BlissCONNECT Powers Full Circle America

Full Circle America Case Study: Aging in Place and Community Interview with Allan Teel

By Jean Galiana and William A. Haseltine ACCESS Health United States December 2015

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Copyright Š 2015 ACCESS Health International ACCESS Health International, Inc. 845 UN Plaza, Suite 86A New York, New York 10017-3536 United States

Introduction Seniors around the world are demanding better options for care and support.

That demand is driving impressive and disruptive innovations in the delivery of person centered care. The Full Circle America home and community care program is one such innovation. Full Circle America links technology, people, and clinical processes in a holistic care setting across the care continuum.

Dr. Alan Teel is the founder of Full Circle America. Dr. Teel is one of the early pioneers of aging in place and community and healthcare at home in the US. Aging in place is the ability of an older person to stay in their homes as long as possible. Aging in community refers to an older person remaining connected to his or her community assets, including libraries, senior centers, companies that offer senior discounts, Young Men’s Christian Associations (YMCAs), and churches. Aging in community also refers to an older person having knowledge of and access to their community supports and services, such as transportation, meal delivery, and volunteer opportunities. Healthcare at home is a broad range of health supports given to those who need care at home. This care could include chronic care management, disability support, mental health support, and postoperative rehabilitation and recovery. Healthcare at home serves people of all ages.

The outcomes of the Full Circle America care model include large cost savings, increased access to care, better healthcare delivery, better health outcomes, and dramatically better quality of life for participants. Dr. Teel uses computer and monitoring devices to stay connected. Bliss CONNECT, designed by Pankaj Khare, is the technology platform supports the Full Circle America care model.

Mr. Khare spent seven years designing the coordinated care platform, which enables healthcare, aging in place and community, long term care, and disability support at home.

The Full Circle America vision is to offer the integration of health and wellness, safety and security, purpose and communications, lifelong learning, and community engagement in one easy to use technology platform. The secure video, phone calling, and chat features are HIPAA (Health Insurance Portability and Accountability Act) compliant. Bliss CONNECT enables contact with a virtual support team of warm community health workers, nurses, and doctors, along with selected family, friends, and volunteers, from within the homes of frail elderly and adults with disabilities living in the community.

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A client’s Full Circle America care plan exists in tandem with the client’s existing doctors, much like if the client was in an assisted living home. Full Circle America is like virtual assisted living, with the addition of sophisticated technology housed in one place. The model also divides the care burden into manageable pieces by connecting to the client’s local supports and services and volunteers.

The homepage of the Bliss CONNECT platform is much like a social networking website, allowing an older or disabled person to connect with others. Users can chat and share photos in a Facebook style communication board, use a Gmail style email, shop at online stores, and reference a calendar. There are apps that are customizable to the user’s interests. The endless choice of apps ranges from favorite old movies, to recipe books, news, sports, weather, music, Kindle, and pizza delivery.

From the first social page, users can connect to their care teams. They can see photos of their care circles, which include a doctor, a nurse, a case manager, and all others involved in their care, such as family and community volunteers. This page is used to video conference and teleconference, or chat electronically with all in the care network. The page also has a panic call option. Stored on page two are all of the client’s electronic health records, complete health record, insurance records and required documentation for third party billing, a place to store documents, and a place for the healthcare team to document their care and set up medication alerts. The user can choose who has access to this page.

Full Circle America uses passive video monitoring devices and motion sensors, combined with protocols, to provide peace of mind for loved ones living at a distance. The specifics of monitoring vary with the need of the person aging in place or receiving care at home.

All of the health monitoring devices can be connected to a tablet. Health results will be sent directly to the care team and stored on the Bliss CONNECT platform. Full Circle America has a service menu that ranges from twenty to eight hundred dollars per month. This menu is tailored each client’s needs.

In this interview, Dr. Allan Teel describes his thirty years of experience enabling aging in place and community to his patients. Dr. Teel offers his insights into elder care and the Full Circle America care model. The Full Circle America model cuts costs of care substantially and provides equity of access while improving health outcomes and quality of life for clients.

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About Allan Teel Allan S. “Chip� Teel, MD, graduated from Dartmouth College and the University of Vermont Medical College. He trained at the Family Medicine Residency at Lancaster General Hospital in Lancaster, PA. He now resides in Maine. He has been a family physician in private practice in Damariscotta since 1988. He holds a Certificate in Geriatrics. He has been the medical director and provided patient care at nursing homes and assisted living facilities. In 1995, he cofounded the nonprofit ElderCare Network.

The ElderCare Network owns several small assisted living homes in Lincoln County, Maine. In the mid 1990s, Dr. Teel was an original incorporator of the multispecialty Miles Medical Group. In 2003, he became the founding partner of Full Circle Family Medicine. In 2011, he started Full Circle America to provide home based elder support on a larger scale.

Interview Jean Galiana (JG): What inspired you to start an aging in place and healthcare at home organization?

Allan Teel (AT): It has been a long road. I was the medical director of a nursing home when the nursing home moved from the top floor of the hospital to its own building, in the early 1990s. I tried to modernize the care model for the nursing home. Over a few years, it became apparent that my efforts were not enough. This fact was most pronounced in the skilled care unit, where I was a physician for many people in rehabilitation who wanted to go home.

Some home health agencies had sprung up. These agencies tended to only a small slice of the services that a fragile or frail person needs to stay at home. These agencies would help manage wound care or maybe listen to your heart and lungs and make sure you were taking your medicines. Older and frail patients, who

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were often recovering from an illness or surgery, needed more comprehensive home healthcare. There were really no options.

The most disgusting part of this whole story is that the medical supports were primarily, and still largely are, available only for people who are completely homebound. If you left your house to have your hair done, to go to church, to go over to a family member’s home for a meal, you were not considered homebound; you did not qualify for Medicare nursing services. Everyone at the time recognized that these activities were part of living and could potentially aid and speed your recovery. This limitation in Medicare policy disqualified people from care they needed in a perverse way.

I wanted a model to treat those who were falling through the cracks and trying to deal with a Medicare regulatory environment I spoke about, which was anything but holistic. Honestly, at times, I became quite exasperated by having to tell very old, very determined people that they could not go home because they did not have the support system in place.

“Early on, it became crystal clear to me that neighbors and friends had to be a big part of the solution, especially if the healthcare system was not stepping up.”

I started working on a case by case basis to try to solve this need. My initial efforts were quite rough and informal. I would enlist a neighbor or friend to do something a bit more comprehensive then what they had been doing in the past.

Early on, it became crystal clear to me that neighbors and friends had to be a big part of the solution, especially if the healthcare system was not stepping up.

Eventually, I began experimenting with an early version of what would now be called home sharing. There were many older individuals in my practice. I saw them downsizing within their own house by closing off the second floor, closing off half of the first floor, and perhaps not driving. They were effectively living in their condo of one or two rooms at the center of a big house.

At the same time, other patients of mine were parents with a newborn who struggled to afford a place to live, or a newly divorced woman who did not have FULL CIRCLE AMERICA CASE STUDY: AGING IN PLACE AND COMMUNITY

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enough income to buy her own place. It quickly occurred to me that we could find ways to match people who needed housing with people who had excess housing.

In the mid 1990s, I created a small home sharing pilot project with about a dozen different couples. Some of the participants became really excellent caregivers.

The sharing worked in both directions: an individual or couple could move into the elder’s house, or the elder would move into the spare bedroom of the couple’s house. Very often, the sharing arrangement was economically viable.

There might be a woman or man who wanted to be a stay at home parent with his or her newborn. This option was more desirable than the option of going back to work for entry level wages while having to pay for childcare. It was more cost effective and rewarding to stay home and get paid the effective assisted living rates for having an older person living in your house. The older person acted as a surrogate grandmother or grandfather.

In theory, the sharing arrangement could be win/win for everyone, but there were only a few highly successful matches. I underestimated how quickly older individuals’ situations might change. I had not factored in the difficulty of a younger person taking care of someone who could become paranoid or combative as she aged.

That was my first foray into seeking a way for seniors to age in place and in community. Another sobering issue was and is that many older people are poor.

To maintain a house or to move into someone else’s house and pay rent was not affordable.

My next step was a five or six year detour where I started a small network of affordable, home like assisted living facilities. The goal of finding a way for people to stay in their own homes was always in the back of my mind. From 2001 to 2003, I began to reexplore the use of technology to help people stay at home.

Cell phones were becoming more of a staple than they had been just a few years earlier. Having an easily accessible communication tool for isolated elders opened the door to new possibilities. That led to my understanding that the solution had to be a combination of high tech and high touch. It was not truly high tech or high touch, but it was more technology than what the elder community was using at the time. That was the beginning of what inspired me to start Full Circle America.

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JG: At that time, were other organizations providing aging in place or healthcare at home?

“One cannot pick up any periodical and not find stories about how old we are becoming as a country, and how much worse it is going to be in the next ten to twenty years if we do not innovate our care delivery.�

AT: Ambulatory care was growing, but there were no comprehensive aging in place options. Today, there still is nothing comprehensive. I expected enormous growth in the field of aging in place and community. Over the last decade, and more so every year, one cannot pick up any periodical and not find stories about how old we are becoming as a country, and how much worse it is going to be in the next ten to twenty years if we do not innovate our care delivery. Given the demographics, the economics, and the potential opportunity, I expected many players to become comprehensive home health providers. I was quite surprised that even though everyone was talking about home health, very few were entering the field.

There were pioneers in different areas. I was fortunate enough to meet a couple of them. One was originally from the Silicon Valley area. Another one came from North Carolina via India. They both lived in my neighborhood in Maine. They spent a few years experimenting with technology to enable elders to stay in their own homes. They convinced Time Warner to give them their patent research space so they could continue to design their technologies. They had a number of patents and a prototype that I think would even wow people today. At that point, there was no bandwidth. There was still no community wide internet to access.

They were ahead of their time and ahead of internet accessibility. Even seven years ago, when I was trying to provide video monitoring services to someone in a town nearby, one street had internet and another street did not. You could not really build a business without internet access. This remains the sad case in much of rural America today. Those were some of my initial hurdles.

Xanboo was another small home health video monitoring platform. Xanboo would compete against anything in the market today. I started using some of

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their equipment. I worked with some of their engineers to design fancier things than what they had envisioned.

Quiet Care was another company that pioneered much of the artificial intelligence around motion sensing. If someone went in and out of the refrigerator and moved around the kitchen, the technology would tabulate all of those movements. If it sensed a half an hour or forty five minutes of activity around the kitchen, it would label that activity lunch. If a client just opened and closed the refrigerator and then moved to another room, that was labeled snacking.

Quiet Care designed several things that would enable us to determine common or unusual behavior for an individual. I used devices from both Xanboo and Quite Care in the same houses to learn where they were complementary and where they were at odds with each other. I was able to learn what motion sensors and video monitoring accomplished. I began to design a care model around those capabilities.

There were a number of companies experimenting in the field. I had the chance to communicate with and occasionally be courted by people who were doing work with Bell Labs and AT&T. AT&T was starting a digital division. Verizon was experimenting with what now is their webcam for homecare. Cisco was dabbling in the field also.

Interestingly, all of the business communities were looking at this area primarily through the lens of home security and not necessarily people security. I had my points of view solicited by many fairly big players. They all thought that I was too much of a dreamer.

More importantly, their business model was to make a gadget that they could charge a recurring revenue fee for and be done. The idea of human interaction and dealing with the messy daily lives of people was more liability and more complexity than they wanted to take on. That was discouraging.

AT& T had some very forward thinking people in their digital division, but, at the end of the day, they said very pointedly to me that they would rather see if I succeeded and buy my company for one hundred million dollars, five years from now, than give me five hundred thousand dollars to help me get started. Their business model was to buy the providers that were left standing rather than to FULL CIRCLE AMERICA CASE STUDY: AGING IN PLACE AND COMMUNITY

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help pioneer the work that needed to be done. I think that was illustrative of other challenges I have faced.

The Birth of Full Circle America JG: Did you approach the Centers for Medicare and Medicaid Services for support?

AT: Yes. In 2011, I had been fortunate to cross paths with Doris Buffet, Warren Buffet’s sister. She has a summer place in Maine. I approached her and gave her a copy of my book, Alone and Invisible No More. 1 Several months later, she gave me the funds to compete for a grant from the Centers for Medicare and Medicaid Services.

In 2012, the Centers for Medicare and Medicaid Services were accepting applications for programs that would address the needs of their frail and elderly beneficiaries in a way that would reduce costs of care and improve quality of life.

I thought Full Circle America was a perfect fit. The Centers had several billion dollars in total and were giving away ten to thirty million dollar grants.

I began hiring a team of people and building a platform. I created a group that could bring the fledging model that I had developed over the preceding five or six years to a number of other communities. Our proposal was ambitious. I wanted to replicate this model in twenty five communities in year one, one hundred communities in year two, and another five hundred communities in year three. It was clearly absurd in some respects.

If we enrolled fifty people in each of those five hundred communities, and we kept growing at that rapid pace for a decade, at the end of a decade, we would have reached one half of one percent of the target population. The ambitious proposal was not based on my megalomania. It was based on the fact that this was the scale of work we had to do if we really wanted to address the aging tsunami that we are facing.

The reviewers at the Centers for Medicare and Medicaid Services must have been intrigued enough by the proposal. The reviewers replied with a five page critique of my one hundred page proposal. In summary, they said that they hoped it would succeed, but it needed much more refinement. The proposal needed to be conducted on a much smaller scale first.

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The reviewers doubted that elders could embrace technology. They doubted that volunteers could play a significant role in the lives of elders. The summation sentence was that they turned down my proposal because I was “thinking outside the box” for an innovation grant. At that point, I was quite discouraged. I did not have a strong Plan B. At least we had fleshed out what we would do if we had funding. We then just continued to refine the model within whichever communities agreed to provide some funding and supportive services.

By that time, my book, Alone and Invisible No More, had been picked up by a national publisher. Many people were interested in the Full Circle model of care delivery. The book inspired many people around the country who, I am convinced, are absolutely ready to implement a model of home health like Full Circle America.

Many sent me heartwarming stories about how they planned to retire from their day job and make elder care their second career. Nurses expressed that person centered elder care is why they went into careers in healthcare. People from religious communities and younger people wrote that they had become inspired to work in elder care. There were many affirmations that we do have a potential workforce and service sector that is absolutely primed to make aging in place and community a reality for our elderly.

Developing Metrics JG: Have you developed standardized assessments for your clients?

AT: Yes. That came out of expediency and necessity. Most of the caregiving agencies wanted to know how to know if somebody qualifies for the services we offer and how we know it will help them. It was reasonable to develop a common language to assess the situation and design a care plan collectively. I created the Independent Living Assessment. The assessment informs the scope of the care plan. Data show that addressing the activities of daily living effectively reduces a person’s healthcare spending and enables her to stay in her house longer.

My assessment has the acronym BFAMES: be famous (See Appendix). It stands for the different components of living independently. The B stands for bathroom and bathing needs and capabilities, including dressing, doing laundry, showering or bathing, shaving, teeth brushing, and hair washing and brushing.

F represents activities having to do with food, such as remembering to eat regularly, cooking, meal planning, eating, and cleaning up. A represents activities FULL CIRCLE AMERICA CASE STUDY: AGING IN PLACE AND COMMUNITY

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like walking, getting in and out of the car, climbing stairs, and getting in and out of a chair. M stands for memory, money, medications, and keeping track of the basics. It gives me insight into the level of cognition. E is everything to do with equipment, including operating the toaster, the stove, the refrigerator, the washing machine, the television, the computer, and running the vacuum.

S is everything to do with support, including having neighbors, friends, or family that are interested. Is the family estranged or living far away? Has the client alienated his care team because he has been such a curmudgeon? It works very well. The client and I can have a five minute conversation and that will enable me to reassure the family members that I have a good idea what the client’s care profile will look like.

The Katz Index of Independence in Activities of Daily Living2 is an assessment that is being used by state agencies to decide how much to reimburse facilities for the amount of care they provide. It is used primarily in long term care facilities.

My assessment was designed to understand the client’s situation and to determine what the client needs in order to stay in his home.

JG: What health outcomes do you measure and how do you measure them?

AT: Before my Centers for Medicare and Medicaid Services rebuff, my metrics were simply, if one wanted to stay in his own home and did not have much money, we would make it possible at a lower cost than other options. I thought that enabling people to stay at home and receive high quality care at a substantially lower cost were the only metrics needed.

The financial metrics in terms of Full Circle America virtual assisted living have always been compelling. When I tally up a client’s expenses here in Maine, including housing and the basics, and add to that expense a three or four hundred dollar monthly support package of technology and targeted homecare from Full Circle America, I come up with a total monthly expense of 1,500 to 2,500 dollars a month. Assisted living facilities charge ten to thirteen thousand dollars a month, depending upon what part of the country one is living in. The savings are somewhere between seventy and eighty percent of what assisted living would be. Even if I am off by a factor of two, it is still a sizable difference.

In terms of the other metrics, I recently created what I call the Chronic Care Vulnerability Index. In January 2015, the Centers for Medicare and Medicaid Services published their Chronic Conditions Data Warehouse.3,4 At this time, the FULL CIRCLE AMERICA CASE STUDY: AGING IN PLACE AND COMMUNITY

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Centers began to offer reimbursement for chronic care management. The reimbursement allows for people who provide for chronic care needs to be paid a monthly chronic care management fee. The goal of the reimbursement was to encourage primary care doctors to care for individuals with chronic needs.

There are three parts to my original vulnerability index: What diseases does the client have? What healthcare services has he or she used recently? What are the client’s social determinants? These make for a rather complicated scoring system.

It is something that should be validated over time. It addresses the triple aim of Centers for Medicare and Medicaid Services: better quality of life, better quality of healthcare, and reduced costs. The index was another way to demonstrate that, since most older individuals are poor, we need to have third party payment from Medicare and Medicaid. Third parties are interested in how to translate various factors into a relatively easy scoring system that many people can use.

The metrics that I added to my original vulnerability index include the independent living assessment that I described earlier, the Healthy Days Measure,5 and a Quality of Life Scale6 These are validated instruments that have been around for twenty years, but I never found anyone in healthcare in the US who uses them. They are used in other parts of the world. The Quality of Life measures have been validated in twenty to thirty countries, with people in all populations and of all ages.

The Healthy Days Measure is a series of simple questions: How would you rate your health: good, bad, or miserable? How many days in the last month has your mental health kept you from doing what you want to do? How many days in the last month has your mental health been good? How many days in the last month has your physical health been good or bad? How many days in the last month has your physical or mental health kept you from doing something you wanted to do?

The assessment takes less than a minute to administer. It is a fairly easy way for us to be able to track outcomes using instruments designed by other players, like the National Institutes of Health, the Centers for Disease Control and Prevention, and the World Health Organization.

We administer each of these instruments on a staggered basis over the course of a year so that we can gather outcomes over time, without taxing the individual. One of the hardest measures is healthcare dollars spent. There is no easy way to access data on an individual’s past healthcare spending. As a provider, I need to have a working relationship with an insurance company, with a Medicare regional office, FULL CIRCLE AMERICA CASE STUDY: AGING IN PLACE AND COMMUNITY

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and with a Medicaid state office to determine a client’s pre enrollment and post enrollment spending. This information is useful in proving that the Full Circle America model creates substantial cost savings.

JG: Can you request shared savings from the insurers?

AT: Absolutely. We could make an arrangement to take on the highest users in a neighborhood and agree on goals. We could share the profits and the risk. The insurers would not have to pay us if we do not deliver. If we deliver savings, then the insurers share that with us. It seems like it would be appealing to insurance providers to have a partner who is willing to make that agreement.

JG: Would the provider using your care model then be able to have a profitable program?

AT: Definitely, yes. I should note that the goal is different for the client and for the family. We offer peace of mind to the family that lives far from their loved ones. They are interested in finding someone to look after their mom or dad.

Oftentimes, the care burden is too great, even for the siblings and children who live in close proximity to their relative. There can be a profound sense of isolation on the part of the adult sons and daughters. Family members often do not know where to turn for help. It is surprising how many adult children of aging parents have tears of gratitude when they find a supportive partner in us and the local supports and services that we connect them too.

Financing Aging in Place and Community JG: How do most of your clients pay for your services?

AT: Most of them pay privately. I have a few clients who are on state assistance and are under a Medicaid program called Money Follows the Person.7 Money Follows the Person is a program sponsored by the federal government. The program takes people who have been residents of nursing homes for a relatively short period of time and returns them to live in the community. The program will end in another year or two.

The federal government will pay one hundred percent of the transition costs and one hundred percent of the first year costs to get people back in the community.

On year two, the payment declines to ninety percent, and year three, to eighty percent.

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For this program to work, states must realize that they will spend less in the long run through this program than what they would have to pay for Medicaid nursing home costs. The Money Follows the Person placements have mostly been for disabled younger adults rather than for elders. Much of that has to do with the array of support systems that many disabled younger adults have in place. In the case of an eighty five year old woman who is in a nursing home, one of the main reasons she is in a nursing home is that she did not have a social support system in her community. Reconfiguring existing community assets – that is, the resources and supports available in the community – is important in enabling aging in place and community.

Several of the long term care insurers will allow people to submit their invoices from Full Circle America as part of their payout benefit from their plan. Only about eight percent of elders in America have a long term care insurance policy.8 Most long term care provider policy writers have stopped writing policies because they cannot control the payout and the cost of the payout.

We have created a model whereby the annual payout is three hundred dollars a month or 3,600 dollars a year, which is far less expensive than senior living and nursing facilities. If an at home solution like Full Circle America and a defined benefit payout produces an affordable premium for the client and a return on investment for the insurance companies, we could revitalize the long term care insurance market. It is a triple win. The providers make a profit, the insurance companies can make a desirable return on their investment, and people can afford long term care insurance. This development has the potential to change the dynamic. Today, the only long term care payout available is for residential care in a nursing home. Residential care is an exorbitant expense for insurance providers.

JG: Is it a challenge to find experienced caregivers? Do you use caregivers of various skill levels?

AT: One does not need an advanced degree to be able to identify that a client is sitting on the couch, walking around the house, or eating at the kitchen table.

One does not need healthcare credentials to gather that useful information. One just has to be organized.

An ideal employee is a part time mom who wants to do this kind of work. Since the services are web based and easily distributed, a stay at home mom could work three or four hours a day, a few days a week, to be a part of the Full Circle FULL CIRCLE AMERICA CASE STUDY: AGING IN PLACE AND COMMUNITY

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America support system. I have mothers of newborns that are doing some of our client monitoring around their parenting duties. There are many nurses, social workers, and other caregivers who went into healthcare to do something more holistic. I have a file folder filled with resumes of people who would love to participate in the Full Circle America program. I do not think that there will be a labor shortage in this model of care.

Tapping Community Assets JG: Could you talk about the peer to peer volunteer component of Full Circle America?

“If we consider each elder client to be a volunteer for someone, each client is a care recipient as well as a caregiver.”

AT: If we consider each elder client to be a volunteer for someone, each client is a care recipient as well as a caregiver. This arrangement makes almost everyone who is enrolled as a participant a potential volunteer. One of the biggest issues for frail elders is isolation and loneliness. There is hardly anyone who cannot participate to some degree. For example, how many elders do you know who are unable to talk with someone on the telephone once or twice a month for five minutes?

Many adult sons and daughters do not have forty hours a week to devote to their parent’s care. If you ask them for a targeted hour or two throughout the course of the week, it is manageable. I start looking for volunteers within the client’s own circle first. Then, I find others who are already in the care network, such as friends, neighbors, relatives, and church mates. Working outward from there, we can fill a fairly substantial care grid. Finally, we access the at large local volunteer supports and services.

We make the volunteer opportunities commensurate with people’s interests and abilities. Some want to be a fireman of sorts and help out when there is a crisis.

They are not the volunteer for playing checkers or bridge once a week. A lot of the volunteering is about making those sticky connections. Once you do, that person is regularly reminded how important they are. Part of our job is to continue to FULL CIRCLE AMERICA CASE STUDY: AGING IN PLACE AND COMMUNITY

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remind people that they are relevant and needed. Volunteers want a connection to their community as much as an isolated elder does.

JG: How do you involve the local supports and services within your client’s community?

AT: I reconfigure existing community assets. I look for infrastructure that already exists and try to build that into the connected support system. These supports are all housed for our client’s on the Bliss CONNECT software platform.

There are many different ways to facilitate relationship building within the community that do not cost much. We find local organizations that provide what our client needs.

Local churches have an established network. Churches are trying to grow their congregation and make it more intergenerational. Churches have community outreach arms for transportation, meals, and companionship. We use their untapped capabilities as part of the client’s care team. We ask them to be a part of the care ecosystem by emailing, texting, phone calling, or otherwise reporting on their occasional interaction with our client. This makes them an integral part of the support solution.

We also engage other local supports. There are approximately ten thousand communities in the United States of around fifty thousand people that make up our population of three hundred million. There are more than ten thousand Young Men’s Christian Associations (YMCAs) in the United States.9 There is a YMCA for almost each pod of fifty thousand people. YMCAs have a wonderful array of facilities with a variety of programs.

The YMCAs were not initially designed to take care of the older population, but, over the years, many have morphed into community based resources. The YMCAs have fitness classes and social events for seniors. The intergenerational interaction is beneficial for all members. The YMCAs are dabbling in chronic care management, obesity prevention, diabetes control, and arthritis programs. Many YMCAs offer seniors a twenty dollar monthly membership. I defy anyone to find as great an array of resources for twenty dollars a month.

Most communities have libraries. Libraries are generally comfortable places for seniors. We make libraries part of our client’s support network. Most towns have junior high schools. If they are serving four hundred students for lunch, having five more lunches for elders is not a tax on their resource. If we at Full Circle FULL CIRCLE AMERICA CASE STUDY: AGING IN PLACE AND COMMUNITY

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America can arrange for our client to enjoy a five dollar lunch and be around the buzz of youthful energy and kids, we create social connection with a bit of entertainment.

Once you put people in those environments, often you have some of the kids taking a shine to some of the elders and asking them if they will come back to their English class and talk about what it was like during the depression because they are reading Grapes of Wrath or go back to their art class and pose for the class to be a model for a portrait. If you do this once a month for an elder who rarely gets out of his house, it has great impact on loneliness. It does not work for everyone everywhere, but I have done it enough to know that local schools are a resource that should not be overlooked.

We take the local community supports that are acting as independent silos and connect them to our clients. We are now able to join these supports together into an easily captured network. I have just begun to use the Bliss CONNECT 10 software that houses all of a client’s support within what I call the Circle of Caring.

JG: How do you find local supports and services for each client?

AT: I found that it takes us at Full Circle America somewhere between an hour and two hours to completely mine what a client’s community has to offer. There is a methodology to that process. We look for churches, libraries, schools, senior centers, YMCAs, community colleges, interfaith action programs, meal providers, volunteer transportation services, and lifelong learning institutions.

Bliss CONNECT and the Role of Technology JG: How does the Bliss Connect platform work within your care model?

AT: Pankag Khare, the designer of Bliss CONNECT, has a team of about fifty engineers and people in India that supplement the business support group in North Carolina. This platform addresses all of the nonmedical and medical needs in a sophisticated way.

In the past, Full Circle America had a robust video monitoring platform, but that was all it did. The video monitoring platform did not have a way to host secure multiparty video conferencing. The platform did not have a way to notify and collect secure, active communications among all members of a care team. The platform did not have the ability for multiple members of the care team to be FULL CIRCLE AMERICA CASE STUDY: AGING IN PLACE AND COMMUNITY

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notified about different things. The platform did not have the ability to give alerts and reminders to our clients. The platform did not have the ability to connect clients to blogs and social networking. The platform did not have the ability to shop online. The platform did not have the ability to integrate personal entertainment like music videos. The platform did not have a way for clients to create end of life or emergency preparedness plans, or keep medical and other important documents in one secure and accessible place.

An example of one of the noteworthy capabilities of Bliss CONNECT is that when a client visits an emergency room in another town, she or her children can use a tablet to access her advanced directive and medical records from her primary doctor. Bliss CONNECT also provides the ability to fax the hospital and doctor the information stored in the secure vault on the platform. It is a common concern among people that they do not have an easy way to carry around their health records.

JG: What devices do you use for remote monitoring and how do they incorporate the Bliss CONNECT platform?

AT: We use active and passive devices. For our passive devices, our clients do not have to press buttons or have any computer literacy. Passive devices include video and motion monitoring systems. These involve a couple of webcams, a couple of motion sensors, and a door sensor. These cameras and sensors are all connected to a central hub. The cameras create live video and stored snapshots that are date and time stamped. That information can quickly identify whether a client’s pattern is the same as any other daily pattern or whether it is unusual behavior.

“It is hard to convey to people who have not done this how much we all are creatures of habit.”

It is hard to convey to people who have not done this how much we all are creatures of habit. It is hard to convey how informative it can be to have someone looking at the camera in your living room for two minutes, once a day. We can determine whether something is out of place or everything is exactly the same as what it was before.

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Often, our task is as basic as noticing that a client isn’t sitting in the particular chair that he or she always uses. We could also observe that the mail is on the side table and it is always in the kitchen. We could observe someone in their bathrobe at noon while their regular pattern is to be dressed by 6 or 7 am. A client could be telling us that he has not had company in weeks while the video tells us there have been many people visiting him. In that case, the client does not remember or does not have a sense of time. Passive video monitoring gives us a phenomenal amount of information.

The client must participate one way or another with the active devices. The active video or interactive video is important. Our clients confirm that having a video conversation is a richer experience for them than a phone call. Video connection helps to address loneliness and isolation. We make the video connection process easy for our clients, including frail elders. Clients only need to tap a touch screen.

To ensure ease of use, Full Circle America uses technology that requires a one or two step process. Anything more than two steps has the potential to overwhelm a person who is not used to using computers.

We are morphing Bliss CONNECT into an expansive care team that coordinates care and information through one secure location. We are able to bring the whole care team, medical and nonmedical, into our client’s house via a video call.

This capability enables us to do telemedicine and telecare. Telecare allows the nurse, social worker, physical therapist, occupational therapist, and medical assistant to communicate with our client in the same way. The care team members all have access to an electronic health record that is stored on the platform. The members of the care team all have a way to play on the same team and break down the isolated silos that typically exist, either in the healthcare world and, just as importantly, in the informal care community. Using Bliss CONNECT is the game changer for Full Circle America expansion.

JG: Are there any other devices that you use as monitors?

AT: We put together a chronic care kit that includes a blood pressure cuff, a pulse oximeter, a peak flow meter, a pedometer, a glucometer, and a scale. The monitors can either be manual, which is cheaper, or Bluetooth enabled, which sends information directly to the platform. The clients take the reading and give a number to store in the device. A client can either read that number to me when I talk to her, or her caregiver can enter it into the her file on the Bliss CONNECT platform. Monitoring blood pressure several times a week rather than once every FULL CIRCLE AMERICA CASE STUDY: AGING IN PLACE AND COMMUNITY

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three or four months is a big improvement in managing a client’s cardiovascular status.

The impact of remote monitoring is impressive with diabetes. Diabetes management is far ahead of other fields. There are many improvements in glucose monitoring because of active consumers in that field. In terms of elder care, there is not the same amount of advocacy. I can put together a kit that includes a pulse oximeter, pedometer, blood pressure cuff, scale, and a peak expiratory flow meter for around seventy five dollars. That price should be within the budget of every healthcare plan because it allows us to measure heart and lung health and to manage chronic disease. The Bliss CONNECT platform has the ability to store and graph the monitoring data. Bliss CONNECT can also send alerts when appropriate.

Another aspect of chronic care management is the correct use of medications.

Medication errors are a common cause of hospital admissions. Roughly fifty percent of people over sixty five are taking their medications incorrectly.11 Failure to adhere to recommended prescription doses and schedules are the cause of over eleven percent of hospital admissions.12 When you consider the contribution to healthcare spending, anything we can do to improve medication adherence should be a big part of all providers’ chronic care solution.

JG: How do you address the issue of adherence to medications?

AT: The way we address correct medication adherence ranges from simple to exotic. We use a little seven compartment flip top device that organizes a client’s daily medications. Our computer platform can remind our clients to take their medications by email, text, or automatic phone call. With Bliss CONNECT, we can send and receive alerts when they have not taken their medications at the correct time.

Sometimes, we use the electronic medication management device called MedFolio.13 MedFolio is an electronic device that sends alerts to clients to remind them to take their medication. If our client has not taken his medications within thirty minutes of the scheduled time, MedFolio starts to beep. If our client has not taken his medications thirty minutes later, MedFolio phones them. If our client hasn’t taken his medications another thirty minutes later, MedFolio calls me. The device is very efficient. We can even change the programming online. We also do a medication review from time to time.

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Problems related to medications in the over sixty five population create health system costs that rival the individual costs of Alzheimer’s disease, cancer, cardiovascular disease, and diabetes.14 Another issue is what is prescribed.

Benzodiazepines that the American Geriatric Society has listed as an inappropriate drug for older people since 2012 are still widely prescribed. The British Medical Journal (now known as the BMJ) linked the use of benzodiazepines to an increased risk of Alzheimer’s disease.15 We do periodic reviews to ensure that our clients are not overmedicated. It is increasingly apparent to most in the healthcare world that blood pressure, diabetes, and cholesterol medicines are used too aggressively in treating seniors.

There is a plethora of data about the overmedication of the senior population.

One statistic estimates that seniors sixty five to seventy nine years of age receive over twenty seven prescriptions for new drugs per year.16 We need a different guideline for prescription medications for seniors. Today, seniors are medicated using the same guidelines of the younger healthier population.

JG: Are your devices interoperable?

AT: Yes, our devices are interoperable. They use a Linux operating system. The system can easily integrate the communication from any other tools or devices that use the common operating system. The only limitation that exists between the tablet device and its operating system is when they are working with a vendor that does not want to share information. It is possible for the Bliss CONNECT system to integrate with others, but there are players who have proprietary technology and do not want to integrate. If they do not share their machine, the machine communication, or operating system abilities, we are locked out.

JG: How do your clients access all of this stored data?

AT: The data is all web based. Our clients communicate via the internet, through their home computer or through a tablet. We have chosen a tablet or a mini personal computer that is affordable and works well.

JG: Do you provide the devices for your clients?

AT: If our client has a tablet that he is fond of, he uses that. If he has nothing already, we will sell him a preloaded, preconfigured system for approximately four hundred dollars. With that, we can provide a robust Android device that is preconfigured with all of the components. Clients can either pay up front or pay FULL CIRCLE AMERICA CASE STUDY: AGING IN PLACE AND COMMUNITY

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twenty five dollars a month until it is paid off. We try to make it easy to obtain and use.

JG: Who makes up the care team other than you, the doctor?

AT: At the core of the Full Circle America care team is an angel. An angel is our term for someone whose job it is to be a surrogate son or daughter, a good friend and confidant, and a fitness coach. The angel is someone who stays closely connected to the client through a phone or video call, at least once per week.

We also use a case manager, who organizes the logistics of the workload for each angel. The caseload of each angel ranges from one to forty to one to eighty customers. We have three angels to every nurse and two nurses for every doctor.

The doctor’s load is anticipated to be approximately one per five hundred.

This structure allows us to provide a team on a regular basis for each client, for an average of three hundred dollars, per client, per month. Bliss angels spend a minimum of a half hour per week with each client. Nurses spend around an hour a month with every client. The doctor spends a half hour per month with every client. Our clients can have a virtual doctor visit and a nurse visit every month, along with a half hour of a support person every week for three hundred dollars a month. That is a good price.

JG: Do you coordinate your services with the client’s primary care team?

AT: Absolutely. It is important to connect with the client’s medical providers early in the enrollment process. We have a nurse or doctor call the client’s doctor’s office to tell them that their patient is enrolled in one level of our care programs. We invite the doctor and other care team members to be as involved with our support of their patient as they like. Health and treatment information is shared fluidly with the existing medical team.

JG: Do you foresee health insurers funding your services and this kind of aging in place care?

AT: Eventually. I do not see the tide turning very quickly. That just has not been the experience that I have had to date. I think the missing link is a strong grassroots movement. The pressure will come from individuals and communities clamoring for this.

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If Full Circle America can establish a handful of very successful, very visible community efforts, things may change quickly. If we wait for the Accountable Care Organizations and the typical healthcare policymakers to come around, we are going to be waiting for a long time.

JG: Wouldn’t insurers push for your model of care?

AT: Insurers could realize financial gain. Yet, the Medicare Advantage plans are having a record year, in terms of profits. They are making so much money that even though they are giving lip service to the triple aims of cost cutting, better health outcomes, and more access along with shared savings, they do not have an incentive to change. I wish I had a rosier outlook, but congressmen do not listen to stakeholders who have a financial gain in this. It can appear to policymakers that I am advocating only to profit from my model of care.

Reimbursing for Full Circle America and others’ home healthcare and support services has the potential to save insurers a lot of money. As long as insurers are making as much money as they are making right now, I do not think that they feel any sense of urgency to reimburse any differently.

JG: What are your plans for the future of Full Circle America?

AT: I hope to inspire grassroots movements. I am going to southern Rhode Island next week to begin building a team and to establish a care network for new clients. We are also preparing for a pilot program in Steuben County, New York.

The Steuben County Office for Aging, the Senior Services Fund, the churches, and a fleet of other service providers in the area are prepared to promote and support a Full Circle America pilot program. Together, the local support and service organizations have put together their action plan and a timeline for broadly rolling out Full Circle America and letting the work of Full Circle America define a good part of the work of their organizations. The work these organizers have put in toward launching this pilot program shows their level of commitment to the community and their dedication to their elderly population.

JG: Is there anything you would like to add to our discussion?

AT: Internet connection is still an issue in rural America There is a telecom initiative to provide internet to every library in Steuben County. There are about fifteen or twenty libraries scattered throughout the county. There are several initiatives, through the rural telecom carrier networks, working to provide FULL CIRCLE AMERICA CASE STUDY: AGING IN PLACE AND COMMUNITY

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broadband coverage to the remotest parts of America.17,18,19 Many of those initiatives are looking for what services they can run through their lines to justify their investment. I try to convey to them the advantages of delivering telemedicine and video medicine support to the community.

Having the Bliss CONNECT software platform is important in encouraging companies to run internet connections to rural neighborhoods. The ability to bring the visiting nurse, the social worker, the physical therapist, the occupational therapist, the doctor, and other specialty medical support into the homes of elders could be compelling enough to bring in better internet connectivity. Better connectivity could transform the ability of underserved areas to get such specialty care, from rheumatology to psychology to neurology, cardiology, pulmonology, and renal specialists. Once you have a system for other players to work through, the possibilities are limitless.

JG: Thank you for this very interesting discussion.

AT: Thank you.

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Appendix Full Circle America Metrics Summary Name: Date of Birth: 1) Member Goals and Aspirations (Taken from intake/interview form) a). b). c).

2) Member Financial Outcomes (Some items from member, rest of financial data from third party insurers) a). Out of pocket healthcare costs b). Living expenses c). Family support ($ or in kind) d). Emergency department expenditures e). Hospital costs f). Skilled nursing facility costs g). Long term care residential costs h). At home support costs

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3) Independent Living Assessment INFORMANT: DATE ASSESSED:

BY WHOM: 1

ACTIVITY/SCORE

0

(CHECK APPROPRIATE BOX)

(CAN'T DO AT ALL)

2

(CAN DO SOME (CAN DO MOST OF OF THE ACTIVITY THE ACTIVITY MOST OF THE MOST OF THE TIME TIME) WITHOUT HELP)

TOTAL SCORE

BATHROOM TASKS FOOD TASKS AMBULATION MENTAL HEALTH EQUIPMENT SUPPORT/SAFETY

4) Healthy Days Measure a) Would you say that in general your health is excellent, very good, good, fair or poor? _______ b) Now thinking about your physical health, which includes physical illness and injury, how many days during the past thirty days was your physical health not good? _______ c) Now thinking about your mental health, which includes stress, depression, and problems with emotions, how many days during the past thirty days was your mental health not good? ________

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d) During the past thirty days, approximately how many days did poor physical or mental health keep you from doing your usual activities, such as self care, work, or recreation? _______ 5) World Health Organization Quality of Life Questionnaire 1. How would you rate your quality of life?

1 Very Poor/ 2 Poor/ 3 Neither/ 4 Good/ 5 Very Good 2. How satisfied are you with your health?

1 Very Dissatisfied/ 2 Dissatisfied/ 3 Neither/ 4 Satisfied/ 5 Very Satisfied How much you have experienced the following things in the last two weeks?

3. To what extent do you feel that physical pain prevents you from doing what you need to do?

1 Not At All/ 2 A Little/ 3 A Moderate Amount/ 4 Very Much/ 5 An Extreme Amount 4. How much do you need any medical treatment to function in your daily life?

1 Not At All/ 2 A Little/ 3 A Moderate Amount/ 4 Very Much/ 5 An Extreme Amount 5. Do you have enough energy for everyday life?

1 Not at all/ 2 A Little/ 3 Moderately/ 4 Mostly/ 5 Completely 6. How well are you able to get around?

1 Very poor/ 2 Poor/ 3 Neither Poor Nor Well/ 4 Well/ 5 Very Well 7. How satisfied are you with your sleep?

1 Very Dissatisfied/ 2 Dissatisfied/ 3 Neither Satisfied Nor Dissatisfied/ 4 Satisfied/ 5 Very Satisfied 8. How satisfied are you with your ability to perform your daily living activities?

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1 Very Dissatisfied/ 2 Dissatisfied/ 3 Neither Satisfied Nor Dissatisfied/ 4 Satisfied/ 5 Very Satisfied 9. How satisfied are you with your capacity for work?

1 Very Dissatisfied/ 2 Dissatisfied/ 3 Neither Satisfied Nor Dissatisfied/ 4 Satisfied/ 5 Very Satisfied 10. How much do you enjoy life?

1 Not At All/ 2 A Little/ 3 A Moderate Amount/ 4 Very Much/ 5 An Extreme Amount 11. To what extent do you feel your life to be meaningful?

1 Not At All/ 2 A Little/ 3 A Moderate Amount/ 4 Very Much/ 5 An Extreme Amount 12. How well are you able to concentrate?

1Not At All/ 2 Slightly/ 3 A Moderate Amount/ 4 Very Much/ 5 Extremely 13. Are you able to accept your bodily appearance?

1 Not At All/ 2 A Little/ 3 Moderately/ 4 Mostly/ 5 Completely 14. How satisfied are you with yourself?

1 Very Dissatisfied/ 2 Dissatisfied/ 3 Neither Satisfied Nor Dissatisfied/ 4 Satisfied/ 5 Very Satisfied 15. How often do you have negative feelings such as blue mood, despair, anxiety, depression?

1 Never/ 2 Seldom/ 3 Quite Often/ 4 Very Often/ 5 Always 16. How satisfied are you with your personal relationships?

1 Very Dissatisfied/ 2 Dissatisfied/ 3 Neither Satisfied Nor Dissatisfied/ 4 Satisfied/ 5 Very Satisfied 17. How satisfied are you with your sex life?

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1 Very Dissatisfied/ 2 Dissatisfied/ 3 Neither Satisfied Nor Dissatisfied/ 4 Satisfied/ 5 Very Satisfied 18. How satisfied are with the support you get from your friends?

1 Very Dissatisfied/ 2 Dissatisfied/ 3 Neither Satisfied Nor Dissatisfied/ 4 Satisfied/ 5 Very Satisfied 19. How safe do you feel in your daily life?

1 Not At All/ 2 Slightly/ 3 A Moderate Amount/ 4 Very Much/ 5 Extremely 20. How healthy is your physical environment?

1 Not At All/ 2 Slightly/ 3 A Moderate Amount/ 4 Very Much/ 5 Extremely 21. Have you enough money to meet your needs?

1 Not At All/ 2 A Little/ 3 Moderately/ 4 Mostly/ 5 Completely 22. How available to you is the information that you need in your day to day life?

1 Not at all/ 2 A Little/ 3 Moderately/ 4 Mostly/ 5 Completely 23. To what extent do you have the opportunity for leisure activities?

1 Not at all/ 2 A Little/ 3 Moderately/ 4 Mostly/ 5 Completely 24. How satisfied are you with the condition of your living place?

1 Very Dissatisfied/ 2 Dissatisfied/ 3 Neither Satisfied Nor Dissatisfied/ 4 Satisfied/ 5 Very Satisfied 25. How satisfied are you with your access to health services?

1 Very Dissatisfied/ 2 Dissatisfied/ 3 Neither Satisfied Nor Dissatisfied/ 4 Satisfied/ 5 Very Satisfied 26. How satisfied are you with your transportation?

1 Very Dissatisfied/ 2 Dissatisfied/ 3 Neither Satisfied Nor Dissatisfied/ 4 Satisfied/ 5 Very Satisfied Score: ____________% FULL CIRCLE AMERICA CASE STUDY: AGING IN PLACE AND COMMUNITY

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6) Combined UCLA / DeJong Gierveld Loneliness Scales Total Score: ____________ Marital status: a) single or b) married; Living arrangements: a)lives alone or b) not alone.

How often do you..... Hardly Ever (1 pt), Some of the Time (2 pts), Often (3 pts) a) feel a general sense of emptiness? b) feel that you lack companionship? c) feel left out? d) feel isolated from others? e) feel there is someone I can rely on when I have a problem? f) feel your neighborhood is safe? g) volunteer? > one hundred hours a year? How many? ___ h) provide or receive any kind of family help?

1 http://www.amazon.com/Alone-Invisible-More-Grassroots-Technologies/dp/1603583793 2

http://consultgerirn.org/uploads/File/trythis/try_this_2.pdf https://www.ccwdata.org/web/guest/home 4 https://www.ccwdata.org/cs/groups/public/.../ccw_userguide.pdf 3

5

http://www.cdc.gov/hrqol/pdfs/mhd.pdf http://www.who.int/substance_abuse/research_tools/whoqolbref/en/ 7 http://www.medicaid.gov/medicaid-chip-program-information/by-topics/long-termservices-and-supports/balancing/money-follows-the-person.html 6

8

http://www.aplaceformom.com/senior-care-resources/articles/long-term-care-costs http://www.ymca.net/history 10 https://blissconnect.com/bliss/ 11 http://www.aplaceformom.com/blog/10-30-13-common-medication-mistakes-to-avoid/ 12 Marek, K.D., Atle, L (2008). Patient safety and quality: an evidence based handbook for nurses.

Agency for Healthcare Research and Quality (U.S.).

13 https://www.medfoliopillbox.com 9

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14 American Society of Consultant Pharmacists Fact Sheet. https://www.ascp.com/articles/aboutascp/ascp-fact-sheet 15 Billiotti de Gage, S, Moride, Y., Ducruet, T., Kurth, T., Verdoux, H., Tournier, M., Pariente, A., & Bégaud, B. (2014). Benzodiazepine use and risk of Alzheimer’s disease: case-control study. British Medical Journal, 349:g5205.

16 Beveridge, R., MD (2014). Many senior citizens take too many medicines –here’s how to fix it.

Forbes Pharma & Healthcare, Dec. 10.

17 https://www.fcc.gov/general/telecommunications-service-rural-america 18 https://www.fcc.gov/news-events/blog/2014/11/20/closing-digital-divide-rural-america 19 https://www.whitehouse.gov/the-press-office/2011/02/10/president-obama-details-plan-winfuture-through-expanded-wireless-access

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ACCESS Health International works to help provide high quality, affordable care for the elderly and the chronically ill. Our method is to identify, analyze, and document best practices in managing the elderly and chronically ill patients and to consult with public and private providers to help implement new and better cost effective ways to care for this population. We also encourage entrepreneurs to create new businesses to serve the needs of this rapidly expanding population.

At present, ACCESS Health works on these issues in high income countries, including Singapore, Sweden, and the United States. ACCESS Health is working to expand this work to low and middle income countries, including India and China.

According to estimates from the US Department of Health and Human Services, people aged sixty five and older will represent nineteen percent of the population by 2030, up from just over twelve percent in 2000. And a 2013 survey by the Pew Research Center found that seventy five percent of adults in this age group are living with a chronic condition, such as high blood pressure, diabetes, or heart disease. With four in ten Americans currently tasked with the care of their elderly and chronically ill relatives, the US healthcare system urgently needs to adjust to meet the rapidly growing demand for high quality and affordable elder and tong term care. ACCESS Health United States helps practitioners and policymakers locate, learn from, and scale up pockets of excellence in elder and long term care.

Learn more at www.accessh.org.