she said, consider an individual’s long-term care needs and requires a long-term, committed public–private partnership with support from communities, the DoD, and the VA.

DISCUSSION

Commenting on Guice’s presentation, Bruce Chernof of The SCAN Foundation said that care coordination is key and that if there is one takeaway from this workshop, it should be the importance of taking on the challenge to think about how to build the kind of care coordination that has been implemented between the DoD and the VA and extend it across all domains while being centered on the community. Guice responded that it is quite powerful to harness all of the services and benefits an individual needs and cut through the bureaucracy and confusion so that individuals can easily access those services and benefits.

Stephen Kaye of the University of California, San Francisco, asked why the Veteran-Directed Home and Community Based Services⁶ program is implemented in so few places and providing services to so few veterans even though it is a good program. Guice, who said she worked at the VA before moving to the DoD, agreed that this is a terrific program and said that the challenge is raising awareness among veterans of the

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⁶ For more information, see http://www.va.gov/geriatrics/guide/longtermcare/VeteranDirected_Care.asp (accessed August 31, 2016).

program’s existence. She said that her hope is that by making service teams’ lead coordinators aware of this program, more veterans will benefit from it.

Bringing Coordination Models to Scale

Amy York of the Eldercare Workforce Alliance asked the panelists for their thoughts on how models and systems already in place can be scaled up to a larger system that integrates health and social services. Markwood said that there is a great deal of interest from aging and disability organizations in working together on ways to integrate, partner, and then contract with the health care community. For the past several years, n4a has been working with the disability community and the Administration for Community Living (ACL) to pilot learning collaboratives aimed at determining how social services can be paid for by health care dollars to create a bridge between health care and social services and between the acute care world and the home. The goal now, she said, is for collaborative initiatives between aging and disability organizations to take the results of these pilots to a much broader base to enable further partnering between the community-based aging and disability organizations and the health care enterprise. Markwood also noted that while the number of caregivers is growing and the demands on caregivers are growing as the population ages and as the number of Americans with disabilities rises, there are limited federal dollars to meet the demand for services. “When we look at the future of integration between health and social service, we need to look at new and different diverse funding patterns and partnerships to be able to make that happen,” said Markwood. She applauded the investments that The John A. Hartford Foundation, The SCAN Foundation, and other foundations are making to move these partnerships and collaborative efforts forward.

Golden replied to York’s question by calling for a demonstration project between CMS and ACL that would “finally and legitimately fund the unfunded mandate for aging and disability community-based services.” White added that he would like to see more of an effort to look at alternative training and capacity-building models outside of the traditional academic route that could meet the increasing demand on the caregiving workforce.

Michael Johnson thought it would be helpful for a convening organization to bring together organizations and entities such as BAYADA Home Health Care and others represented at the workshop to share best practices and to identify pilot programs on which to collaborate and bring to scale. Campbell agreed and added that one function of the convening organization could be to serve as a clearinghouse for successful pilot

programs and models as well as for components of those programs and models that could be adapted for various contexts to meet the specific needs of a given community.

Gail Hunt from the National Alliance for Caregiving asked Golden what the barriers are to taking The Bridge Model to scale. Golden said that she worries that the complex evaluation to determine whether The Bridge Model and other community-based care transition programs like it are successful might lead some people to call this type of program a failure. “The evaluation was a bit quirky, but the intention [of The Bridge Model] was still a good one and still a valuable one in bringing social services to the hospital and the health care services to the social service world and the community,” said Golden. She said she believes there are easy fixes to the challenges with these types of care transition programs that would enable any of them—not just The Bridge Model—to be taken to scale.

Developing Measures for Assessing Coordination

Terry Fulmer commented that future progress will require outcome measures and, in particular, quantitative outcome measures for the programs discussed by the panelists. She said that The Bridge Model’s 20 percent reduction in hospitalization readmissions is a good example of outcomes data supporting the value of the program and asked the panelists how they were addressing this type of data need in order to demonstrate progress toward the Triple Aim. Markwood said that her organization has had discussions with ACL about approaches for collecting different types of outcome measures. The idea, she said, is to shift the long-time focus of social services agencies from output measures to outcome measures. For example, “By providing a home-delivered meal,” Markwood asked, “did you keep Mrs. Jones out of the [emergency department]? Did she have better health outcomes?” Markwood also commented that the lack of outcomes data by social services networks is not a result of a lack of will, but rather the result of a lack of investment to collect the necessary data and report those data. Fulmer questioned whether the National Health and Nutrition Examination Survey⁷ could serve as a vehicle for collecting those data. White said that the American Time Use Survey,⁸ which captures daily activities and correlates well with disability level, could help answer the question of whether these programs are effective. He added that while most research looks at proximal outcomes, there is a need to look at distal outcomes too in order to determine if programs

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⁷ For more information, see http://www.cdc.gov/nchs/nhanes (accessed August 31, 2016).

⁸ For more information, see http://www.bls.gov/tus (accessed August 31, 2016).

are facilitating participation in the community. Furthermore, White said that the Centers on Independent Living have traditionally been required to report what were largely output measures, but the National Council on Independent Living has been considering how to generate more outcomes-focused data. One challenge, he said, is that researchers are not running the centers and thus the centers are not equipped to do the type of research needed to generate useful outcomes data. He said that stakeholders are working together to determine what data are needed and what outcome measures will be able to produce those data.