Maine’s aging demographic and the goal of having people age in their communities is a permanent feature of our society. Addressing the challenges that come with aging has been in the forefront of our mission for over 40 years. However, it was not until the advent of the Accountable Care Act that we realized the value our services could offer to healthcare and the patients it serves.

Spectrum Generations developed CHRIS from of a combination of research and evidence-based pilot programs conducted nationally and from our own experiences working with health systems and insurers in Maine.

National research and evidence–based programs that informed CHRIS include:

• The SCAN Foundation
• The Commonwealth Fund
• Center for Health Care Strategies
• The American Geriatrics Society
• The Altarum Institute Center for Elder Care and Advanced Illness
• The Care Transitions Program (The Coleman Model)
• Johns Hopkins’ Community Aging in Place — Advancing Better Living for Elders 
• Centers for Medicare & Medicaid Services, Quality Improvement Organizations

Since 2011, Spectrum Generations has participated in four demonstration projects or grant funded pilots centered on introducing community-based services and interventions into the local healthcare systems. All have demonstrated incredible potential in changing the healthcare delivery landscape here in Maine for older and disabled adults. The specific demonstrations and pilots include:

• 2011-2016 CMS Innovations Grant Community-based Care Transitions Project (CCTP) (in coordination with MaineHealth and SMAA)
  • Overall MaineHealth 30 day readmissions was reduced by nearly 40%
  • Less than 5% of the 183 patients receiving the CHRIS intervention were readmitted within 30 days of discharge
• 2014-2016 Maine CDC Community Health Worker (CHW) Grant
  • 127 people served; 1120 community referrals made
  • 93% patient satisfaction
• 2015 Aging & Disability Resource Center Grant
  • In partnership with Community Health Options and MaineGeneral Health
  • 24 high risk patients received CHRIS intervention
• 2014-Present Imbedded Community Resource Navigator on Beacon Health Community Care Team
  • Over 1500 CHRIS contact hours

As the Area Agency on Aging serving central Maine, Spectrum Generations is uniquely positioned to assist health systems in engaging high

risk patients. With over 40 years of working with older and disabled adults we fully understand the daily challenges they face living in the community and the adverse effect these challenges have on their health. 

We are experts at connecting people to community resources and preventing a promised quality of life from slipping away as you age.

The CHRIS program offers two separate but complementary services for high risk, clinically complex patients. CHRIS is a complementary, low cost intervention that augments and extends your Care Team in reaching out to the patients you are most concerned about.

Post Discharge Meals-Only Option

Many studies indicate that meals and proper nutrition play an important role in responding to "Post-Hospital Syndrome" a condition described by Dr. H.M. Krumholz that suggests that patients return home from a hospital stay nutritionally compromised as a result of missed meals due to tests and/or surgery. Home delivered meals post discharge can target stressors that contribute to the high baseline rate of readmission. For patients in this situation, we offer 10-14 meals/week through Maine-ly Delivered Meals.

Transitional Care Management (TCM)

• Assist hospitals and post-acute care rehabilitation centers with care transitions
• Our Transition Health Coach and/or Community Resource Navigator coordinates closely with post-discharge care team.
• Face-to face home visit within 5 days of discharge
  • @Home Risk Assessment and Community Resource Connection Plan
  • 7 to 14 post-discharge home delivered meals (Maine-ly Delivered Meals)
• Patient followed closely for 30 days

Chronic Care Management (CCM)

• Patients who are struggling to manage their conditions while living in the community and at risk for excessive ED utilization and hospital admissions
• Face-to face home visit within 3-5 days of referral
  • @Home Risk Assessment and Community Resource Connection Plan
• Community Resource Navigator reports results to the practice’s Nurse Care Manager
• Patient is closely followed for 90 days

We are your window into the home.

@Home Risk Assessment yields a Community Resource Connection Plan

The patient has immediate next steps at the end of home assessment

A formal plan is provided to the Care Team within a few days.
Continuous follow-up and assistance is provided throughout the intervention.

Special consideration has been taken to ensure the reports you will receive are:

• Detailed
• Easy to read
• Sensitive to your time
• HIPAA compliant

We believe it is important to continuously measure the effectiveness of the CHRIS model, specifically whether it is returning value to both the patients and providers.

From the patient's perspective: a) Is the quality of care they are receiving high?; b) Are they feeling that their quality of life has improved?; and c) Are they more in control of their future health needs?

From the provider's perspective: a) Are they receiving new and needed information on the patient that contributes to their improved understanding of their patient's basic health needs?; b) Does this new shared information lead to better treatment and clinical outcomes?; and c) Does the value of the CHRIS intervention far exceed the cost and lends itself to future contracting with Spectrum Generations?

In order to best determine the answers to the above set of questions, both our TCM and CCM strategies continuously measure the following specific outcome objectives:

• Reduced discharge readmission rates: A maximum of 10% of TCM patients will be readmitted (for any reason) to a hospital or healthcare facility within 30 days of discharge.
• Improved Patient Satisfaction: 90% of all TCM patients surveyed will be satisfied or strongly satisfied with the intervention.
• Improved Patient Activation: a) 90% of all medical appointments will be attended by CCM patients; b) 80% of all CCM patients will understand and therefore adhere to their prescription and non-prescription drug regimen; c) 80% of all CCM patients will follow-through on recommended benefit filing and enrollment applications; d) 80% of all CCM caregivers surveyed will be satisfied or strongly satisfied with CHRIS.
• Proper Utilization of Healthcare: 90% of all CCM patients will receive their care in an outpatient setting, reducing ER visits, admissions and readmission.
• Improved Information Exchange: 80% of providers surveyed with TCM/CCM patients will be satisfied or strongly satisfied with the intervention.

Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) and the resulting Merit-based Incentive Payment System (MIPS) or the Alternative Payment Models (APMS) will impact how every physician practice, Accountable Care Organization (ACO), Commercial Medicare Plan, insurer, and health system gets compensated in the future.

Outcomes achieved now will directly effect reimbursement for services starting in 2019.

In the past, healthcare providers and insurers have had minimal impact on what happens in the home of their patients. Social and economic determinates of health create barriers that appear indestructible to patients and will now directly cause providers to be penalized if not addressed.

By partnering with Spectrum Generations for our low cost CHRIS model, you will now have a community-based aging and disability expert who closely coordinates and is aligned with your Care Team in addressing your patients social and economic needs that have been contributing to high costs and poor clinical outcomes.

Spectrum Generations can partner with you via fee-for-service or shared-risk contract.