Developing and Sustaining Integrated and Collaborative Services in a

Community: Roseville Area Healthy Living for a Lifetime

Prepared by the Roseville Area Consortium

Presented By:Mary Ann Blade, CEO

Minnesota Visiting Nurse Agency

Where Are Elders (65 years and older) Located in Minnesota?

• Minnesota: 12.0% of total population

• Metro Area: 13.0%• Minneapolis: 9.1%• St. Paul: 10.3%• Ramsey County: 11.64%• Roseville: 20.3%

(US Census Data 2000)

Suburban older population is more than three times larger

than the urban older population in Minneapolis and St. Paul

From 1990 to 2000 Roseville paralleled the Metropolitan area

losing population in both the very young (0-5) and the 20 through 34

age group. The most dramatic difference was the growth in the

older seniors (75+), where Roseville had nearly four times the growth as

the County and Metro areas.

(City of Roseville Demographic Summary, January 2003 ed.)

Our Service Area Includes

1. Roseville

2. Little Canada

3. Falcon Heights

4. Lauderdale

5. Parts of Arden Hills,

6. Shoreview &

7. Maplewood

Historic Evolution of the Collaboration

• A Community group formed a Block Nurse Program.

• Partnered with the school system to be the fiscal agent and share a

project coordinator.

• Partnered with MVNA to provide the Home Care Services.

• Block Nurse Program dissolved in 2007 because of lack of funding.

• However, the seeds of what could be were planted because of these

visionary and enthusiastic citizens.

• Two organizations continued to fund and vowed to work together to bring a new collaborative together

•School District 623•MVNA

• Continue to pay for basic services that were not covered from mid-

2007 until today.

Task Force

Representatives of the following organizations:• North Suburban Senior Council• Roseville Area School Board• School Community Education• Roseville Area Senior Program• Home Care Agency – MVNA• Lyngblomsten• Local Parish Nursing• The Community

Task Force Members Include

- Karen Schaub - Jerry Irsfeld

- Janell Wampler - Sandi Krohn

- Mary Ann Blade - Paul Mikelson

- Lisa Edstrom - Esther Tatley

Vision

We, the people;• Could stay at home as long as we’re

able,• in our own familiar setting,• live in a community that provides us an

opportunity to stay healthy and engaged,• provides access to an array of services

when we are ill,• and allows us to die with dignity in the

setting of our choice.

Goals

• Keep the seniors of the Roseville Area physically, mentally, and spiritually

healthy. • Provide seniors with a coordinated

package of formal and informal services and resources that will keep them independent as long as possible.

• Utilize current community resources and long-standing and collaborative partnerships to augment and support a new system.

Goals (continued)

• Ensure that seniors in the Roseville District understand how to access services provided by the consortium.

• Reduce or delay nursing home placement as well as unnecessary hospitalization.

Secret

Most organizations in a community have all the services necessary to provide comprehensive care and

support!

Challenges

1. Breakdown the silos that separate organizations

2. Open to look at ALL the possibilities

3. Think in the “We” versus “I”

4. Modify, enhance, tweek, what my organization offers to meet the broad needs of the senior population

5. Taking a risk when health care is so competitive

6. Finding the money and resources to be creative

Key Components

1. A voice for seniors that enables them to plan and create the services available for them in their community.

2. A central place where people can access guidance for all types of service needs, whether the person provides services or receives services.

Key Components(continued)

3. Prevention and early treatment of chronic illness• Activity for Seniors• Exercise• Social and Entertainment• Education and Support

• Medical/Dental/Emotional Health• Yearly check-ups• Early detection

Key Components(continued)

• Services that are available to help people before they are ill:

• Financial• Chore• Homemaker• Nutritional/meals/grocery shopping• Lifeline• Community resources• Foot care

Key Components(continued)

4. Acute & Chronic Illness (Additional services)• Medical/hospital• Care Coordination• Home Care

• Skilled Nursing• Home Health Aide• Therapy Services – PT, OT, Speech• Pharmacist• Social Worker

• Caregiver support• Transportation• Parish Nursing• Respite• Housing and Assisted Living• Nursing Home

Key Components(continued)

5. Death & Dying• Palliative Care Services• Hospice Services• End of Life Support

Financial

Many of these resources are already being paid for or funding raised

$

Barriers to Our Process

1. Time to plan2. Finances to fill in the gap areas where no

funding is available today

However, we’ve developed a camaraderie resulting in:• Trust• Innovation• Sharing “the elephants” in the room• Moving forward together• Thinking broader than our own organization

Roseville AreaSenior Program

North Suburban

Senior Council

MedicalCare Coor.

Medical

Clinic

PA/NP

Physician

County State

Involvement

ThinkTank

Fundraising

Guidance

Design

Volunteer ActivitySocial

Activities

Caregiver Support

Education Programs

Information Resources

Transportation

Drop-InDining

Exercise

Home Delivered

MealsOther

Community Non-

traditional Services

MVNACare

Coor. HC

Lyng-blomstenCare Coor.

AL/NH

Hospital

Skilled Nursing

Therapies

Case Coordination

LifelinePharmacist

Hospice

Financial Worker

Transitional Care

AssistedLiving

Parish Nurses

RehabSeniorCenter

Gathering

6 Church Affiliations

Foot Care HHA

HMK

Volunteer Training

CommunityWellness Nurse

Care Team Ministry

Advocacy

Chair

PalliativeCare

Club 100

Roseville AreaHealthy Living for a Lifetime