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Hebrew SeniorLife
Organizational Overview and
Affordable Housing with Services (R3)
HPC Board Meeting - Sept 2017
Right Care, Right Place, Right Time: Effectively Integrating Senior Care and Housing (R3)
Hebrew SeniorLife – At A Glance
113 year old organization
2,600 employees serving 3000+ seniors across 8 campuses and communities, and in-homes
– 1,500 units of senior living (independent and assisted)
– 775 beds of long term chronic care, sub-acute, and rehab care
$210+ million in annual revenue
– 4th largest nonprofit in Massachusetts (per BBJ)
Medical staff with 40 physicians and nurse practitioners
Affiliated with Harvard Medical School
– Largest aging research institute in a clinical care setting
– 700+ clinical professionals trained annually
Boston Globe Top Employer – last two years
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HEBREW SENIORLIFE OUR DNA: ONE COMMITMENT – REDEFINE THE EXPERIENCE OF AGING
… and Teaching
• Medical Students • Residents & Fellows • Nursing &Therapies • Interns
Redefine Senior Health Care • Home Care • Geriatric Primary Care • Outpatient Care • Medical Acute Care • Rehabilitative Care • Long-term Care • Hospice
Reimagine Senior Living
• NewBridge on the Charles • Orchard Cove • Center Communities of Brookline • Jack Satter House • Simon C. Fireman Community
Rediscover Every Senior’s Potential Through Research •Aging Brain Center •Syncope & Falls •Translational Research •Center for Musculoskeletal Research •Genetics & Geriomics •Quality of Care/Standards
Reach out for Philanthropic Support Recognize the Power of Partnerships
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HSL COMMUNITIES 4
HSL has developed a focused new strategy
Who? What Aims?
Dire
ct se
rvic
e an
d ca
re
Indi
rect
Impa
ct
Measurably improved quality of life
• Seniors 55+ and their families across the nation and globe
• Health care & senior care organizations, policy makers
• Geriatric professionals and researchers
HSL seeks to improve the quality of life for a growing number of seniors
and their families
• In Eastern Massachusetts
• Embracing all religions while remaining rooted in HSL’s Jewish heritage and values
• With a focus on the most vulnerable and under-served seniors, e.g.: - Age 75+ - Low and middle income - Medically complex - With Alzheimer's and other dementias
Health Cost
effective- ness
Personal satisfaction
• Mobility
• Mental health
• Cognition
• Comfort
• Autonomy
• Empowerment
• Respect
• Security
• Lower out-of-pocket costs
• Higher ROI for society
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Vitalize 360 – Key Component of Our Model
What Matters Most Coaching and assessment model supporting seniors to identify what is important to them and reach personal goals
Research Based Evidence-based assessment tool to with person-focused wellness plan
Software Supported Lifestyle survey, Health and
Social Check up, Vitalize Plan, reporting tools
Population Health Outcomes data for evaluation of individual and population health, benchmarking, and informed program design
The 360 View Health, nutrition, physical and
mental fitness, community, connections, spirituality, purpose,
learning
Innovative Solution Created by Orchard Cove,
expanded to 5 HSL communities, in partnership with Kendal,
Now in 33 communities and growing
HSL’s future approach will allow us to proactively reach more populations of seniors
Develop measures, metrics and tools to track outcomes 7
• Institute for Aging
Research
• ReAge Solutions
• Teaching Institute • Replicable model of
Affordable Housing with Supportive Services
• Brookline Master Planning
• Roslindale Campus
• Alzheimer’s Disease and Center of Excellence
• Prevention of Elder Abuse
and Neglect
• Home and Community-Based Services
• Continuing Care @
Home
• Shared Savings Initiatives
• Geriatric Care
Management Optimize our campuses
Primary and Secondary Aims
Goals Create a platform for housing and healthcare collaboration & measure effectiveness
Wellness Teams
Partners
Timing
R3: Right Care, Right Place, Right Time: Effectively Integrating Senior Care and Housing
Our vision is to create a replicable, scalable, and sustainable model of housing with supportive services to enable seniors to live independently as long as possible, receiving the right care in the right place at the right time, while reducing health care costs for this growing population.
Wellness Coordinator and Wellness Nurse
6 mo preparation period, 18 mo implementation
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Payers, hospitals, ASAPs, emergency service providers, mental health, housing
R3 Initiative: Total Funding, Scope, & Evaluation
Combined Funding Sources
of $1M
7 Senior Housing Sites
1,100 Residents 400 Enrollees
Health Policy Commission * MassHousing *
DHCD *
* Enterprise * Beacon Communities * WinnCompanies
HSL CCB Danesh * HSL CCB Cohen *
HSL CCB Goldman* Winn – TVAB *
* HSL - Fireman * MRE – Unquity House * MRE – Winter Valley
Evaluation / Research
UMass Boston * LeadingAge Collaboration *
* Pre/Post & Control Group * Impact Analysis
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Aims and Key Performance Indicators for R3 Ai
ms
Key
Perf
orm
ance
In
dica
tors
Increase utilization of wellness programs by 20%
Improve quality of life and ability to live independently by 10%
Reduce re-hospitalizations by 20%
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• Falls
• Wellness checks
• Medication adherence support
Health Cost
Effective- ness
Personal satisfaction
Increase linkages to mental health services by 20%
Reduce transfers to hospitals, emergency rooms, and long term care by 20% for target
population
• Wellness program attendance
• Health education
• Self-management/care
• Satisfaction with life and independence
• Transfers to long term care
• Transports to hospitals and emergency rooms
• Hospital readmissions within 30 days of discharge
R3 Initiative: Key Components & Current Status
Resident Engagement 400+ residents recruited across 7 sites
(210 Brookline, 190 Rand/Milt) Baseline assessments completed
Potential impact on all 1,100 residents
Wellness Teams 2 Coordinators & 2 Nurses embedded in housing
Trained in IRB and Vitalize 360 Analytics – PI team
Partnerships Emergency responders: data, training Housing: open door, recruiting
ASAPs: care managers, evidence based programs Health plans: care teams, sustainability Mental health: referrals, awareness
Programming/Health Education Targeted programs added
(brain health, med mgmt, falls prev, mindfulness) Vitalize coaching concepts utilized
Monthly newsletter Interventions
What matters most – assessments, risk groups Monthly check in calls/data gathering Supportive services teams, eyes on
Care manager collaboration and referral Transitions management
Research UMass Boston – design, ongoing
Control sites – 2 in process (baseline) Quant/Qual, Interv/Comparison
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R3 INITIATIVE: SUSTAINABLE MODEL OF HOUSING WITH SERVICES
POOLED FUNDS
ENHANCED SUPPORTIVE HOUSING WITH SERVICES
BETTER
OUTCOMES
SAVINGS
• Insurers
• Housing Providers
• State agencies
• PMPM, shared cost, or convener model
• Eyes on
• Emergency Response
• Care Coordination
• Community Services
• Assessment
• Wellness Programming
• Mental Health
• Nutrition
• Decreased hospitalizations
• Decreased Emergency Room visits
• Decreased Long Term Care Placements
• Decreased Falls
• Increased Medication Adherence
• Increased Self Care
• Increased use of Home and Community Based Services
• Pooled funds cover cost of wellness services
• Place based services result in savings to healthcare system
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HSL’S R3 INITIATIVE: IN THE NEWS
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