WATERTOWN, MA – November 19, 2013 – The Massachusetts Healthy Living Center of Excellence (HLCE), a collaboration between Hebrew SeniorLife and Elder Services of the Merrimack Valley, announced today that it has secured more than $1.3 million in funding over three years from the Tufts Health Plan Foundation and the John A. Hartford Foundation. The grants will fund a centralized infrastructure and six new regional coalitions to expand disease management and wellness programs across the Commonwealth and improve the way community based groups, health care providers and consumers work together to improve care.
This infusion of private funding will enable the HLCE to address the growing need for health care consumers – mainly older adults – to better manage their chronic conditions and become active participants in their own care. According to a Health Policy Brief published in the February 2013 issue of Health Affairs, people actively involved in their health and health care tend to have better outcomes and incur lower costs.
The HLCE aims to accomplish this “triple aim”—better care, better health outcomes and lower costs – by making evidence-based disease management and wellness programs more easily replicated and sustainable across the Commonwealth, and making it easier for health care providers to refer their patients to these programs. Evidence-based programs, typically offered in community-based settings like senior centers, area agencies on aging, community health centers, hospitals, etc., focus on topics such as chronic disease self-management, healthy eating, physical activity, fall prevention, family caregiving and more.
“The HLCE is in essence creating an integrated delivery system in which health care systems, community-based social services and older adults collaborate as partners to improve care and lower costs,” said Jim Roosevelt, president of the Tufts Health Plan Foundation and CEO of Tufts Health Plan. “With all eyes on health care reform, this new model has the potential to set the stage for national change in the way health care is delivered and embraced.”
Until now, the HLCE has been funded through federal and state grants including start-up funding from the National Council on Aging in collaboration with the Massachusetts Executive Office of Elder Affairs (EOEA) and Massachusetts Department of Public Health (DPH).
Why It Matters
Based on research and tested models, evidence-based programs are proven to significantly help people with chronic diseases – such as hypertension, arthritis, heart disease, stroke, lung disease and diabetes – by empowering them to make lifestyle choices and behavior changes, adhere to prescribed medical treatments, and become educated, responsible and informed consumers.
A recent national study from Stanford University on the effectiveness of its chronic disease self-management program – the same program offered by the HLCE – showed a number of positive outcomes including a 41 percent increase in participants who are “moderately active” and a $740 per person cost reduction in hospital and ER utilization.
This is important because The State of Aging and Health in America 2013 report from the Centers for Disease Control and Prevention shows that two out of three older Americans have multiple chronic conditions and 95 percent of health care spending for older adults is attributed to chronic disease. Since the HLCE was founded in 2008, its programs have reached more than 7,500 participants throughout Massachusetts, yet this number represents less than .02 percent of all cases of chronic disease in the Commonwealth.
“HLCE is an example of why a focus on healthy living – in particular, prevention and self-management – is such an integral part of the Affordable Care Act,” said Rosanne DiStefano, executive director of Elder Services of the Merrimack Valley. “There’s huge opportunity with this funding to expand the volume of referrals to and participation in evidence-based programs, making consumers active members in their own health care and furthering the triple aim.”
How the HLCE Works
The HLCE’s centralized approach to program dissemination is based on a virtual hub through which it will provide referral support and program enrollment as well as training, evaluation and other tools to ensure the quality, integrity and efficiency of community-based programs.
The HLCE will then work in collaboration with six regional coalitions across the Commonwealth, each of which will include representatives from health care systems and plans; governmental agencies; area agencies on aging, councils on aging and aging service network providers; local community health centers and health departments; business and industry; and faith-based organizations. Coalition members will work together to disseminate evidence-based programs to older adults in their regional communities, sharing in-kind resources to fill any holes in program availability and ensure program fidelity.
The HLCE has selected lead regional agencies to coordinate in each geographic market. These include Elder Services of the Merrimack Valley in Northeastern Mass.; Ethos in Boston; BayPath Elder Services in MetroWest Mass.; Elder Services of Worcester Area in Central Mass.; Franklin County Home Care Corporation in Western Mass., and Old Colony Elder Services in Southeastern Mass.
Integrating with Health Care Providers
Traditionally, community-based social service agencies lacked the business structures, technology and security protections needed to be effective partners in integrated care systems for older adults. While these organizations have shown efficacy in implementing evidence-based programs, medical providers are generally unaware of program availability and even less aware of when their patients participate in programs.
One of the ways the HLCE aims to address this challenge is through its medical director, Dr. Robert Schreiber, whose role is to educate providers on the value community-based organizations bring to the health of their patients. As an experienced geriatrician, Dr. Schreiber will also help physician groups and other health care systems to target those high-risk elders appropriate for evidence-based self-management programs. HLCE’s centralized hub will then be available to the medical practices for referral and scheduling purposes.
“Providers don’t have the bandwidth to help patients become active members of their own health care, regardless of whether a patient is newly diagnosed with a chronic disease or has slipped five years in his or her management of it,” said Dr. Schreiber, who is Hebrew SeniorLife’s medical director of Outpatient Primary Care Practice, Community-Based Programs, Innovation and Development. “By linking physicians to community-based agencies, we’re offering providers another tool to help their patients in a system that’s overburdened.”
“The health-promoting services delivered through community agencies are serious ‘treatments’ that need to be a part of the plan for older adults,” said Christopher Langston, PhD, program director for the John A. Hartford Foundation. “With this grant we see tremendous potential to make community-based programs part of the continuum of care so that older adults can maintain their health and independence.”
“The evidence-based model works in part because of its community focus, taking consumers out of the hospital and providing practical, hands-on skills in a group setting which encourages peer support, discussion and problem solving,” said Ruth Palombo, senior health policy officer for the Tufts Health Plan Foundation. “What’s more, when people know how to manage their chronic diseases, they feel better. And, if they feel better, they’re more likely to participate in their communities, volunteer, spend time with their grandchildren or pursue other purposeful engagement activities that reduce isolation and depression.”
About the Healthy Living Center of Excellence
The Massachusetts Healthy Living Center of Excellence (HLCE) aims to help older adults remain independent and in the community as long as possible through the use of proven evidence-based programs that promote behavior change and encourage older adults to become active partners in managing their own health. Combining expertise in both the aging services and medical networks, the HLCE is led by Elder Services of the Merrimack Valley and Hebrew SeniorLife, and offers a centralized infrastructure and regional coalitions that will make evidence-based disease management and wellness programs more easily replicated and sustainable across the Commonwealth. For more information about HLCE programs, visit http://www.healthyliving4me.org/.