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Healthy Aging At Home

Heathy Aging at Home (HAH) Program

The Upper Peninsula Health Care Solutions – Healthy Aging at Home (HAH) project addresses the needs of an aging population in Michigan’s Upper Peninsula by coordinating regional primary health, behavioral health, and social services and by improving access to integrated care for some of the most vulnerable older adults in the region. The goal of the HAH project is to increase the number of people who are 55 years of age or older, have a chronic disease diagnosis of heart disease, diabetes, or cognitive change, and who are currently living in their homes in Baraga, Gogebic, Houghton, Keweenaw, or Ontonagon counties, to age in place. The project brings together clinical partners, the regional health information exchange, and community-based organizations to identify, outreach, engage, and provide a broad range of supports to enrollees in these rural communities.

The HAH project will address the shortage of programs and services to help older adults maintain their health and independence by implementing a home-based, patient centered care coordination approach for people over the age of 60 living in the target region who have a chronic disease diagnosis.

Who is eligible?
• Individuals 55 years+ of age.
• Have a chronic diagnosis of heart disease, diabetes and/or cognitive change.
• Currently living in their home in the five-county region of Baraga, Gogebic, Houghton, Keweenaw, and Ontonagon Counties.

HAH Team are experienced, compassionate health professionals who can:
• Help remove barriers that prevent patients from receiving services.
• Help improve the quality of care.
• Help provide some health monitoring and services without leaving home.
• Help ensure the home continue to be safe and has all needs met.
• Help patients connect with and access eligible programs and services.

Projected Outcomes
• Enhanced access to programming and services for enrollee social determinant of health (SDoH) needs through partnerships with external organizations, improving healthcare providers’ ability to address referrals.
• Increased compliance with recommended care and services by providing in-home assessments, resulting in a higher percentage of enrollees having received comprehensive physicals, cognitive screenings, and documented advance care plans.
• Improved health outcomes for enrollees through better adherence to care recommendations, remote services, and monitoring, leading to better blood pressure control for those with hypertension and reduced hemoglobin A1c levels for those with diabetes.
• Project staff will utilize UPHIE data to evaluate outcomes regularly and collaborate with partners to address any deficiencies.
• Anticipated community-level benefits include decreased emergency department utilization and hospital readmission rates among UPHCS HAH program enrollees, along with improved self-reported perceptions of health. Surveys conducted annually will gather enrollees’ feedback on the project and suggestions for improvement.

Partners
• Keweenaw Bay Indian Community
• Upper Great Lakes Family Health Center
• Caregiver Incentive Program
• Superior Alliance for Independent Living (SAIL)
• Little Brothers Friends of the Elderly (LBFE)
• Upper Peninsula Commission for Area Progress (UPCAP)
• Alzheimer’s Association

Healthy Aging at Home is proudly funded through the Michigan Health Endowment Fund.
The Michigan Health Endowment Fund works to improve the health and wellness of Michigan residents and reduce the cost of healthcare, with a special focus on children and seniors. You can find more information about the Health Fund at www.mihealthfund.org