Goal:

Our goal is to connect more adults and disabled persons with resources that will allow these persons to remain as independent as possible in the least restrictive environment, and in turn reduce the number of nursing home and also hospital/emergency room admissions. We also assist individuals who are in need of the PASRR process for nursing home admission. Adult Evaluation and Review Services is a program that links individuals (mostly non-Medicaid) to resources in the community that they probably were not aware were available or that they qualified for.  We offer nurse and social work oversight when the evaluations are completed (most visits are done in the client's home).  Some of the many things we assist people/connect them with are: Alzheimer's Resources, assisted living, cancer programs, dental and denture referrals, chore assistance, senior care, food banks, food stamps, home-delivered meals, vision assistance from the Lion's Clubs, medbank, medical equipment, mental health, national family caregiver program, nursing home placement,  personal emergency response systems, private duty caregiving agencies, short term medication program, smoking cessation, transportation, and veterans administration. The goal is to allow clients to stay in their homes longer and enjoy the best health using the resources available to them.

Strategy Description:

The AERS program is implemented through the local health departments. They conduct long term care evaluations of those persons with health, pyschosocial, and functional impairments who are at risk of institutionalization, to determine the most appropriate services to meet their health needs in the least restrictive setting.   The staff provides a comprehensive health and social assessment of the over age eighteen/disabled population (target population being 60 and over) in order to determine which community and private resources will meet their individual needs. We also assist individuals with the PASRR process when seeking nursing home placement and assist nursing facilities with interpretation of the PASRR rules and regulations/processes. Strengthen relationships with community referral sources to increase participation from the community.

Level of Change:

Programs

Primary Focus Area:

Access to Care and Linkages to Community Resources

Data Category Tag:

GCHD AERS

Strategic Planning Alignment:

Estimated Implementation Date:

2017-01-02

Estimated Completion Date:

2022-12-29

Estimated Ease of Implementation:

Moderate

Estimated Cost of Implementation:

Moderate

Potential Community Benefit:

High

Health Equity:

Research:

By connecting individuals with resources in the community, the number of nursing facility and hospital/emergency room admissions in the community has decreased or delayed.  This benefits both the individuals who are more comfortable and recover more quickly in the least restrictive environment, and the community.  It also benefits the local hospital by assisting people with services that then decrease the need for emergency room visits and hospital admissions/re admissions. The hospital now has staff whose specific goal is to decrease repeat visits to the emergency room, and they often send referrals to AERS to help these patients find resources to assist them (many times these referrals from from the hospital to MAP, and from MAP to AERS).

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Contributing Community Participants

Bevian Hensley (MD), Juliet Sanders, Elaine Stemple, Regina Gearhart, Martha Layton, Tiffany Fratz, Carol Bass, Teresa Friend, Jennifer Lee-Steckman, Kathaleen Skipper, John Corbin, Shelley Argabrite,