Thriving in Place Aroostook County

Covers: Aroostook County

Start Date: 2014

Mission, Vision & Goals

Mission:
The mission of TIPS-Aroostook is to help people with chronic health conditions maintain their health so they can remain living in their home and community, and to identify what is working and what needs to be improved through coordination of community resources.

Broad Overview

There are four major areas of focus for Thriving in Place Aroostook County:

  • Medical Transportation,
  • Adult Day Services - Caregiver Respite,
  • Home Care
  • Information

TIPS-Aroostook targets adults with chronic health conditions, especially the elderly and frail, by working with at-risk individuals through enhanced screening and care plan development. Our screening tool identifies top medical diagnoses at risk for hospital re-admission, including all cardiac, diabetes, and pulmonary diagnoses, and other at risk contributing factors, such as usage of 8 or more medications, recently discharged patients from local hospitals, patients without a primary care physician, patients experiencing a transition of care, and patients being discharged from medical facilities outside of Aroostook County back to the County.

Referrals to County-wide coordinated community supports emphasize screening, self-management, education and check-in services; our extensive base of collaborative partners includes hospitals, outpatient medical providers, home-care agencies, several colleges, mental health, state, and transportation providers, Acap and other community organizations. All services and follow-up will be monitored through a centralized information system. Individual care coordination will be aligned with policy-related education to impact our key areas of need which are transportation, homecare, in-home supports, and respite/adult day care. Extensive volunteer networking, resource development and community integration and ownership will also build these services.

Decision-making is shared among a stakeholder partnership, a consumer/family/caregiver steering committee and coordination with Aroostook’s district public health council.

How is your age-friendly initiative structured?

Thriving in Place Aroostook County has an agreed upon work plan with objectives tied to specific activities identify the responsible party and the measurement criteria.

Describe any partnerships you have developed?

Our extensive base of collaborative partners includes hospitals, outpatient medical providers, home-care agencies, several colleges and universities, mental health, state, CAP, and transportation providers, and other community organizations.

What is the role of volunteers?

Extensive volunteer networking, resource development and community integration and ownership is built into the program.

Strategies that have contributed to your success? Barriers you have encountered?

Meeting regularly with our partners as well as speaking in public forums whenever possible help with the success of the initiative. Finding funding (streams) to provide sustainability are a challenge.

Types of funding that your initiative has received

Grants

Community Initiatives

Transportation

Thriving in Place Aroostook County serves as a point of contact for those looking for rides and with the ability to direct those who need a ride to the appropriate provider; Aroostook Regional Transportation System, Veteran's Administration Van Service, LogistiCare (MaineCare eligible) Medical Transportation Service, Retired Senior Volunteer Program volunteer drivers and a wheelchair van donated to the Aroostook Area Agency on Aging and supported by help from Pines Health Services for those not covered otherwise.

Health & Wellness

Thriving in Place Aroostook County works with partners in a number of programs: yoga, nutrition, matter of balance exercise, t'ai chi, collaboration with Northern Maine Community College's Wellness Center and a sliding scale rate for seniors for use of the gym.

We collaborate with Northern Maine Community College's Wellness Center and a sliding scale rate for seniors for use of the gym.

Food, Gardening & Cooking

Thriving in Place Aroostook County coordinates the Meals on Wheels program and Fresh Produce.

Communication

Thriving in Place Aroostook County gets work out about the work we are doing through speaking engagements and brochures and visits to senior center programs throughout the county.

Region

Contact

Diana Nadeau
Thriving In Place, Project Director
One Edgemont Street, Presque Isle, Maine 04769
DianaNadeau@AroostookAging.org
207-764-3396, X102