1. RURAL STEARNS LIVE WELL
AT HOME COALITION
This project is supported, in part, by a
CS/SD grant from the Minnesota
Department of Human Services.

2. WHO ARE WE? INTRODUCTION
The Rural Stearns Live Well at Home Coalition is a joint venture
between health care entities and community programs that provides
older adults and their caregivers with opportunity to overcome barriers
that prevent successful community living. The collaborative has
designed a program that is customizable to each individual’s needs and
provides a one-call solution to address concerns.

3. OBJECTIVES
Participants will hear a detailed explanation of the Rural Stearns Live Well at Home Coalition, it’s
development, implementation needs, project goals, future expectations and more.
Take a tour the Coalitions’ developed model and understand the navigational process of an
individual who would be enrolled in the program at each step of the way, and gain insight into the
care coordination and continuum of care following program enrollment.
Reflect on establishing partnerships between a Health Care Entity and Community Partner.

4. RURAL STEARNS LIVE WELL AT HOME COALITION
FORMATION
Coalition Development
Implementation needs
Project Goals

5. RURAL STEARNS LIVE WELL AT HOME COALITION
PARTNERS
Rural
Stearns
Faith in
Action
Central
Minnesota
Council on
Aging
CentraCare
Health
Paynesville
Belgrade
Nursing
Home
Catholic
Charities
Lake Region
Home
Health
The
Paynesville
R.O.S.E.
Center

6. CENTRAL MINNESOTA
COUNCIL ON AGING
PROGRAM DEVELOPMENT

7. CENTRAL MINNESOTA COUNCIL ON AGING
PROGRAM DEVELOPMENT
Role of CMCOA
Relationship development between partners
Community resources working together can prevent
readmissions/long-term care placement

8. THE PAYNESVILLE R.O.S.E. CENTER Reaching Out to Seniors Effectively
Volunteer Services

9. THE PAYNESVILLE ROSE CENTER
Overview of The ROSE Center
Services Offered
Community Partner Perspective

10. The ROSE Center or Paynesville Area Living at Home/Block Nurse
Program opened its doors in 2000 with the help of a DHS grant from the state
of Minnesota. It was developed to establish a community based network of
volunteers and professionals to provide services to Paynesville Area Adults
which will support independent living.
In the past fifteen years services have been provided to over 1000
unduplicated seniors and disabled with over 375 volunteers donating 107,000
hours of their time.
THE PAYNESVILLE R.O.S.E. CENTER
REACHING OUT TO SENIORS EFFECTIVELY

11. THE PAYNESVILLE ROSE CENTER
SERVICES
Transportation Chore
Services
Homemaker
Services
Friendly
Visiting
Support
Groups
Phone Buddy
System Respite Care

12. LAKE REGION HOME HEALTH Skilled Nursing
Home Health Aids

13. LAKE REGION HOME HEALTH
Overview of Lake Region Home Health
Services Offered
Community Partner Perspective

14. Lake Region Home Health offers quality nursing care to individuals of
all ages in their homes, allowing them to remain independent in the
comfort and security of their home and family.
Through the Coalition partnership, Lake Region Home Health is able to
offer two FREE in home nursing assessments to program participants.
Lake Region works directly with the individual to develop a care plan
based off of their needs and hand in hand with the support planner to
ensure all needs are met.
LAKE REGION HOME HEALTH

15. LAKE REGION HOME HEALTH
SERVICES

16. CATHOLIC CHARITIES
Eat Well Get Well
Meals on Wheels
Senior Dining
Evidence Based Classes

17. CATHOLIC CHARITIES
Overview of Catholic Charities
Services Offered
Community Partner Perspective

18. Catholic Charities offers a program called Eat Well Get Well. This program provides
10 free meals to discharged seniors who are at high risk for readmission. The meals
are a combination of hot and frozen meals delivered from the Catholic Charities
Paynesville Senior Dining kitchen. This program is the nutritional link to seniors
maintaining their health and well–being and reducing hospital readmissions. The
Support Planner maintains contact with the individuals following the end of the 10
meals, and offers Meals on Wheels or Senior Dining at that time.
CATHOLIC CHARITIES
NUTRITIONAL COMPONENT
Added Bonus: Driver Safety Checks

19. CATHOLIC CHARITIES
EVIDENCE BASED CLASSES Catholic Charities also offers
evidence based health workshops
which introduce seniors to
prevention and continued
well-being.
The Health Promotions Specialist
facilitates and presents those
workshops to the rural Stearns
County community.
Tai Ji Quan: Moving for Better Balance™
A Matter of Balance: Managing Concerns
about Falls
Chronic Pain Self-Management (or) Living
Well With Chronic Conditions (Stanford
Chronic Disease Self MGMT)

20. CENTRACARE HEALTH PAYNESVILLE Health Care Entity Perspective

21. CENTRACARE HEALTH PAYNESVILLE
HEALTH CARE ENTITY PERSPECTIVE
Role of CentraCare Health Paynesville
Overview of Implementation
Ease of Referral Process

22. RURAL STEARNS FAITH IN ACTION
Support Planning
Caregiver Consulting
Volunteer Services

23. RURAL STEARNS FAITH IN ACTION
Overview of Rural Stearns Faith in Action
Services Offered
Support Planning Models & Assessments
Outcome Measurements

24. RURAL STEARNS FAITH IN ACTION
Rural Stearns Faith In Action ( RSFIA) is a program of
Assumption Community Services, Inc., a non profit
organization that collaborates with congregations, social
agencies and community organizations to come together for the
purpose of providing assistance to people in need of a variety of
services so they can remain in their homes and communities.

25. VOLUNTEER BASED
SERVICES
Transportation
Homemaking/Chores
Home Repair/Modification
Friendly Visiting
Help with Errands
Grocery Shopping
Respite Care for Caregivers
RURAL STEARNS FAITH IN ACTION
SERVICES
PROFESSIONAL
SERVICES
Caregiver Consultation
Caregiver Education Sessions
Support Planning

26. RURAL STEARNS FAITH IN ACTION
PROFESSIONAL SERVICES
Caregiver Consultant
A personalized service that equips family
caregivers with knowledge, skills and tools
to achieve a balanced lifestyle while caring
for another person. The caregiver consultant
assists caregivers in identifying needs and
values, facilitates goal-setting and
development of person-centered plan. They
provide ongoing coaching and support to
assist caregivers in reaching established
goals.
Support Planning
The role of the Support Planner was developed as a
form of Care Coordination and a one stop shop to
connect individuals who face barriers at home to
community supports and professional services to
help them overcome. Referrals come directly from
Health Care Entities and Community Partners as
well as word of mouth from community members.
When referrals are received, the Support Planner
meets with the individual in their home to develop an
action plan to help reduce identified barriers.

27. SUPPORT PLANNING
BASIC REFERRAL PROCESS
Referral Received; Support
Planner completes
enrollment and Live Well at
Home Rapid Screen©.
Assess barriers to successful
community living: including
nutrition, safety, medication
management, and activities
of daily living
Develop an action plan to
overcome those barriers;
refer to community
partners and professional
services as needed

28. CentraCare Paynesville will complete Rapid Screen© and refer moderate to high risk individuals.
Belgrade Nursing Home will work directly with the Support Planner in the discharge planning process.
The Support Planner will then meet with the individual prior to discharge or when referral is received:
Introduction to the Rural Stearns Live Well at Home Coalition
Program Registration and Intake
Initiate contact with Catholic Charities for Eat Well Get Well; other referrals made as needed
3-5/30/60/90 DAY FOLLOW UP
Live Well at Home Rapid Screen ©
Continued Services or adjustments made to Care Plan
Satisfaction Survey Completed
Following the 90 day follow up, the Support Planner will
meet with individuals on a quarterly basis until they
graduate the program, or decline to continue with services.
Readmission rates will be complied on a quarterly basis
to measure program success.
SUPPORT PLANNING
DISCHARGE REFERRAL MODEL

29. ASSESSMENTS
NAPIS/RSFIA REGISTRATION
Community or Faith based organizations
Caregiver Presence & Support Systems
Medication Management
Disability Screening/Bridges to Benefits
Activities of Daily Living
Nutritional Screening
Demographics & Income

30. SUPPORT PLANNING
DISCHARGE REFERRAL MODEL

31. OUTCOME MEASUREMENT:
PARTICIPANT SATISFACTION SURVEYS
On a scale of 1 to 5 (1 being the least) how would
you rate the following questions?
How well do you
feel you are doing
living at home?
How confident are
you in your ability to
remain living at
home?
How satisfied are
you with the services
you are receiving?

32. OUTCOME MEASUREMENTS
SURVEY RESULTS
How well do you feel
you are doing living at
home?
14%
improvement
14%
decline
72%
same
How confident are you
in your ability to
remain living at home?
14%
improvement
14%
decline
72%
same
How satisfied are you
with the services you
are receiving?
14%
improvement
0%
decline
86%
same

33. OUTCOME MEASUREMENTS:
QUARTERLY READMISSION RATES
Program
participant
DID NOT
readmit to a
health care
facility
Quarter
1
Matter of Balance class serviced 15
individuals; results are unknown
Quarter
2
100% of the participants did not
readmit to a health care facility
Quarter
3
96% of the participants did
not readmit to a health care
facility

34. QUESTIONS THANK YOU

35. Lindsey Sand
Rural Stearns Faith in Action
320-348-2355
lindseys
@assumptionhome.com
Kayla Kildahl
Rural Stearns Faith in Action
320-247-9790
kildahl.kayla
@assumptionhome.com
April Stadtler
CentraCare Health Paynesville
320-243-7705
April.Stadtler
@CentraCare.com
Inez Jones
Bonnie Schwartz
The Paynesville ROSE
Center
320-243-5144
Paynesvillerosecenter
@gmail.com
Roxie Knisley
Lake Region
Home Health
320-354-5858
www.lakeregion
homehealth.com
Mare Simpler
Ruth Hunstiger
Catholic Charities
320-253-1280
www.ccstcloud.org
Kathleen
Gilbride
CMCOA
320-253-97479
www.cmcoa.org
Phil Lord
Belgrade Nursing Home
320-254-3513
phillord@USA.com