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Spotlight on Innovations and Achievements: Elder Options

Learn how this Florida AAA partnered with a local hospital to help provide physical and mental health assistance, information, services and resources to older adults and people with disabilities who are just released from stays at a hospital or rehabilitation facility and need help while they recuperate in their own homes.

We're proud to highlight the award-winning work of the 2020 winners of n4a's Aging Innovations and Achievement Awards in this weekly spotlight feature. This week, we are focusing on Elder Options' Take Charge program. The agency was a 2020 Aging Innovations Award winner in the Health-LTSS Integration category. The AIA Awards are made possible thanks to the support of Centene.
 
Discharge from any care setting is a critical and vulnerable time for older adults. AAAs have long recognized the seriousness of this issue and have been on the forefront of developing effective strategies to make smooth transitions more commonplace. Since 2015, the Elder Options Take Charge program has contracted with University of Florida Health (UF Health) to provide a care coordination intervention to patients identified by the hospital as individuals who use the health care system with extraordinary frequency and have high health care costs.
 
Take Charge coaches regularly noted that many of their clients experienced depressive symptoms in addition to having a chronic disease. To address the issue, Elder Options integrated Program to Encourage Active and Rewarding Lives (PEARLS), an evidence-based depression management program targeted to adults age 60 and older and their caregivers, into Take Charge in 2018.
 
Based on data collected by UF Health, in 2018, hospital admissions for patients receiving PEARLS services decreased by 32 percent and emergency room visits decreased by 11 percent. The Patient Health Questionnaire-9 (PHQ-9), a depression screening instrument, now is incorporated into the overall “Take Charge Healthy Living Program Assessment” and administered to all Take Charge clients. Clients scoring high on the PHQ-9 are referred for PEARLS services so their social and psychological needs can be addressed alongside physical issues. PEARLS services have provided a measurable health benefit for Take Charge patients and have resulted in reduced medical costs for UF Health and insurers.
 
This program has allowed us to reach individuals who may not have heard of Senior Services. Once connected, we introduce them to a myriad of resources, including chronic disease and fall prevention workshops, Medicare counseling, small equipment to monitor their health as well as in-home assistance and home delivered meals,” said Katina Mustipher, Chief Operating Officer of Elder Options. “The Take Charge program has reached not only clients but the professionals who also engage in their care such as primary care physicians, pharmacists and home health agencies.”
 
Prior to the COVID-19 pandemic, Take Charge coaches were able to attend doctor appointments if asked by the client. This service is especially beneficial for those who live alone and do not have family members or friends. “We helped a client who is unable to read and write and was not comfortable revealing this to their physician. The Take Charge coach was able to go to the appointment with the client and worked with their pharmacist to develop a color-coded system to help the client understand when to take each medication as prescribed,” said Mustipher.
 
With permission from the developers at the University of Washington, Elder Options has been providing the PEARLS program virtually during the COVID-19 pandemic. To allow coaches to work remotely, all coaches have been equipped with cell phones, as well as “soft phone” interfaces that allow them to conduct visits over the internet. If clients do not have a computer and/or Wi-Fi, 15 tablets are available for clients to check out. Elder Options has seen an increase in referrals to the overall Take Charge program since the start of the pandemic.
 
Data collected by UF Health on the positive benefits of introducing PEARLS services to patients being released from the hospital can help persuade local health care facilities of its effectiveness. When approaching hospital administrators about testing a Care Transitions intervention with a PEARLS component, emphasize the potential cost savings.
 
To learn more about Elder Options' Take Charge program, contact Kristen Griffis, griffisk@agingresources.org.
 
For more information about the 2020 winners, see the press release and read the book of winners! To read about past winners and find other best practices for your agency to consider, visit our Best Practices page.

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