1 Care Coordination Workgroup Meeting #1 for Aging Action

Care Coordination Workgroup Meeting #1
for Aging Action Initiative (AAI) of Marin County
Meeting of October 6, 2014
20 N. San Pedro Rd. #2016
1:30pm to 3:30pm
Participants:
Sharon Jackson, Marin General Hospital
Brian Alexander, Novato Community Hospital
Nancy Masters, Jewish Family and Children’s Services
Deanna Euritt, Novato Human Needs
Pam Osborn, West Marin Senior Services
Eli Gelardin, Marin Center for Independent Living
Mitesh Popat, Marin Community Clinic
Ana Bagtas, Marin County Aging and Adult Services
Steve Siegel, Coastal Health Alliance
Lee Pullen, Marin County Aging and Adult Services
Shelley Hamilton, MarinSpace
Gary Lara, Marin County Aging and Adult Services
Invited/Unable to attend due to schedule conflicts:
Lynn Von der Werth: Sutter Care at Home
Lisa Brinkmann: Marin Village
Teri Rockas: Healthy Marin Partnership
Andrea Kmetz: Meritage Accountable Care
Linda Tavaszi: Marin Community Clinic
Reverend Carol Hovis: Marin Interfaith Council
AAI Definition:
A County wide age-friendly environment, especially for those in need, collectively created by a
strong network of aging service providers through public education, policy advocacy and service
coordination.
Outcomes:
a) Shared understanding of the context
1
b) Shared understanding of the workgroup’s scope, focus, objectives and timeline
c) Identification of participant strengths and participation benefits
Welcome and Introductions:
Lee Pullen, Aging and Adult Services Director for Marin County, opened the meeting by
welcoming and thanking the participants for being part of the Care Coordination Workgroup and
spoke briefly about the AAI project and its objectives and goals. The meeting was turned over
to faciliator Shelley Hamilton from MarinSpace who asked participants to introduce themselves
and share something about their organization and background.
Meeting Agenda and Outcomes:
Shelley Hamilton stated the Aging Action Initiative will be focusing on two distinct time lines; a 6
month initial planning period for projects and a one year action plan. Details are as follows:
Action Planning: setting context for the 6 month process Process/Milestones Workgroup launch (Oct.)
Identify possible actions (Oct. / Nov.)
Cross-pollination, convening (Nov / Dec.)
Develop action plans (2-3 mtgs.)
Synthesis convening (Jan. / Feb.)
Focus Areas Nutrition and food insecurity
Mental Health and Wellness
Dementia and Cognitive Impairment
Care and Information Coordination (service, access, referrals, etc.)
Economic Gap Research
Objectives Transitioning into action
Build and strengthen relationships
Identify 1 to 3 “doable”, 1 year “pilot” actions
2
Year One Actions:
Scope 1-3 “pilot” actions launched or completed
Policy recommendation and/or Advocacy Plan
Funding identified and/or secured
Program/service coordination plan
Joint education, outreach, I&A, I&R
Summarization:
Action plan implemented after one year with the objective of building strength in relationships.
Participant Observations:
Shelley Hamilton asked attendees to write down one thing they are hopeful about and
something they have a concern or “pause” about in regard to their participation in this
workgroup. These are noted as follows:
Items to Anticipate 1)
2)
3)
4)
5)
6)
7)
Meaningful collaboration established
Better coordination among resource partners
Better connection of services for seniors
Addressing transition care
West Marin Senior Services included on par with other areas
Meaningful impact on people’s lives
Defined roles of this group
Items of Concern -
1)
2)
3)
4)
5)
6)
7)
8)
9)
No significant outcome or impact even after a meaningful discussion; no action taken
Miss helping the broader population
Time commitment and practical follow-through
Not having well-defined case management
Hospital to home transition too broad
Exclusion of funding sources
Competing priorities
Not clear on issue; measurable output
How much time can people commit?
Shelley commented that it is important to stay flexible and develop trends as we move forward.
This workgroup will find a balance to start with which is not the “whole” or the “end.”
3
Other Planning Initiatives in the Community:
1)
2)
3)
4)
5)
6)
7)
8)
Area Agency on Aging Area Plan Update, FY 2015-2016 (spring 2015)
Health and Human Services enhanced update for Information and Assistance Services
Senior Access Strategic Planning Advisory Group meeting facilitator
Age-friendly Community Task Forces
Whistlestop 2.0 (replace existing establishment with housing, active aging center)
Marin Villages
Marin Community Foundation strategic planning
Housing Authority – alternative housing options that are affordable; create vision of
hiring person to oversee public housing (triage person)
9) Crisis mobile response
10) Revitalization vision for Golden Gate Village (communication starting)
11) Healthy Marin Partnership
12) Medicare ACO – 1st Year implementation / data exchange
13) Coordinative Care Initiative – on horizon
Context:
What is the challenge and need description? What parameters should be put in place? Social
isolation is the key to alot of problems; e.g. emotional well being.
Challenge/Need Description 1) Small number of big users with complex issues
2) Legitimate silent group of need not connecting
3) Navigating I&R, I&A, Care Coordination, Case Management
Drivers/Barriers 1) Many different but overlapping systems
2) Lack of coordination among coordinators
3) Lack of connecting between community and medical
4) Uncomfortable with technology
5) Different Systems, different goals
6) High staff turnover; constant re-education
7) IT System is complex but not there (consumer / provider)
8) Overall management healthcare puts limits on systems
9) Not connected to other social services
10) Small transition funding
11) How to find out about what’s out there
12) Lack of case management; “light” check-ins
13) Need to link with postal service, police, etc. for referrals
14) Need ongoing training and support which is time consuming
15) Need management resources
16) Not all have informed coordinated stats, senior specialist, discharge planner
4
Assets/Contributions/Give - What is it your organization can get out of the process
and what can you bring to the table?
1) Multiple service programs equals many check-ins for coordinated services
2) Services exist and are good; no duplication in West Marin
3) Small county with good relationships
4) Existing strong programs
5) Well educated with strong volunteers
6) CASS and Bridges meetings
7) Existing research
8) Strong motivation and will
9) Family Caregiver Support Group
10) Volunteers equal check-in options
11) Disablity Benefits website
12) Increased efficiency
13) Something I can’t do alone
14) Community knows where to go for information
15) Better discharge services makes staff happy
16) System to know what’s working
Parking Lot (items tabled for further discussion) 1) A system of empowered users / dynamic system
2) Updated inventory
3) Follow-up with absent participants
Homework for Participants:
Get input from your staff; reach out to your network and inquire about what’s working and what
is not.
Next Steps:
2nd workgroup meeting date will be announced later this week. Covening date scheduled for
Tuesday, November 18th; time and venue to be announced soon.
Questions may be sent to Shelley Hamilton at [email protected] or Lee Pullen at
[email protected]
Meeting Facilitator: Shelley Hamilton
Minutes taken by: Gary Lara
5

Download Report