Executive Office of Elder Affairs

State Innovation Model Grant (SIM-Grant)

Stakeholder Meeting

Update on Community
Links Portal

M o n d a y, S e p t e m b e r 2 9 , 2 0 1 4 2 : 0 0 P M - 3 : 3 0 P M

O n e A s h b u r t o n P l a c e
Vi d e o C o n f e r e n c e R o o m , 1 0 t h F l o o r B o s t o n , M A

Agenda

Project Context

Current EOEA sub-projects under SIM- Grant
SIMS – Senior Information Management
System

What is Community Links Portal (CLP)?

Vision: Bridging the gap & changing perspectives
Patient information visible on portal
Administration & Consent

CLP Demonstration

Implementation & Challenges

Pilot Group
Matching Patients to Consumers
Standardization & Promotion

Lessons Learned (so far…) Current Project Status Questions?

Four (4) EOEA projects under SIM-Grant

AGD – AFC/GAFC Determination Streamline

Section-Q Reporter

Community Links Portal

Professionals

Connector
Community Links
Portal: Professionals

SIMS

SIM
Grant

Section Q notifications

Caregivers

Formerly: Physician Portal
SIM
Grant

Senior Information Management System

Service Hub

Secure User Portal

450 Nursing Facilities

SIM
Grant

Professionals

Community Links Portal:  Caregivers

Formerly: Caregiver Connect

EOEA’s HCBS system-of- record for state Home Care Program & Frail Elder Waiver

SAMS	Provider Direct

System-to-system exchange

ADRC Referrals

ADRC Refer als ADRC Referrals
11111I1LILCILCCss

SIM
Grant

AFC & GAFC
Providers
220 orgs

11 ILCs

ASAPs/AAAs

3

AADDRRCCRReeffeerrrraalsls 11 ILCs
27 orgs

ADRC Referrals

1   ILCs

ADRC Referrals

Direct-service Providers
ASAP co1n1traILctCorss; 300 orgs

SIMS (Senior Information Management System)

Statewide consumer database
Administered centrally
Standardized data
Managed locally by ASAPs

27	Aging Services Access Points	

(ASAPs)	

2,900	
SIMS users: Case Managers, RNs	

(5,500 total active users)	

42,000	Active Home Care consumers	

Average per month, active state/Waiver programs	

What is the Community Links Portal?

Vision: Bridging the gap & changing perspectives

HCOs have limited knowledge of ASAP system & function

Value of ASAP comprehensive
data source

CLP was ASAP group initiative
(Mass Home Care)

Patient Information Visible on Portal

Based on regular Home Visits (180 days or less)

Consumer information, including
informal supports

Service Plan

Clinical information: self- reported meds, ADLs & IADLs

High-quality documentation, with interdisciplinary case review at ASAP

What is the Community Links Portal?

Administration & Consent

ASAPs – easy data update to make patient info (in)visible
Light support burden
Easy for ASAP to add org
User management is delegated to Health Care Organization
CM gathers consent, updates record to make it visible in CLP
New standardized protocol: Informed consent forms updated for all home- care

Executive Office of Elder Affairs

CLP Demonstration

Executive Office of Elder Affairs

Community Links Portal: Screenshot #1

Screenshots of the
Community Links Portal

•Left-hand: full frame view of the portal (7 total)

•Right-hand side: same screen, cropped & zoomed to better show content of interest

Executive Office of Elder Affairs

Community Links Portal: Screenshot #2

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black & white I stuU\1"  dark	Constuner list I  1anage U sers I  1r Accotm!   log out

Xample Healthcare, Inc.

Community Links Portal· Xample Healthcare, Inc.

James Example

Abate, Sam
119 Wesn,·ood Road, Peabod·, 01960
(445)  950--4785

Primarv Care Manager: lama ­
Default Agenc·: Korth Shore Elde
Agency Phone:

Abate, Sam
119 Westwood  Road , Peabod1·, 01960
(445) 950--1785

Pnmarl" Care Manager: laura eckman (01)
Deiault Agencl":1\orth Shore Elder Sen·ices, Inc.
Agencv Phone: (978) 750-4540

DOB: 10/30/1926 (87)
I

DOB:10/30/1926 (87)

Current Services

Personal Emerge tcv Response Sp (:'.lonthlv) -1tuut (Cmt Tvpe = lonth) monthly
Homemaker- 8.00 tmits (Unit Type = 15 Minutes) weeklv (Fri: 8.00)
HDM Meal lunch Weekday Hot - 3.00 tuuts {U11it Type= Meal) weekly (Yion: 1.00 Wed: 1.00 Fri:
1.00)

Assessment Date:9/10/2014 Comments
Cm conducted an ammal home 1·isit with ell and dil on 3nO/l4. Ot was appropriately dressed  and groomed and her home was neat and clean.All necessary papen   ork was signed and completed.Public benefits were discussed.Clts fuel assistance application was se tl in by SIL She stated that while they did not receive an appro1·al letter it appears as though they were appro1·ed as she has a $1000 credit 011 her gas bill. CM called fuel assistance and spoke to a representative who stated that the application ,,as receil"ed but has not bee11 processed yet. CM relayed this informati011 to Sandi and suggested that she contact the Gas Company in regards to the credit.

Cit denies any rece1!falls or hospitalizations.Ot reports that her appetite is good and she sleeps "·ell. Clts last visit with her PCP, Dr. Ford,was at the end of the summer and has another scheduled for some time inJanuary. Sandi reported that the elder will be going back to her fomter

Executive Office of Elder Affairs

Current Services                                                                                          I

Personal Emergency Response Sys (Monthly) - 1tuut (unit Type = Month) monthly
Homemaker - 8.00 tmits (UtutType = 15 :tvlinutes) weeklv (Fri:8.00)
HDM Meal Lunch Weekday Hot - 3.00 tuuts (Utut Type = :Meal) weekly (Mon:1.00
1.00)

Assessment Date: 9/10/2014

Comments

Cm conducted an annual home visit with clt and dil on 3(10/14. Clt was appropriate and groomed and her home was neat and dean.All necessary papenvork was signe completed. Public benef its were discussed. Clts fuel assistance application wa.s sent stated that wlule they did not receive an approval letter it appears as though they w

Communi	Links Portal: Screenshot #3

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support system, which continues tobe strong. assist in all other areas including some shopping.
transp01tation,escort,financial and  medication management.

Ot currently receives 12 muts of home making provided bv lndepet1dence. Clt stated that she
does not feel comfortable witl1 the hometnaker tl1at is currently providing sen·ice for her.The clt
and dil requested a new worker. CM called John who fertmd a new \\'Orker,named AleX<\ who

an provide service for the clt on the same day and time, \ eds mornings. Clt also receive
)£ cab rides monthly provided by Yellow Cab, as well as a PERS, 1tmit monthly,provide
Lifeline which is now paid for by Mass Health. Clt denies the need from additional servic
:une.CSP remains appropriate. Next home visit will be 6/H.

can provide senice for tl1e clt on the same day and time, Weds momings.Clt also receives 4 tutits of cab rides monthly prot·ided by Yellow Cab, as ,,·ell as a PERS, l tutit monthly, protided by lifeline which is now paid for by Mass Health. Cit de1ties the need from additional sen·ices at this time.CSP remains appropriate.Next home visit will be 6[14.

Memory loss Screen Score=O,1,or 2 possible
impainnentj J,-l,or 5 S!tggests !to impaimmzt

Indicate the date of the
03/10/2014

Physical Findings

Estimated Height

59
U1Chr

Memory loss Screen Scort=O, 1,or 2 possiblt impairmtn J, l,or5 snggrsts no impaim tnt

Physical Findings

59

Memorv Loss Screen

Indicate the score of the
3
Memorv loss Screen

Estu11ated  Weight 	142 1
Pain

Indicate the date of the Metno1v loss Screen Indicate the score of the
Metnorv loss Screen
h1dicate the reason for the
Memonr loss Screen

03/10/2014

Annual

Estimated Height
inches
Estimated Weight	142lbs.

Pain

Frequencv with wltich client
Pain complains or shows evidence

Indicate the reason for the
Ammal
Memorv loss Screen

Responsibility I Advanced Directives

Frequency with which client
Pau1
complains or shows evidence
daily of pain

Responsibility I Advanced Directives

of pain

daily

Client has a legal guardian	Yes

Intensity of pain	Mod•

Oient has a legal guardian	Yes
Paul

lntet1Sily of pain	Moderate From client's point of t·iew,
pain intet1Sily disrupts usual	Yes

Paul
Legal Guardian's Name
Abate

From client's pou1t of view,
pain intensity disrupts usual	Yes
activities

legal Guardian's Name

Abate

actit-ities

localized

Local

Visits in last 90 Days or Since last
Assessmen t

Owacter of pain	- single site

Visits in Last 90 Days or Since last
A ....> ..c:m > n t

Character of pau1	- smg

Nwnber  of  times ADMmED TO HOSPITAl with an ovenught  stay

From tl1e client's point of
t-iew, medicatio11S adequately    No pain control pain

Community Links Portal: Screenshot #4

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Self-Reported  Medications

PERFORMANCE CODE- MANAGING MEDICATIONS-How

Self-Reported Medications

PERFORMANCE  CODE- MANAGING  MEDICATIONS-How
medications are managed (e.g., remembering to take medicines,	Done \\"ith help opening bottles,taking correct dmg dosages,giving it ections,	some of the time applying ointments)
DIFFICULTY CODE- MANAGING MEDICATIONS-How
medications are managed (e.g., rememberit 1g to take medications,
Some difficulty openit1g bottles,takit1g correct dmg dosages,giving it ections,
apphng oit1tments)	

Name	
Dosage	
Fom1 (Route of
Administration)	
Frequ ency	Taken as needed (PR:'II)	
Comments	

Calcium	600
Milligram
(mg)	
by mouth (PO)	
(BID) twice dailv
(ewry 12 hours)	
No	
supplement	

Bayer	81
Milligram
(mg)	
bv mouth (PO)	
(PRN) as
necessary	
No	
pain, blood thim1er	

Fosamax	70
Milligram
(mg)	
bv mouth (PO)	
(QD or HS) once daily	
No	
osteoperosis	

Acetomenaphen	325
Milligram
(mg)	
bv mouth (PO)	
(PRN) as
necessarv	
No	
pam	

medications are managed (e.g., remembering to take medicines, opening bottles, taking correct drug dosages, giving injections, applying ointments)
DIFFICULTY CODE - .MA    AGING MEDICATION S-How
medications are managed (e.g., remembering to take medications, opening bottles, taking correct drug dosages, giving injections, applying  ointments)

Name	

Dosage	
Form (Route of
Administration)	

Frequency	Taken as needed (PRN)	

Conu	

Calcium	600
Milligram
(mg)	

by mouth (PO)	
(BID) hvice daily
(eve1y 12 hours)	

I No	

suppl	
	81		
--- -			

I

Communi

	
Mood and Behavior Pattems

A FEELING OF SADNESS OR
BEING DEPRESSED-that life
is not II'Orlh living, that	Once or
nothing matters,that he or she   twice is of no use to anvone or
1\'ould rather be dead
PERSISTE NT ANGER WITH
SELF OR OTHERS-e.g.,easil1·   Not atmoved, attger at care	exhibited receil•ed
EXPR ESSIONS OF WHAT APPEAR TO BE
Not
UNREALISTIC FEARS-e.g,
exlubited fear of being abandoned,left
alone, being "·ith others
REPETITIVE  HEALTH
COMPLAINTS-e.g.,
Once or
persistentlv seeks medical
l11ice attention,obsessive concem
"'ith bodv  functions REPETITIVE  ANXIOUS COMPLAINTS,CONCERNS--
e.g.,persistently seeks
Once or
attention/reassurance
l11ice
regarding sdtedules, meals,
latmdry, clothing, relationship issues
SAD,PAINED,  WORRIED
Once or
FACIAL  EXPRESSIOl\5-e.g.,
l11•ice fmrowed  brows

RECURRENT	Not	Home Environment • Living Space Hazards

Heating or cooling problems Flooring or carpeting problems

Infomtal Support Services

Abate,
Primary Helper
Gladys
Li1·es ll'ith client	Yes
Relationship to client	Spouse
Ifneeded, willingness (11·ith
ability) to increase help with	No advice or emotional support
More
Ifneeded, willingness (11'ith
thm2
ability) to increase help ll'ith
hours
ADL care
per day		

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Mood and Behavior Pattems	Home Environment ·living Space Haza

A FEEL IKG OF SADNESS OR	Heating or  cooling  problems
BEI   G DEPRESSED-that life		Flooring  or carpeting problems is not wotih living, that	Once or
nothing matters, that he or she   twice	Infom1al Support Services
is of no use to anvone or
would rather be dead	Primary Helper	Abate,
Gladvs

PERSIST£  T ANGER WITH
SELF OR OTHERS-e.g.,easily	1\ot	Lives with client	Yes aJ.moyed, a11ger at care	exhibited	Relationship to client	Spouse received		If needed, willingness (with
EXPR ESSIONS OF WHAT	ability) to ilmease help with	No

APPEAR TO BE		advice or emotional support 1\ot
UNREALISTIC FEARS-e.g,	exhibited	More
fea1·of being aba11doned, left	If needed, willingness (with	thaJ.l 2
alone,being with others	ability) to ilmease help with	hours
ADL care

REPETITIVE HEALTH
COMPLAINTS-e.g.,

per day

Communi

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IADL (Instrumental Activities of Daily Living)

Perf ormance Code, difficultv,who helps, device needed,type of device or mode (when
indicated)

Meal preparation
Done with help all of the time, Some diffimlty
Housework, Ordinary
Needs assistance most of the time,Great difficultv
Housework, Heavy
Does with maximum help
Manage finances
Needs assistance sometimes, Some difficulty Telephone use
Independent, No difficultv
Shopping
Done 11·ith help all of the tin1e, Great difficult\• Transportation use
Done with help all of the time, Great difficulty

ADL (Activity of Daily Living)

Perf onnance,difficulty, who helps, device needed, tvpe of assistance I de1ice I applicances/ medical equipment

Mobilitv in bed
Independent
Transfer in/out of bed/chair
INDEPENDENI - but experiences difficulty
Locomotion in home
Uses device
Locomotion outside of home Linuted  assistance

Shopping

Done '"ith help all of the tin1e, Great dlifficull0

Transportation  use
Done with help all of the time, Great dlifficttli0

ADL (Activity of Daily Living)

Perfor1nance, difficulty, who helps, de\ ice needec

1nedical equipment

JVIobilitv in bed

Independent

I

Transfer in/out of bed/chai1:
INDEPENDENT - bt1t experience-s difficull0

Locomotion in home

ses device

Locomotion outside of hotne

Litnited assistance

Community Links Portal: Screenshot #7

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Home Evaluation 9/14/2014

During most recent 1·isit,Care Manager noted that railing on stairs from first to second floor is in need of repair. One of the balusters appears to have loosened from the handrail. CM asked COllStuner if she would be agreeable to having this fixed,and she said this has been needed for some time.C will approach superYisor for increase in sen·ice plan to pav for home repair services and update record once repair is scheduled.

Laura Teckman (CM)
1\orth Shore Elder Sen·ices, h1c.

Risk Evaluation 9/14/2014

Care Manager Update
Recent phone call with constuner about a service issue became a discussi011 regarding her fear of falls. She has indicated in the past sewral assessments that she prefers not to venture outside due to this perceived risk. She explained that she was recently inl'ited by a neighbor for ltmch and declined because of this. Various options to address this were discussed,as it hasbecome apparent that her level of socialization has decreased in recent vears.She feels that her quad cane is adequate for getting arotmd outside,but going anvwhere bv herself "doesn't feel safe."She doesn't feel that asking her elderly neighbor to walk her over is appropriate,and her daughter-in-law is frequently tmavailable during the day.She was asked if the PERS button ga1·e her a sense of security, and she replied that she "wouldn 't want to bother tl1ose nice people" who manage tl1e service. She was assured that this is their main ftulction.She was also told that she should not 1·enture out if she was not comfortable with the idea. Eventually she decided that she would ha1·e her neighbor over for ltmch next week and discuss the issue.

Laura Teckman (CM)
N01th Shore Elder Sen·ices, h1c.

Retum to Consumer List

Executive Office of Elder Affairs

Implementation & Challenges
ASAP initiates contact -> Signed Organizational Agreement -> Submits to EOEA

Pilot Group

10 signed organizational agreements
Varied group of HCO types & plans for usage
Implementation pace dictated by partners (with EOEA’s encouragement)

Matching Patients and Consumers

Challenge #1 – no quick and easy method
ASAPs can initiate process with database reports
Small starter group / Initial larger batch / ongoing process

Standardization & Promotion

Evolving “Quick Start” implementation
ASAPs must see benefit outweighing effort (project lead, gathering consent..)
Existing relationships key

Executive Office of Elder Affairs

Lessons Learned (so far…)

CLP – Health Care Organization Types:
Standard Physician’s Practice
Community Health Centers
Large Providers with Multiple Sites
Hospitals

CLP – Different Applications:
“Standard” Use – Physician’s Office
CCTP Tool (Boston Senior Home Care)
New Program Initiative (Elder Services of Worcester)

Feedback
Recognized as high value information
HCOs love up to date service data!
Dedham Medical Associates:
CLP part of routine roster reviews (standard operations) with MDs, SWs
Nursing Managers use CLP information to supplement phone contact with ASAP

Executive Office of Elder Affairs

Current Project Status

10 Signed Partnerships	(ASAP – HCO)

HVMA/Chelmsford
ESMV

HVMA/Beverly [9] Northeast PHO [26]
North Shore Medical Center NSES/SCI
Dr. Mark Messenger NSES/GLSS

HVMA/Medford
MVES

Reliant Medical Group ESWA

HVMA/Kenmore
[10]
BSHC

Manet Community Health SSES

Dedham Medical Associates [62] HESSCO

Executive Office of Elder Affairs

Questions?

Thanks!

Contacts
EOEA Project Leads: Jim Ospenson
James.Ospenson@state.ma.us

Andy Grigorov
Andy.Grigorov@state.ma.us

Executive Office of Elder Affairs