ND Building a Culture of Health Think Tank Meeting

Elderly Population Asset Map Sticky Notes

Statewide

  • Resource and Referrals (focused case management)
  • Peer Support Mentoring, mailings-resources and quarterly newsletter, monthly education calls, Building a Better Caregiver Workshop
  • Dementia/Memory Clinic Work-ups and follow-ups, Fargo VA, Telemedicine VA with CBOCS (Bismarck, Williston, Grand Forks, Devil’s Lake, Jamestown), VHA Dementia Steering Committee, work with Alzheimer’s Association and developed a shared medical appointment, Dementia Demonstration Project
  • Primary Care- focus on geriatric- Fargo VA, VA Geriatric Scholar Program- continued geriatric education based off rural area
  • Use of health information technology
  • System-wide- leading life sustaining, Treatment decision initiatives, revamping order sets and increase goals of conversation for high risk patients
  • Community service- geriatric presentations, longevity dividend, healthy lifespan
  • Geriatric research- Alzheimer’s disease, elderly recovery from acute illness
  • Geriatric education- geriatric fellowship- Bismarck and Grand Forks, Geriatric Education for Medical Students and Residents, CME on Geriatrics
  • Antibiotic stewardship- education, information, resources
  • OAA Services (Congregate HDM)- senior nutrition, preventive health, legal services, vulnerable adult protective services (VAPS), LTC ombudsman, guardianship establishment fund, administer federal Medicaid and state funded HCBS, aging disability resource link (ADRL)
  • Stepping on- falls prevention, adult foster care licensing, HCBS case management, local contact agents, options counseling, family caregiver support program
  • Education of long term care staff, provide networking and sharing of best practices, lobby for resources and funding for BC/NF, provide nurse scholarships
  • Caregiver appreciation events (November CG month)
  • Community Transitional Care Coordination- reduce admissions and readmissions and medical harm
  • Medication safety- reduce ADE related to high risk medications and improve safety in all settings
  • Nursing home care- improving safety and clinical processes and reducing preventable harm
  • NDSU Extension- community development- statewide aging collaborative, all statewide activities
  • Evidence-based programs- powerful tools for caregivers stepping on, education programs- delivered by county staff, educational publications, research on aging issues, NDSU Extension-family and consumer science county agents
  • Advance Care Planning
  • Population health/preventive care specifically- cardiac immunization, diabetes colorectal cancer
  • Clinical services- geriatric telehealth for critical access hospitals
  • Regular visits to hospice patients by medical director and NPs- palliative care
  • Telemonitoring program for CHF/COPD and HH patients
  • Work with tribes to administer an Identifying our Needs: A Survey of Elders to be used to meet requirements for grant funding applications for Title VI nutrition and caregiving. We provide the survey, process, analyze the results and send to the tribes. This occurs every 3 years. NRCNAA- not only state- but nationally.
  • NRCNAA- well balanced curriculum (wise-elders living longer) can be used by tribes to help reduce the risks of hypertension, diabetes and other health disparities. Also, to help reduce the number of falls. We provide the training. Native Elder Caregiver curriculum. To help CHRS or family caregivers to care for Native Elders and help to “age in place”
  • Quality Improvement- Great Plains QIN- chemical restraint reduction in LTC
  • Education on Advanced Care Directives, community engagement speaking events- being mortal, Future-telehealth and medical directors for hospice patients who can’t
  • Post-hospital home visits with a nurse, connecting VIN, ipad- pharmacy med reconciliation

Fargo

  • Developing ADV-GV program and implementation. In Fargo- but will expand
  • Clinical service- memory disorders clinic- Fargo
  • Funding for senior programs and services in the Fargo area
  • Clinical services- comprehensive geriatric assessment- Fargo
  • NDSU Extension- Cass County Aging Collaborative
  • Fargo VA- coordinates with home health agencies and hospice agencies to provide care to Veterans
  • Coordinate and partner with licensed adult foster care homes to provide care to veterans (via the Medical Foster Home Program)- 65 mile radius of FM
  • VA Home based primary care- Fargo - primary care team comes to the veterans home (NP, RN, SW, OT/PT, Dietician, Psychologist)- for veterans with complex medical conditions who need close follow-up
  • Connect veterans with respite care options at the Fargo VA and in the community (statewide)
  • Stepping on- falls prevention
  • VA Caregiver Support Group
  • Clinical service- balance and fall clinic- Fargo
  • Sanford transitional care-training FCNs using an EB model, gap-funding, many unpaid
  • Sanford Depression implementing Columbia Screening, gap-MH services and providers
  • Sanford Falls Prevention- encouraging implementation of Stepping on, gap- not enough locations
  • Sanford- Advance Care planning- training professionals how to have a patient centered conversation, gap- western ND and NA sites, hospice in rural areas
  • Sanford- numerous collaborative focus groups, faith community advisory groups, poverty, nutrition, backpack program, mental health, depression, suicide prevention, opioid epidemic, Columbia screening
  • Annual free caregiver conference/resource fair- Moorhead but includes Fargo
  • Funding for senior programs and services- SE ND area
  • Sanford- collaborative CH assessment, Essentia, NDSU/UND- faith placed, faith-based
  • Provide veterans with an option for long term care in a family setting (medical foster home) 65 mile radius of F-M
  • VA contract nursing home program- statewide. VA pays for skilled nursing home care for high service connected Veterans as well as Veterans receiving hospice level care

Grand Forks

  • Clinical services- comprehensive geriatric assessment- Grand Forks
  • Grand Forks Senior Center, Grand Forks County- home delivered meals, health-foot care, transportation assistance, senior health insurance and counseling, social activities, rural frozen meal delivery, assistive device loan program
  • Grand Forks- Powerful Tools for Caregivers Classes
  • Grand Forks- Memory Café-education and support for those affected by dementia, Memory Choir- making music for people with Dementia and Parkinson’s Disease
  • Grand Forks- Stephen Ministry- spiritual ministry, support for anyone dealing with life challenges
  • Funding for senior programs and services- Grand Forks Area
  • Clinical Service- Senior patient centered medical home for under-resourced elderly (Valley Community Health Center- Grand Forks)
  • Volunteer in Home respite program- Grand Forks and 40 mile radius
  • Altru- Home health services, hospice services, Northeast ND west to Devils Lake, South to Buxton, North To Cavalier and west to Polk county
  • Grand Forks Senior Center, Nelson County- rural frozen meal delivery, health care, foot care, assistive devices loan program, senior health counselors

Bismarck/South Central

  • VA Home based primary care- Bismarck- primary care team comes to the Veterans home (NP, RN, SW, OT/PT, Dietician, Psychologist)- for veterans with complex medical conditions who need close follow-up
  • Crisis Management
  • HCB’s development as part of LTSS
  • VA Caregiver support group- Bismarck
  • Funding programs and services for seniors- Bismarck area
  • Senior services outreach
  • Chronic disease outreach
  • Consultation with elder population and elder advisory group
  • Interprofessional collaboration with community, local and regional, tribal
  • Service learning development with academic partners
  • Face to face caregiver education events (throughout the year)
  • Some transportation
  • Home delivered meals
  • Community outreach with use of CNAs and RNs
  • Elder Abuse
  • Injury Prevention (falls prevention) through Stepping On

North Central /Minot

  • Funding programs and services for seniors for the Central ND area
  • Funding and programs and services for Seniors in Minot Area