Pittsburgh Care Partnership Inc Community Life

Programs: In 2016, the organization delayed and/or prevented permanent nursing home placement for 668 unduplicated persons in parts of allegheny and westmoreland counties. Community life, a pace program, preserved health, function, and quality of life for 668 unduplicated members, more than 99% of whom are on medicaid, in eastern allegheny county, new kensington, and the trafford/irwin area. Community life has health centers in mckeesport, homestead, wilkinsburg, and tarentum pa which provide primary medical care, rehabilitation services, medical transportation, adult day care, home care and numerous other services. Two of these areas are designated as being underserved with medical professionals and all are marked by high concentrations of low-income, frail elderly. Our success rate in keeping seniors out of nursing homes is 93% and they are less likely to be hospitalized from conditions which may be worsened by lack of information and access to services. We also coordinate care among all of our members' treating professionals which lowers the risk of unintended problems from multiple medications and treatments. 95% of our members are both medicare and medicaid eligible, the well-known duals" population with long term care needs that are typically the highest cost medicare members. Medicare pays capitated rates thus limiting their exposure on these complex individuals and medicaid rates are set below the average per capita cost of long term care in the state - an average cost savings of over $21,000 per year for every person who joins the program instead of choosing nursing home care. Community life has the first co-location of a pace program (homestead 2002) with senior public housing and has been toured and studied by hud and other pace programs; the model was replicated in 2007 in tarentum. In addition, community life pioneered an innovative relationship with the mckeesport housing authority in 2009, financing accessibility improvements to 13 apartments, and providing staff and remote monitoring systems round the clock so that seniors could age in place in a community setting even longer. Community life was able to relocate a dozen individuals back out of a nursing home and has also solved vacancy problem for the housing provider. Community life provides service coordination programs free of charge in twelve senior high rises in our service area, helping individuals to access services from rental assistance to health care to legal. These relationships enable seniors in public housing to age in place, reducing vacancy rates and providing solutions for housing providers whose tenants have problems maintaining their domicile. A team of experts in geriatric care planning - including a physician, nurse, social worker, dietitian, physical and occupational therapists, personal care assistants, drivers, and others - provide the daily care and arrange all other needed services, follow up with problems, and educate our members and their family caregivers about their conditions and setting goals for their care. In addition to having a care manager who knows all of the member's needs and history, the member and their family are relived of the burdens of dealing with multiple insurance requirements, making appointments, transportation, and coordinating multiple services.