Editor’s note: The SCAN Foundation, The John A. Hartford Foundation, the Administration for Community Living, the Gary and Mary West Foundation, the Marin Community Foundation and the Colorado Health Foundation have united to fund a three-year grant to develop and establish the Aging and Disability Business Institute, housed within n4a. Under the grant, ASA and n4a are collaborating on a series of articles in Aging Today that will help to prepare, educate and support aging and disability community-based organizations and healthcare payers to provide quality care and services. This is the second in a series of case studies of organizations in the midst of evolving their business models.
Perhaps it has to do with being from the sparsely populated and self-reliant state of Maine, but Larry Gross has a commonsense, patient approach to integrated care. He serves as chief executive officer of the Southern Maine Agency on Aging (SMAA), an independent nonprofit organization that provides social and health promotion services to approximately 20,000 older adults and their caregivers annually.
An Award-Winning Business Innovator
Honored to recently receive the first John A. Hartford Foundation Business Innovator Award, Gross said that in Maine, “personal relationships are easy to establish, and you do things that are just commonsense.
“[The award] gave us great insight into the good work we’re doing,” he said.
Chief Executive Officer of the National Association of Area Agencies on Aging (n4a) Sandy Markwood spoke about the award at the 2016 n4a annual conference: “This award recognizes a social services agency that has made significant strides to partner with healthcare entities to improve the quality of life for older adults and-or people with disabilities.”
Fifteen agencies applied for the award, all of which were recognized at the conference, particularly the two honorable mentions—the County of San Diego Aging and Independence Services and Aging & In-Home Services of Northeast Indiana.
Southern Maine Agency on Aging was nominated by Dr. Elizabeth Johnson of the Maine-Health Accountable Care Organization, an independent LLC that coordinates healthcare for more than 1,400 providers and 10 hospitals in the MaineHealth system, as well as several independent provider groups, who singled out the Agency for the “tremendous leadership of Larry Gross,” and for “their innovative work and partnership with the MaineHealth ACO that meets the needs of their constituents.”
Gross’s agency has 85 full-time equivalent employees and a service area that includes about a third of Maine’s older adult population (100,000 people). It provides home-delivered and community dining meals, runs two adult day centers, manages a 150-bed assisted living facility for the local housing authority and operates a retired senior volunteer program with 450 volunteers. The agency is also the regional state health insurance program (SHIP) that helps people to understand Medicare. SMAA also offers several evidence-based health and wellness programs, including the Stanford-originated Chronic Disease Self-Management program, Matter of Balance, falls intervention and the Savvy Caregiver program. As well, SMAA sponsors the Maine Senior Games for 600 participating older athletes.
Healthcare Partnerships Based on Intention and Mission
Aiming to “position his agency away from the stagnant discretionary funding of the [Older Americans Act],” Gross says he wanted the agency’s revenue to grow as the numbers served grew, by connecting to Medicare, Medicaid and other programs where they would be paid as the amount of service rose. At the same time, healthcare entities were beginning to realize the importance of social determinants of health and saw a need for collaboration with agencies like his.
“We developed a number of contractual arrangements with local hospitals, health plans, and medical practices to embed our staff in their facilities, and collaborate in engaging older adults in the work we do [in evidence-based programming],” Gross says. The agency just finished a four-year Community-Based Care Transitions Program worth approximately $5.2 million that served 11,000 high-risk Medicare beneficiaries.
Gross also was motivated to “really address our mission to improve quality of life for older adults, and to work more closely with others who shared our interests,” he says. “As health systems move to a more global health perspective, they’re realizing the advantages of partnering with CBOs.” And he says older adults are interested in learning ways to address the social determinants of health that are destabilizing their lives, causing them to end up in the emergency room or with long hospital stays.
SMAA’s first step toward forming such partnerships was to cultivate champions of their work within the healthcare community. Gross asked heads of local health plans or hospitals to join the agency’s board of directors and then made a case for how SMAA’s s embrace of evidence-based health education and wellness programs provides a return on investment for health partners under the emerging Triple Aim paradigm.
Next Steps in a Long Process
As has been said of other successful managed care transitions, it was not a quick process for SMAA. Beginning in 2006, the agency, in partnership with MaineHealth and the University of Southern Maine, led the translation of the Matter of Balance program to a lay-leader model using trained volunteers as facilitator-coaches. The partners collaborated on analyzing the program’s impact, demonstrating that their outcomes matched or exceeded outcomes of Matter of Balance programs run by nurses and physical and occupational therapists, at much lower cost. The Matter of Balance Lay Leader Model program has now been adopted in 41 states and the Virgin Islands, serving more than 75,000 older adults.
Investments in the Savvy Caregiver program showed similar effects. Statewide, 2,100 people have been reached by the Savvy Caregiver program, which is directed to family caregivers of people with dementia. These caregivers have demonstrated improved competence, personal gain, meaning, self-efficacy and a reduction in negative reactions to the care receiver’s behavior at five months, post-program. These results were sustained at 12 months. SMAA has collaborated with Emory University to test Savvy Caregiver Advanced, a follow-on class for caregivers later in their trajectory.
MaineHealth partnered with the agency to document the impact of modifying SMAA’s home-delivered meals program, and was able to demonstrate a 17 percent reduction in 30-day admission rates for high-risk Medicare patients. SMAA used that data to approach a local Medicare Advantage plan as a partner, and it is in the process of developing that financial relationship.
SMAA has a three-year contract with a local hospital to co-sponsor the Matter of Balance program, and Welcome to Medicare classes. The hospital had found, when analyzing bad debt, that many older people who could not pay their hospital bills had not fully understood the cost-sharing details when signing up for Medicare plans. Plans in which patients pay a lower monthly premium but higher co-insurance (versus co-payment) share of the cost meant some older adults were unable to pay out-of-pocket expenses following a hospitalization.
But when SMAA volunteers walk Medicare patients through the open-enrollment process and explain plan features and their potential financial consequences, the hospital’s reputation in the community as an advocate, not a debt collector, is enhanced. SMAA has tracked the impact its staff and volunteers make for older adults during the annual Medicare Open Enrollment counseling sessions. It averaged almost $1,400 per person, per year, in out-of-pocket expenses for prescriptions, premiums and cost-sharing.
SMAA has also embedded a community resource specialist staff member within the medical practice InterMed, P.A.—the second largest in Maine—to conduct Matter of Balance classes and to work with older patients and family caregivers who need help accessing social services and entitlement benefits.
Challenges Faced and Lessons Learned
Gross says one of the biggest challenges facing agencies like his is to rise high enough on health plans’ priority list. Despite knowing that the community-based programming is solid and useful, health plans are wrestling with a lot of competing priorities like transitioning to electronic health records and improving the quality of care, so their priorities are not necessarily as urgent as SMAA’s. It is a continuing challenge to keep all parties focused until there is a signed contract.
Though it may sound obvious, Gross underscores the critical importance of asking for a contract. “Don’t do it for free. Sometimes we community-based organizations are just so delighted to be able to say we have a relationship with a health plan, with or without short-term funding, we don’t really start a conversation about sustainability. You need to have [a conversation] at the front end.”
The second big lesson the agency has learned through this process, says Gross, is the capacity of volunteers to perform in high-level paraprofessional roles throughout SMAA. “We realized that there are a lot of people who have the good fortune to retire in their early 60s, or late 50s, and are looking to make a difference in their communities. We’re training and engaging them as coaches in evidence-based programs and in Medicare counseling, where they get tremendous satisfaction out of teaching older adults how to save money on Medicare plans and in helping patients improve their general health status, which is very rewarding work.
“Last year, volunteers gave us nearly 80,000 hours of service, and this volunteer cadre allowed us to increase our service volume by 25 percent,” added Gross. This outcome greatly enhanced SMAA’s pursuit of their mission: “To create better days for older adults, people with disabilities, and those who care for them.”
Editor’s Note: This article appears in the January/February 2017 issue of Aging Today, ASA’s bi-monthly newspaper covering issues in aging research, practice and policy nationwide. ASA members receive Aging Today as a member benefit; non-members may purchase subscriptions at our online store.