Sharepoints MEDCAPS Executive Summary
1. Objective:
OADS, in partnership with the DHHS Office of MaineCare Services and key stakeholders, in the course ofa three-year project, will ensure access to a dementia-capable and sustainable,home and community-based (HCBS) system for individuals with dementia and their family caregivers utilizing at least one evidence-based or evidence informed training and intervention model(s).
As the current system in Maine isfragmented, often insensitive, frequently uncoordinated and confusing, and generally unsatisfactory, this project will enable people with dementia (PWD)and their caregivers to make informed decisions about long term services and supports (LTSS) options and improve health status.
2. Projected Outcome:
Ø Create and sustain a dementia-capable home and community based service (HCBS) system that includes a Single Entry Point/No Wrong Door (SEP/NWD) access for PWD and their family caregivers.
1. Develop project governance and planning process, and plan
2. MEDCAPS Operation Plan approved by HHS Administration for Community Living/AoA
3. Develop and standardize the screening and evaluation process for identification and/or diagnosis of dementia.
Ø Ensure access to a comprehensive, sustainable set of quality HCBS supports that are dementia capable and provide innovative services to PWD and their family caregivers.
1. Identify and implement evidenced-based or evidence-informed training and intervention model(s). **
6. Performance Measures and Targets:
Ø Create and sustain a dementia-capable home and community based service (HCBS) system that includes a Single Entry Point/No Wrong Door (SEP/NWD) access for PWD and their family caregivers.
1. Develop project governance and planning process, and plan:
a. Planning process established and a plan refined by meetings/calls with stakeholders.
· Project planning process and operations plan established on or before 3/25/2014.
2. MEDCAPS Operation Plan approved by HHS Administration for Community Living:
a. Exit conference held with ACL and a plan for MEDCAPS approved.
· MEDCAPS Project Plan approved on or before 3/25/2014.
3. Develop and standardize the screening and evaluation process for identification and/or diagnosis of dementia:
a. Modify existing Level I/ II screens for identification of PWD across all HCBS.
· Level I/II Screens adapted and tested to be dementia capable by 3/25/2014.
b. Number of staff trained and monitored on Level I/II screens at SEP/NWD entities established by the Balancing Incentive Payment Program (BIPP).
· 10 staff from SEP/NWD entities trained/monitored by FY14 (between 3/26/2014 & 9/30/2014)*
c. Number of persons with possible dementia identified and referred.
· 75 persons with possible dementia identified, referred to appropriate services, and recommended for follow up with a physician by FY14*
d. Number of Physicians trained on proper dementia diagnosis and referral.
· 5 Physicians trained on proper dementia diagnosis and referral by FY14*
e. Number of aging network and community partner staff trained to understand the needs/services available for PWD and how to communicate with them.
· 52 ADRC, DHHS, and community partner staff who encounter PWD trained to understand the unique needs/services available for PWD and how to communicate with them by FY14*
f. Number of PWD seeking long term services and supports (LTSS) provided with Options Counseling and a HCBS (home and community based service systems) plan.
· 50 PWD seeking LTSS will be provided with Options Counseling and a HCBS plan by FY14*
Ø Ensure access to a comprehensive, sustainable set of quality HCBS supports that are dementia capable and provide innovative services to PWD and their family caregivers.
1. Identify and implement evidenced-based or evidence-informed training and intervention model(s). **
a. Number of Caregivers trained utilizing evidence-based Savvy Caregiver Training Model.
· 30 Caregivers trained utilizing Savvy Caregiver Training by FY14*
b. Number of Community-based Care Transitions programs (CCTP) utilizing the evidence-based Coleman Model adapted to include PWD.
· 2 CCTPs utilizing the Coleman Model adapted to include PWD by FY14*
c. Number of CCTPs utilizing the Coleman Model expanded.
· 1 additional CCTP offered statewide (2 offered currently) by FY14*
d. Number of aging network and community partner staff trained on dementia and LTSS.
· 25 aging network and community partner staff trained on dementia and LTSS by FY14*.
SEP/NWD entities operationally involve a wide array of community agencies and organizations that can effectively serve a broad range of populations, including at a minimum older adults, people with intellectual, developmental and physical disabilities, all ages and incomes, and family caregivers.
CCTPs are mandated by section 302 of the Affordable Care Act, to provide funding to test models for improving care transitions for high risk Medicare beneficiaries. CCTP goals are to improve transitions of beneficiaries from the inpatient hospital setting to home or other care settings, improve quality of care, reduce readmissions for high risk beneficiaries, and document measureable savings to the Medicare program.