MRT Innovations in Social Determinants of Health Initiative

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Q1 Please provide your contact information below.

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Q2 Please describe your company or organizations overall goals and mission.

SeniorHabitat is a single platform that makes it easy for family caregivers and care providers to work together. We maximize the ability for older adults to age in their community and avoid re-hospitalizations by linking them to the optimal setting of care and supportive services based on their individualized needs. SeniorHabitat's unique algorithm and digital tools address the unique clinical, social, and financial needs of older adults. We created a platform that ensures health care continuity and prevent poor outcomes among older adults throughout the aging journey.

Care transitions occur when a patient moves from one health care provider or setting to another. Currently, nearly one in five Medicare patients discharged from a hospital–approximately 2.6 million older adults–are readmitted within 30 days, at a cost of over $26 billion every year. Poor care coordination is a leading cause for readmission back to the hospital. SeniorHabitat recognizes that family caregivers play a critical role in supporting older adults during care transitions. However, little attention has been paid to involving, educating and supporting them. According to AARP, eighty–seven percent of family caregivers are unaware of available resources that can help them provide proper care and make critical decisions. To decrease preventable hospital readmissions & improve quality of life for older adults, SeniorHabitat created a platform that provides support and guidance to stressed family caregivers by offering objective and qualified solutions for the following social determinants of health: 1) Resources to meet daily needs (ex. housing & nutrition), 2) Access to health care services, 3) Community–based resources (ex. care management), 4) Social & legal support, 5) Opportunities for recreational & leisure activities (ex. adult day & senior centers), 6) Transportation options.

To decrease preventable hospital readmissions & improve quality of life for older adults, SeniorHabitat created a platform that provides support and guidance to stressed family caregivers by offering objective and qualified solutions for the following social determinants of health:

1. Resources to meet daily needs (ex. housing & nutrition),
2. Access to health care services,
3. Community–based resources (ex. care management),
4. Social & legal support,
5. Opportunities for recreational & leisure activities (ex. adult day & senior centers),
6. Transportation options.

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Q4 Innovation Executive Summary. Please describe the innovation, and how it addresses the social determinants of health. Please identify how the innovation addresses the 6 innovation criteria (i.e. ROI, scalability, feasibility, evidence–based support for innovation, relevance to the Medicaid population and speed to market).

To decrease preventable hospital readmissions & improve quality of life for older adults, SeniorHabitat created a platform that provides support and guidance to stressed family caregivers by offering objective and qualified solutions for the following social determinants of health:

1. Resources to meet daily needs (ex. housing & nutrition),
2. Access to health care services,
3. Community–based resources (ex. care management),
4. Social & legal support,
5. Opportunities for recreational & leisure activities (ex. adult day & senior centers),
6. Transportation options.

• SeniorHabitat reduces caregiver stress and burden by guiding family caregivers on what services they need via SeniorHabitat´s CareFinder Questionnaire. We transformed a 4–hour assessment process, previously facilitated by a Geriatric Social Worker into a free digital tool that recommends community–based services and benefits.
• SeniorHabitat improves the quality of life (QoL) for older adults by connecting them to care based on their clinical needs, personal preferences (i.e. diet, language, income), social and cultural factors. Family caregivers can search senior housing options based on 10 categories and 148 individual preferences. In addition, they can search 21 different categories of community resources.
• SeniorHabitat ensures that family caregivers are not wasting their time visiting a "home" that isn´t appropriate for their loved one via SeniorHabitat´s Housing Questionnaire, Online Tour Booking, and Screening Tools. We make it easy for housing providers to screen potential residents based on medical diagnosis and activities of daily living prior to a tour.

Since our platform is self–serving for caregivers and care provides, we don´t need to hire an enormous team to grow.

To ensure that we provide objective resources, SeniorHabitat offers a freemium business model rather than a referral business model for care providers. Although all care providers are listed for free, we also have a paid premium version (that includes our workflow management tools). Our platform is always free to older adults, caregivers, nonprofits and government agencies.

Evidenced based support for innovation:
http://www.aarp.org/content/dam/aarp/home–and–family/personal–technology/2016/04/Caregivers–and–Technology–AARP.pdf
http://www.hindawi.com/journals/jger/2015/678625/
http://www.caregiver.org/sites/caregiver.org/files/pdfs/FamCGing_TransCare_CritRvw_FINAL10.31.2012.pdf
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2768550/

Relevance to the Medicaid population:
SeniorHabitat addresses the unique clinical, social and financial needs of older adults. We connect older adults to community based services and benefits to ensure health care continuity and prevent poor outcomes.

Speed to Market:
SeniorHabitat´s platform is currently active and available to all New Yorkers.

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