The Frail Elderly Pilot project in Pueblo County is building a community-based, self-sufficient system designed to meet frail elders’ needs and advance the Full Benefit Medicare-Medicaid Eligible (FBMME) project in Pueblo and the state of Colorado.
The pilot is based upon the work of Dr. Joanne Lynn of the Altarum Institute who believes that the health care system needs to ensure every person can count on living comfortably and meaningfully through the period of serious illness and disability in the last years of life, at a sustainable cost to the community.
Who are the Frail Elderly?
Frail older adults are often weak, have many complex medical problems, have a lower ability for independent living, may have impaired mental abilities, and often require assistance for daily activities (dressing, eating, toileting, mobility).
- Identify and meet the needs of the frail elderly
- Build a self-sustaining community program and dashboard of goals and progress focused on the needs of the frail elderly
- Ensure care plans reflect the priorities of the client and family
- Achieve multi-organization sharing of care plan
- Integrated Community Health Partners (ICHP) www.ichpcoloardo.com
- Colorado Department of Health Care Policy and Financing (HCPF) www.colorado.gov/hcpf
- Altarum Institute www.altarum.org
- Pueblo Triple Aim Corporation www.pueblotripleaim.org
- Telligen www.telligen.com
To be eligible for the pilot program, clients must meet one of the following criteria:
- Age 80 or older
- Age 65 or older with two or more chronic conditions
- Age 65-79 with two or more cognitive impairments
- Age 65-79 with two or more Activities of Daily Living (ADL) deficits
- Conducting interviews and focus groups with clients, families, physicians and direct care providers to identify needs
- Prioritizing and addressing identified needs
- Analyzing combined claims data monitor improvements to patient outcomes and cost savings
- Developing and updating a publicly available dashboard demonstrating progress towards achieving project goals