MMHA 6540 Week 5 Partner Readiness Map Example

Who Can Deliver, and How Soon? A Partner Readiness Map for Prairie Gate's Falls Prevention Initiative

Student Name

Walden University

MMHA 6540: Population Health Management Applications

Instructor Name

Month Day, Year

Who Can Deliver, and How Soon? A Partner Readiness Map for Prairie Gate's Falls Prevention Initiative

Purpose

Prairie Gate Health Plan has chosen falls among older members as its population health initiative. A plan can identify members and pay for services, but it cannot install grab bars, teach balance classes or answer lift-assist calls itself. This map describes the six partners the initiative would depend on, what each would do, how much each can do each month, how the plan would contract with each, whether data sharing is in place and how ready each is. The map's purpose is to find bottlenecks before the program is designed around partners who cannot yet deliver. Capacity figures are illustrative.

Readiness Table

Table 1 sets out the six partners. Readiness stages run from interested, through agreement signed, to delivering.

Table 1

Partner Readiness (Illustrative)

Area Agency on Aging

The area agency on aging already runs evidence-based group balance and strength classes at senior centers in all three counties. Exercise that challenges balance reduces falls among community-dwelling older people (Sherrington et al., 2019), so the classes are a natural core component. The agency has signed a per-seat agreement and drafted an attendance report the plan can match to members. Its main constraint is rural transportation: classes in Ash and Corley meet at one senior center each, and members without cars may not attend.

County EMS Agencies

The county emergency medical services agencies deliver no part of the program but hold records the plan needs: lift-assist calls, which reveal falls that never reach a hospital. Two counties have signed data use agreements and send monthly files; Corley's agency is waiting on its county attorney. Until Corley signs, members there will be identified only through claims, which will undercount those at risk, especially members who fall repeatedly but refuse transport.

Home Repair Nonprofit

A home repair nonprofit installs grab bars, stair rails, lighting and minor repairs for older homeowners and has signed a per-home contract with a cost cap of $1,000. Home safety interventions reduce falls, particularly among people at higher risk (Gillespie et al., 2012). The nonprofit is the initiative's bottleneck: with one crew, it can complete about 25 homes a month, while the program expects to need about 50 a month once enrollment is steady. Without a remedy, members would wait two months or more for modifications recommended in their home assessments.

Occupational Therapy Group

A contracted occupational therapy group already delivers home visits under the plan's provider contracts and can add about 70 home safety assessments a month. Its therapists identify hazards, recommend modifications and teach safer ways to move around the home. It is the only partner already delivering at the needed volume, and its visit notes already flow to the plan. Its therapists have also worked with the repair nonprofit before, which shortens the hand-off between assessment and installation.

Primary Care Practices and the Health Department

Network primary care practices would receive a request to review medications for members in the program, since some medications raise fall risk. The CDC's STEADI resources give clinicians a structured approach to fall risk screening and medication review (Stevens & Phelan, 2013). Practices are interested but uneven: some have pharmacists, others would need to add the review to a crowded visit. The county health department is a data partner and could promote the program, but it has no service capacity to contribute.

Remedies for the Bottleneck

Three remedies for the repair bottleneck were considered. The plan could fund a second crew at the nonprofit, which keeps one trusted partner but takes about three months to hire and equip. It could contract with private handyman services, which adds capacity quickly but brings quality and trust concerns for older homeowners. Or it could limit enrollment to match current repair capacity, which is simplest but leaves half of the identified members waiting. The recommended remedy is to fund a second crew at the nonprofit and, in the meantime, prioritize modifications for members with repeated lift-assist calls or a recent hip fracture. Programs that combine home repair with occupational therapy and nursing support have reduced disability among low-income older adults (Szanton et al., 2019), which supports keeping repairs with a partner experienced in this population rather than switching to the quickest contractor.

Moving Partners Up the Readiness Stages

Readiness is not fixed. For each partner below the delivering stage, the plan has a next step. The area agency on aging will begin delivering once its attendance report is tested with the plan's member file, a task for the first month. Corley's emergency services agency needs its county attorney to approve the data use agreement; the plan's counsel has offered to meet with the attorney. The home repair nonprofit can begin delivering immediately at its current capacity, while the second crew is hired. For primary care practices, the plan will start with the six practices that have pharmacists and add others as they agree to a simple request-and-response process. The county health department's role will stay limited to data and promotion. Revisiting this map each quarter will show whether partners are moving forward or stalling, and whether the program's design needs to change to match what partners can actually deliver.

References

Gillespie, L. D., Robertson, M. C., Gillespie, W. J., Sherrington, C., Gates, S., Clemson, L. M., & Lamb, S. E. (2012). Interventions for preventing falls in older people living in the community. Cochrane Database of Systematic Reviews, 2012(9), Article CD007146. https://doi.org/10.1002/14651858.CD007146.pub3

Sherrington, C., Fairhall, N. J., Wallbank, G. K., Tiedemann, A., Michaleff, Z. A., Howard, K., Clemson, L., Hopewell, S., & Lamb, S. E. (2019). Exercise for preventing falls in older people living in the community. Cochrane Database of Systematic Reviews, 2019(1), Article CD012424. https://doi.org/10.1002/14651858.CD012424.pub2

Stevens, J. A., & Phelan, E. A. (2013). Development of STEADI: A fall prevention resource for health care providers. Health Promotion Practice, 14(5), 706-714. https://doi.org/10.1177/1524839912463576

Szanton, S. L., Xue, Q.-L., Leff, B., Guralnik, J., Wolff, J. L., Tanner, E. K., Boyd, C., Thorpe, R. J., Jr., Bishai, D., & Gitlin, L. N. (2019). Effect of a biobehavioral environmental approach on disability among low-income older adults: A randomized clinical trial. JAMA Internal Medicine, 179(2), 204-211. https://doi.org/10.1001/jamainternmed.2018.6026