MRT Innovations in Social Determinants of Health Initiative

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Q1 Please provide your contact information below.

Name

Title and Organization


Address

City/Town

State/Province

ZIP/Postal Code

Email Address

Phone Number

Stephen M. Papas

Director of Development, Meals on Wheels Programs & Services of Rockland, Inc.

121 West Nyack Road

Nanuet

NY

10954

spapas@mowrockland.org

(845) 624–6325


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

Agency Mission Statement: To enhance the wellness of Rockland's older adults and their families by providing services that support thei safety, independence and health.

Agency Vision Statement: Every older adult in Rockland is living their life to the fullest.

Program Specific Goals:

  1. Reduce Emergency Department visits in older adults.
  2. Reduce hospital days/visits by older adults.
  3. Improve the overall health outcomes and quality life of older adults.
  4. Utilize current Meals on Wheels program structure and continuum of care to address Social Determinants of Health identified by staff in project population.

Existing Programs include Home Delivered Meals, Adult Day Care of Rockland, Senior Activity Centers, and the Adult Learning Center.

Home Delivered Meals – Meals on Wheels provides peace of mind to caregivers and older adults by delivering nutritious meals to any Rockland resident who cannot shop or cook for themselves due to illness, physical disability or advanced age. In addition to the daily meal, caring volunteers deliver a friendly, personal connection, a safety check, and an important link to the greater community. Home delivered meals, along with all of our services, are part of a greater continuum of care that enable older adults to remain as independent as possible and living in their own homes.

Adult Day Care of Rockland – Meals on Wheels provides peace of mind to caregivers and older adults through its structured social mode adult day care program, the Adult Day Care of Rockland at the Bobbi Lewis Center. The program offers a caring and safe environment while improving the quality of life for participants affected by Alzheimer’s Disease and other related cognitive disorders through recreational and therapeutic programs that encourage mental stimulation and interaction with peers. The Adult Day Care of Rockland, along with all of our services, are part of a greater continuum of care that enable older adults to remain as independent as possible and living in their own homes.

Senior Activity Centers – Meals on Wheels operates five senior activity centers located throughout the County. Our senior activity centers offer a warm, welcoming "home away from home" to hundreds of Rockland residents. Participants develop important friendships and enjoy many activities together with a particular focus on health and wellness. Also, a hot lunch is served daily. The Senior Activity Centers, along with all of our services, are part of a greater continuum of care that enable older adults to remain as independent as possible and living in their own homes.

Adult Learning Center – Meals on Wheels operates the Adult Learning Center, a full–service technology education center run by experienced volunteers devoted to enhancing the technology skills of older adults. Through small classes with individualized instruction, participants, from the novice to the more seasoned technology user, gain valuable skills, and improve technological communication with their family and friends. The Adult Learning Center, along with all of our services, is part of a greater continuum of care that enable older adults to remain as independent as possible and living in their own homes.


Q3 Please indicate which category your organization falls under.

Community Based Organization


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).

Meals on Wheels (MOW), in collaboration with Montefiore Nyack Hospital, Rockland Paramedics Services, Inc., and Crystal Run HealthCare, will be servicing a cohort of 50 patients over the age of 60 years present at Montefiore Nyack Hospital with loneliness and in a weakened physical state due to inadequate nutrition at the end of June 2018. This project was developed with technical assistance provided by the Albert Einstein School of Medicine through the efforts of the Montefiore Hudson Valley Collaborative (MHVC). MHVC is also funding year 1 of this project with an Innovation Fund grant.

Loneliness and social isolation lead to a higher risk of early death greater than tobacco and obesity (1). Furthermore, a recent study has shown that Medically Tailored Meals (MTM) curtail the use of costly health services (2). This innovation will focus on our Cohort’s initial need for physical strengthening through the delivery of daily meals then engage them in a long–term Senior Activity Center to build strong social connection critical to improving health and reducing use of emergency departments and inpatient services. The Centers are free of charge to Rockland County residents and also offer transportation. Upon referral, patients will receive a nutritional assessment for one medically appropriate meal daily and will establish social connection with the daily delivery volunteers. Volunteers will be trained by Crystal Run and Meals on Wheels to identify common physical signs leading to emergency room visits. If these are observed, Meals–on–Wheels will either address the issue through their social worker or refer the individual to Rockland Paramedics Services. Additionally, if volunteers identify any other issues that may be deteriorating the client’s quality of life, the MOW Social Workers will contact the client to address any Social Determinants of Health (SDH) issues and/or make appropriate referrals to services, as well as do follow–ups.

The Meals–on–Wheel Social Worker will work with the patient to build motivation to participate in one of the Senior Activity Centers. The Senior Activity Centers offer socialization transportation to/from the center and to some medical appointments and a safe–staffed environment during the day, with daily meals included. In addition to addressing food insecurity and socialization SDHs, Social Workers will work with the daily volunteers to identify other SDHs that are affecting the patient and either address it or involve another Community Based Organization (CBO) that can.

  1. Citation: Holt–Lunstad J, Smith TB, Layton JB (2010) Social Relationships and Mortality Risk: A Meta–analytic Review. PLoS Med 7(7): e1000316. https://doi.org/10.1371/journal.pmed.1000316
  2. Citation: Berkowitz, Seth A. et al (2018) Meal Delivery Programs Reduce the Use of Costly Health Care In Dually Eligible Medicare and Medicaid Beneficiaries. Health Affairs 37, No. 4: 10.1377 :https//www.healthaffairs.org/doi/10.1377/hlthaff.2017.0999

Innovation Cost for pilot project (Year 1): $200,000

Return on Investment (Year 1) – Meal Delivery + Socialization + Early ID of Medical Issue

  1. Reduced ED Visits: 40 Visits ✕ $500 per visit average =$20,000
  2. Reduced Hospital Days: 120 Days ✕ $1,000 per day average =$120,000
    (1 ED visit avoided for 80% of the Nyack Cohort. Based on preventing ED visits, we can prevent 20 admissions to the hospital of and average of 5 days each and reducing length of stay by 20 days.)
    Return on Investment (Year 2) – Engagement and Participation in Senior Activity Center
    Return on Investment (Year 2/3) –
    1. Engagement in Primary/Specialty Care: Complete Annual Physical and receive supermarket gift card when client brings in documentation from their MD.
    2. Enrollment and Engagement in Health Home by Senior Activity Center clients.

Scalability, Feasibility, & Speed to Market
This program can be utilized by any County Office for the Aging food delivery services or Home Delivered Meals Program throughout New York State as long as it is paired with either a social model senior activity center, along with the services of a social worker component associated with this program. These services are prevalent throughout New York State and with guidance have a high likelihood of implementation success. The length of time to implement this project in each county will vary but will require a minimum of 6 months to restructure the agency(s) involved.

Senior Activity Centers – Meals on Wheels operates five senior activity centers located throughout the County. Our senior activity centers offer a warm, welcoming “home away from home” to hundreds of Rockland residents. Participants develop important friendships and enjoy many activities together with a particular focus on health and wellness. Also, a hot lunch is served daily. The Senior Activity Centers, along with all of our services, are part of a greater continuum of care that enable older adults to remain as independent as possible and living in their own homes.

Adult Learning Center – Meals on Wheels operates the Adult Learning Center, a full–service technology education center run by experienced volunteers devoted to enhancing the technology skills of older adults. Through small classes with individualized instruction, participants, from the novice to the more seasoned technology user, gain valuable skills, and improve technological communication with their family and friends. The Adult Learning Center, along with all of our services, is part of a greater continuum of care that enable older adults to remain as independent as possible and living in their own homes.


Q5 Was your innovation implemented? If so, please explain when, the number of people impacted, and the results.

No


Q6 Please identify the SDH Domain that your innovation addresses. (Select all that apply.)

Social and Community Context,

Economic Stability


Q7 I give the Department of Health the right to share the information submitted in this application publicly (for example: on the DOH website). I understand that there is no monetary reward/reimbursement for my submission or for attending the summit should my innovation be selected.

I consent to have my innovation shared