2007 Model Practice Application (Public)

Maryland Access Point of Worcester County

Worcester County Health Department

The Maryland Access Point (MAP) of Worcester County program targets elderly and disabled citizens age 18 or over and addresses the need for elderly, vulnerable, and disabled adults in Worcester County to receive consolidated, quality care that is efficient and effective in supporting full quality of life. To simplify access to and increase utilization of appropriate direct care services, Worcester County residents were provided with a centralized way to access information about current resources. In addition, residents receive needed assistance and/or services efficiently through the coordination and collaboration of both resources and planning.

The program goals include:

• Goal 1: In order to address the needs of the citizens of Worcester County, the Worcester County Health Department will provide leadership and direction to the Maryland Access Point Project to assure the efficient and effective delivery of services to the elderly and vulnerable adult citizens of Worcester County. Some of strategies involved that will help to accomplish this goal include planning and implementing the annual “Aging in Worcester” conference in order to provide a forum for community and professional input in to services needed by and provided for the residents of Worcester County.
  
  
• Goal 2: By locating the services of three agencies (Worcester County Health Department, Department of Social Services, and the Commission on Aging) in a single site, the project intends to increase the accessibility of services for aging adults in Worcester County. Some of the other strategies that have been employed to help accomplish this goal include the hiring of an Intake Coordinator, as well as the creation of a single, shared intake form used by all three collaborating agencies. The MAP staff participate in monthly team meetings to foster communication and collaboration between the three agencies.
  
  
• Goal 3: The MAP program intends to increase the utilization of services within Worcester County’s older population. This goal will be accomplished by communicating services information directly to the older adults of Worcester County, by developing outreach, education and training programs for professionals and community organizations concerning the behavioral needs of the aging population in Worcester County, and by cross-training of MAP staff in co-occurring behavioral health issues in the aging population.

The outcomes of the program include improved quality of life of target population by increasing the accessibility, utilization, capacity, and efficiency of health and human services delivered to the aging and disabled adults of Worcester County.

This practice addresses the need for elderly, vulnerable, and disabled adults in Worcester County to receive consolidated, quality care that is efficient and effective in supporting full quality of life. To address this need, this practice simplifies access to and increases utilization of appropriate direct care services by providing residents with a centralized way to access information about current resources, and allows them to receive assistance and/or services through a coordinated, collaborative effort. Worcester County is experiencing an influx of retirees, resulting in a quickly growing population of older adults. This trend became clear in the 2000 Census data. This population shift requires planning to provide a broad continuum of service delivery, particularly for those who have little or no family resources. In 2000, the participants in the Aging in Worcester Conference, which included community members and professionals, identified barriers to care faced by elderly and vulnerable adult citizens of Worcester County. Conference participants authorized the conference planning committee to draft an action plan, which identified the need for a single point of entry system providing centralized services to disabled adults and seniors in Worcester County. The resulting project, known as MAP (Maryland Access Point), realized this vision, through the collaboration of the Worcester County Health Department, the Department of Social Services, and the Commission on Aging. The primary goal of this project was to consolidate service in order to avoid duplication, while delivering quality care to the elderly and vulnerable and/or disabled adults in Worcester County, including mental health and substance abuse services. The three agencies’ adult services staff were collocated in the Worcester MAP office, in order to centralize access to information and services. Staff collocation has served to significantly reduce system fragmentation, giving the consumer seamless service delivery.

The MAP program of Worcester County is unique in the field of public health in both the range of services provided (include nursing assessment, social support, information and referral, as well as behavioral health assessment and counseling), and the housing of three agencies (the Commission on Aging, the Department of Social Services, and the Worcester County Health Department) together to provide them. This continuum of care makes efficient use of scarce resources through the collocation of staff and infrastructure, as well as stream-lined service delivery. The Worcester County Health Department’s leadership in the Maryland Access Point collaborative has contributed its vast experience and history of community partnership building to ensure a model program that truly addresses the community’s needs. Another unique component of the MAP program is the availability of mental health services. This required an adaptation of existing models [The Behavioral Health Models (PACT and IMPACT)] to better fit the unique needs of the citizen of Worcester County.

The Worcester County Health Department has provided overall leadership to the MAP program, provided Adult Evaluation and Review Services (AERS) to the aging and disabled residents of Worcester County, sought and provided funding for a MAP Intake Coordinator, and provided Behavioral Health services through the MAP program. Worcester County Commission on Aging was a partner in MAP and provided information and assistance in obtaining resources for services, provided Senior Centers, Meals on Wheels, and Senior Care Services, as well as provided space for the single point of entry office. Worcester County Department of Social Services was also a partner in MAP and provided Adult Protective Services, the Social Service To Adults program, case management, in home aide services, and respite care. Together, all partners will coordinate and provide annual training for providers in the county through the annual conference and other outreach methods. In addition, all will coordinate the development and provision of information and referral, risk assessment, case management, and placement. The role of the community in project planning for MAP includes The Aging in Worcester conference, which will continue to be held annually to serve as a vehicle for consumers and providers to identify needs, receive training in aging issues, and to recommend actions and strategies. MAP is advised by a consumer advisory board, of which at least 50% of the board’s membership includes consumers or consumer advocate groups. The Worcester County Health Department identifies and coordinates community resources that will fill service gaps with the community as a vital partner.

Funding sources for this program included Health Resources and Services Administration, Maryland Department of Aging, and the Worcester County Commissioners. The initial co-location of the three agencies was supported by in-kind costs. Subsequently, funding from the Health Resources and Services Agency provided funds of $199,521 per year. In-kind costs from the Worcester County Health Department totaled $845,212.00 for the first year of the project and $311,473.00 for the second year of the project.

The first overall goal of the MAP Project is for the Worcester County Health Department to provide leadership and direction to the MAP Project. To accomplish this, a MAP Program Manager was hired who works with all MAP staff to design and implement operational and evaluation plans. Also, an Intake Coordinator position was developed and the Health Department obtained local funding for this position. Further, the Health Department worked with the other collaborating agencies to identify training needs, to develop training plans, and to provide cross-training to all team members in the unique needs of aging and vulnerable adults. In addition, one phone line was established for the citizens of Worcester County to use to access needed services. To accomplish another objective of this goal, the Worcester County Health Department applied for and received multiple grants to support this practice.

The second overall goal of the project is to increase the accessibility of services for aging adults in Worcester County. To accomplish this, the project created and implemented a site which serves as a single point of entry office, developed and implemented a universal assessment form used by all three agencies, provided for the coordination of services by having the agencies which are collocated schedule appointments jointly and agreeing on common time frames as appropriate, coordinating home visit, and coordinating case management services. In addition, MAP conducts monthly team meetings which work to foster communication and collaboration between the agencies. This objective is completed and the assessment of the success of this objective is ongoing. Another important aspect of achieving this goal is the defining the risk to and identifying and serving priority needs of consumers, which involves the prioritization of resources to meet highest needs, as well as maintaining a regular team meeting schedule. Progress towards this objective is ongoing.

The third overall goal of the practice is to increase the utilization of services within Worcester County’s older population. To accomplish this goal, the MAP project developed a system for both information dissemination and outreach information to reach the citizens of Worcester County that involved producing a resource guide listing sources of services available to the citizens of Worcester County, conducting the “Aging in Worcester Conference” annually in order to disseminate information to professionals and lay people alike, as well as the development and distribution of the first aging newsletter, which provided information about aging-related issues and resources to Worcester County residents. In addition, the MAP program has developed outreach, education, and training programs for professionals and community organizations concerning the behavioral needs of the aging population in Worcester County. Also, the program has provided training to behavioral health care professionals concerning the specific needs of the aging population. In order to achieve another objective of this goal, the MAP program offers ongoing staff training, supports co-workers in the sharing of scare resources, has worked to increase the number of MAP staff, and strived to improve the communication among staff.

The Worcester MAP project is continuously working towards a sustainable continuum of care for older adults in Worcester County, through the following strategies:

• This project is creating a self-sustaining workforce of in-home care and chore service providers through an Asset Based Community Development process. This workforce will include independent private providers and volunteers from existing associations. By outreaching to community organizations and providers, this project hopes to create a larger, more effective, provider network that will identify and respond to those in need.
  
  
• The behavioral health team will be partially supported by a fee-for-service billable system through the Mobile Treatment Team Program. This team is working to create a full sustainability plan before current grant funding ends.
  
  
• To increase re-imbursement for direct services, Worcester MAP staff connect seniors to special Medicaid/Medicare programs and assists with their applications, increasing both client eligibility and enrollment.
  
  
• Use of the modified IMPACT model allows Behavioral Health staff to increase the provision of treatment within a primary care setting, in order to move the cost burden onto the client’s primary insurer.
  
  
• Worcester County consumer groups and governing bodies have expressed strong support for this project and are expected to continue supporting the project into the future. This is evidenced by growing participation at our annual conference. County funding has already been secured to support the Intake Coordinator. Other funding opportunities, including grants, will be sought by the consortium agencies, to sustain the existing system and to implement future changes or expansions.
  
  
• Worcester MAP was a pilot Aging and Disability Resource Center. Maryland is working with state agencies and advisory boards to create sustainable funding solutions that will streamline application processes for existing programs, and advocate for increased funding for services that would fill growing service gaps.

This practice addresses the need for elderly, vulnerable, and disabled adults in Worcester County to receive consolidated, quality care that is efficient and effective in supporting full quality of life.

Objective 1: The Worcester County Health Department will provide leadership and direction to the Maryland Access Point Project.

Performance Measures: Efficiency and capacity of services (dollars and time per client served). Collaboration perceived successful. Staff training and meetings regularly conducted.

Outcome: Anecdotal evidence exists of increased efficiency and capacity.

Objective 2: The project will increase the accessibility of services for aging and disabled adults in Worcester County.

Performance Measures: Personal care service capacity (number of providers for population, and waiting list length for population). Improved quality of life for the target population. Accessibilty and quality of service.

Outcome: Anecdotal evidence exists for increased accessibilty and quality of life.

Objective 3: The MAP program will increase the utilization of services within Worcester County’s older and disabled population.

Performance Measures: Improved quality of life. Number of outreach materials published. Numbers of and attendance at training workshops d) Increased program referrals, numbers of clients, and visits.

Outcome: Anecdotal evidence exists of increased efficiency and capacity.