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Thriving Downeast Implementation Work Plan 2014-2015

​​TiPD was a 4-year project (1 year of planning and 3 years of implementation) funded by the Maine Health Access Foundation.  Although the grant ended in 2017, its framework of collaboration and community-based planning to support communities where people can remain healthy and engaged as they age has been the foundation of our healthy aging work since that time.

OBJECTIVE I: Secure Staffing for Project 

Activity/Timeframe: Develop job description, recruit and hire TiP Implementation Coordinator. (November 2014)

Responsible Parties: HP Director, HP Advisory Board, WHCA

Measure: TiP Implementation Coordinator hired


OBJECTIVE II: Identify structures, leadership roles, and responsibilities among partners

Activity/Timeframe: Partners review TiP Implementation work plan for Partnership – including MOU’s, roles, responsibilities, leadership structures, timelines, and budget allocations. (November – December 2014)

Responsible Parties: TiP Coordinator in conjunction with TiP Partners

Measures: Leadership roles and partner responsibilities documented in meeting minutes


OBJECTIVE III:  Establish Advisory Council as “oversight” structure to TiP monitor work plan, budget, and “deliverables” in MOUs, to oversee data collection and evaluation, and ensure year-two implementation planning

Activity/Timeframe: Identify executive leadership within TiP partner team and recruit three representatives from among consumer group. (November 2014)

Responsible Parties: TiP Coordinator, TiP partners

Measures: Advisory Council established; minutes of TiP Partner meeting.

Activity/Timeframe: Convene regular monthly TiP Advisory Council meetings and work groups. (Monthly December 2014 – October 2015)

Responsible Parties: TiP Advisory Council Chair, TiP Coordinator

Measures: Minutes and attendance records of Advisory Council and work groups; record of “accomplished” work plan activities throughout the year


OBJECTIVE III:  Strengthen collaboration among support service providers to enable increased awareness and referrals between programs

Activity/ Timeframe:  Establish monthly Provider Network to ensure collaboration and planning among committed partner organizations, other key providers, community volunteers and consumers. (December 2014 – January 2015; ongoing meetings through October 2015)

Responsible Parties: TiP Coordinator, providers/partners

Measures: List of Provider Network and affiliation; attendance records and minutes of Provider Network meetings; documentation of increased referrals


OBJECTIVE IV: Create platform for partner communication and coordination with reach to public


* Establish online program management software among partners, Advisory Council, Provider Network, and community resources personnel to share information among themselves and other relevant participants. Assess appropriate platforms with input from partners, consumers, and key community resources (December 2014 – January 2015)

* Train partners/providers and consumers on program management software (February 2015)

* Implement and monitor use of “internal” communications systems; adjust as needed (March – October 2015)

Responsible Parties: Penobscot Bay Press, Healthy Peninsula, TiP Coordinator

Measures:  Results of partner assessment; agenda and attendance records of training; evidence of online program management software (documents, shared calendars, correspondence, etc.


* Develop an online “resource guide” with organizational and community-based resources for health for providers and the general public. (Start December 2014 – ongoing)

* Complete comprehensive “map” of formal and informal assets/resources for patients, caregivers and elders. Document assets from partners and other providers, volunteer associations, and local towns (November 2014 – January 2015)

* Create and manage online resource guide under banner of Blue Hill Memorial Hospital, enable access to partnering organizations (February – March 2015)

Responsible Parties: Blue Hill Memorial Hospital, TiP Coordinator, Penobscot Bay Press

Measures: Website created (fields for health prevention, chronic disease management, caregiver support, and town-level “embedded” resources). Number of “hits” on site


OBJECTIVE V: Create systems to raise community awareness about TiP initiatives and available prevention, health management, and support resources.

Activity/Timeframe: Promotional ads about prevention, health management, and support resources in local papers–Penobscot Bay Press and Ellsworth American. (2-3 ads every other week, December 2014 – October 2015)

Responsible Party: Penobscot Bay Press

Measure: Copies of ads

Activity/Timeframe: TiP brand development and marketing collateral to raise awareness of TIP activities, resources and benefits to beneficiaries and general public, to include: print and social media advertising; human interest profiles of partners and beneficiaries; Guest columns in PBP newspapers; calendar of events; resource maps; important health links; annual reports. (January – October 2015)

Responsible Party: Penobscot Bay Press

Measures: Creation of basic brand identity (logo), quantification of distribution of content and materials to sites and publishing platforms


OBJECTIVE VI: Expand prevention and support services for elders and patients with chronic conditions on the Blue Hill Peninsula, Deer Isle/Stonington.

Activity/Timeframe:  Retain part-time Community Care Coordinator to provide ongoing needs assessment, program development, and technical assistance for At Home Downeast (AHD) and Coastal Care Team (CCT) patients related to homebound members and those isolated with chronic conditions (December 2014 – January 2015)
Responsible Party: At Home Downeast

Measures: Community Care Advocate hired; needs assessment documented

Activity/Timeframe: Develop “program plan” and intervention strategies for AHD members who are home-bound elders and patients with chronic conditions (February 2015)

Responsible Parties: At Home Downeast, Community Care Coordinator, CCT

Measure: Program plans developed

Activity/Timeframe:  Expand volunteer pool and opportunities for AHD by piloting local Volunteer Coordinator position(s) in at least two communities.  Volunteer Coordinator(s) will identify additional local resources for volunteerism, recruit new volunteers, provide orientation, and manage volunteer assignments. Focus on specific opportunities to increase socialization and promote wellness. (January 2015 – July 2015)

Responsible Party: At Home Downeast

Measures: Volunteer Coordinator(s) hired; increase in volunteers and assignments documented by on-line software

Activities/Timeframes: Establish variety of locally-based, “proven” health prevention and maintenance programs for elders and patients with chronic conditions in Blue Hill Peninsula and Deer Isle, including:

* “Matter of Balance Training” for trainers in Provider Network, EAAA (February 2015)

* Provide Matter of Balance classes at senior meal sites or senior housing, coordinated by EAAA and CCT (April 2015 on Deer Isle; June 2015 in Penobscot/Castine)

* Provide two, 16-week sessions “Tia Chi for Health” Healthy Acadia (January – March 2015 in Penobscot; August – October 2015 in Brooksville)

* Provide three, 6-week “Cooking Matters” classes targeting patients with pre-diabetes or diabetes. (September-October 2015 in Blue Hill; January – February 2015 in Stonington; April – May 2015 in Penobscot)

Responsible Parties: Healthy Acadia, BHMH, CCT, and community volunteers

Measures: Record of scheduled sessions, attendance, and participant evaluations

Activity/Timeframe:  Integrate “care team” of support and services for elders, patients with chronic conditions and caregivers, including:

* Recruit potential community volunteers as Volunteer Health Advocates (CCT, FC, AHD, HVHC, HCHC, BHMH, EAAA and other “Network” providers) (December 2014)

* Provide Volunteer Health Advocate training (VHA) for four community volunteers, professionals and partnering organizations EAAA (January 2015)

* Promote “care team” concept with elders, patients, and caregivers through Provider Network and public awareness campaign (February 2015)

* Manage referrals and VHA program, connecting volunteers to participants, CCT (February -October 2015)

Responsible Party: CCT, Community Care Coordinator, TiP partners and provider network, Penobscot Bay Press

Measures: VHA’s retained; VHA logs, quantifying numbers of participants, contacts, and training and participant program evaluations


OBJECTIVE VII:  Increase caregiver support groups in the Blue Hill Peninsula, Deer Isle and Stonington

Activity/Timeframe:  Provide two, eight-week series of “Grieving on the Installment Plan” for caregivers dealing with chronic grief. Recruit licensed social workers from the Blue Hill Peninsula area for Facilitator Training for the Grieving on the Installment Plan series. This program offers insight, encouragement and tools for self-care for caregivers of people living with chronic medical conditions. (Professional facilitators will donate in-kind time for providing the caregiver support groups) (Recruit licensed social worker January 2015; Hold Facilitator Training Day February 2015)

Responsible Party: Friendship Cottage

Measures: Curriculum for training; attendance records and participants’ evaluations

Activity/Timeframe: Provide two sessions of “Grieving on the Installment Plan” for caregivers. (April – May 2015 in Blue Hill and Deer Isle/Stonington)

Responsible Parties: Professional Social Workers from Friendship Cottage, Hospice Volunteers of Hancock County, Hancock County Homecare and Hospice

Measures: Agenda for group sessions, attendance records, participant evaluations

Activity/Timeframe: Expand caregiver training at a senior meal sites and establish one new “ongoing” support group with professionals at the Island Nursing Home and Island Medical Center on Deer Isle. (Develop caregiver curriculum January 2015; Begin new caregiver support group on Deer Isle February – June 2015; Pilot caregiver training at Penobscot Meal Site May – July 2015)

Responsible Parties: Friendship Cottage, EAAA, and AMHC

Measures: Training curriculum; attendance and participant evaluations

Activity/Timeframe: Create support groups for caregivers of loved ones with behavioral health Issues. (Outreach and PR to caregivers in behavioral health system; determine needs and interests November – December 2014; Develop curriculum- January, 2015, Convene behavioral health support groups January – May 2015)

Responsible Parties: Friendship Cottage, AMHC

Measures: Support group attendance and participant evaluations


OBJECTIVE VIII:  Increase 1-1 support for caregivers

Activity/Timeframe: Host Community Forums at senior meal sites/ community venues in three locations on the Blue Hill Peninsula/Deer Isle. Topics of interest to patients, caregivers and elders may include: the changing face of caregivers, end of life planning, insurance/legal issues/finances, navigating Mainecare, Behavioral Health, aging programs and more. (DIS January and May 2015; Penobscot/Castine February and June 2015; Brooksville March and July 2015; Blue Hill April and August 2015; Evaluation September 2015)

Responsible Parties: TiP Coordinator), Penobscot Bay Press

Measures: Press releases, attendance records and forum evaluation

Activity/Timeframe:  Offer monthly “Clinics of Expertise” where target populations can get information and assistance. Staff from Legal Services for the Elderly, EAAA, Affordable Care Act Navigator, DHHS, and AMHC would be on site 1 day a month to inform about their programs. (Contact providers and organize schedule of Clinic of Expertise November – December 2014; Public Service Announcements January 2014 – ongoing; Clinics offered February – October 2015)

Responsible Party: TiP Coordinator, Penobscot Bay Press
Measurers: Press releases, meeting minutes, attendance records, evaluations

Activity/Timeframe:  Recruit and train volunteer mentors to provide additional caregiver support by using the Hospice Volunteers of Hancock County Model. Curricula will be developed to train volunteer mentors who would like to support adults caring for someone with Behavioral Health issues.  Additional training for the volunteers will help the caregivers “connect the dots” unique to caring for someone with mental health needs. (Curricula developed and professional staff trained February 2015; Train volunteer mentors March 2015; Volunteer mentors will be piloted in Brooksville and Brooklin May 2015; Evaluation August 2015)

Responsible Parties: AHMC, Friendship Cottage, Hospice Volunteers of Hancock County, At Home Downeast, Coastal Care Team

Measures: Volunteers recruited and trained; attendance at training, volunteer monthly log, training evaluation; Caregiver satisfaction survey


OBJECTIVE IX:  Determine the healthcare and social service needs of under-insured, un-insured and/or medically under-served in Blue Hill Peninsula and Stonington/Deer Isle

Activity/Timeframe: Develop data-gathering tools and protocols for key informant interviews and focus groups with underserved patients and caregivers. (December 2014 -January 2015)

Responsible Parties: TiP Coordinator, Advisory Council
Measures: Documentation of survey tools and protocol

Activity/Timeframe: Identify underserved beneficiaries through Partnership and Provider networks, community members and media (January – March 2015)

Responsible Party: TiP Coordinator
Measures: Confidential list of potential beneficiaries

Activity/Timeframe: Gather information, analyze and summarize data from interviews and focus groups (February – April 2015)

Responsible Party: TiP Coordinator, data work group
Measures: Record of interviews and focus groups, attendance records; written data summary

Activity/Timeframe: Use data from underserved participants to develop TiP Year Two Implementation Plan (June – August 2015)

Responsible Party: TiP Coordinator, Advisory Council (with input from Provider Network and program participants)
Measures: Evidence of data in Year Two Implementation Plan (August 2015)


OBJECTIVE X: Establish a ‘Learning Community’ among TiP partners and Provider Network

Activity/Timeframe: Identify pertinent information (articles, books, websites, etc.) to support Partnership/Network implementation plan. Include successful state and national models of care, current healthcare policy trends, and more. December 2014 – October 2015)

Responsible Parties: MeHAF, TiP Coordinator, Penobscot Bay Press

Measures: ‘Library’ of paper and electronic resources (cloud-based drop box), bibliographies; minutes of Provider Network and work groups pertinent to ‘Learning Community’

Activity/Timeframe: Participate in MeHAF’s Learning Community with other grantees. Partners will determine representatives to attend learning sessions and report back to Tip Advisory Council and Provider Network. Resources from MeHAF’s Learning Community integrated in local ‘library’ of resources. (November 2014 – ongoing)

Responsible Parties: MeHAF, TiP Coordinator, TiP Advisory Council members

Measures: Meeting attendance records, agendas, minutes and copies of material from MeHAF statewide meetings (distributed to Partnership, TiP Advisory Council and Provider Network)


OBJECTIVE XI: Establish Data and Evaluation Systems for Partnership and TiP Implementation Plan


* Review current baseline data and evaluations for target population in our region and provide to TiP Advisory Council and Provider Network (December 2014 – January 2015)

* Use Health Information Technology (Health Infonet) to develop system to track pertinent patient data and long-term outcomes (November 2014 – October 2015)

Responsible Parties: TiP Coordinator, Advisory Council and data work group, including EMHS and BHMH

Measures: Summary Baseline Data Report; minutes of TiP meetings

Activity/Timeframe: Establish and maintain data system to track qualitative and quantitative measures for program impact (January – October 2015)

Responsible Parties: TiP Advisory Council, BHMH, Penobscot Bay Press

Measures: Evidence of a Data Plan for TIP Implementation Plan; minutes of meetings

Activity/Timeframe: Monitor and evaluate the TiP implementation process. Collect ongoing data; review quarterly, and refine and revise implementation activities as necessary – what’s working in the Partnership and what isn’t? (February – October 2015)

Responsible Party: TiP Advisory Council

Measures: Advisory Council meeting minutes, evaluation reports, revisions to implementation plans


OBJECTIVE XII: Develop Year Two TIP Implementation Plan, including implementation activities, leadership, partner roles and responsibilities, and evaluation for TIP initiative

Activity/Timeframes: Draft Sections of the TIP Implementation Plan: Partnership work groups to draft goal sections based on data gleaned from beneficiaries, with input from Provider Network, organization executive leadership, supporting community networks, and patients and their families. Drafts will be considered and revised at every level of the Partnership, with final approval by TiP Advisory Council (March – July 2015)

Responsible Parties: Chairs of Work Groups, TiP Coordinator, Advisory Council

Measures: Draft TIP Implementation Plan completed; minutes of Work Group and Advisory Council meetings

Activity/Timeframe: Finalize Year Two Implementation Plan. Final copy of Draft TiP PLAN will be submitted to administration of partner organizations, and partner constituents, representatives from community supports and informal networks, and patients and families for final comment. Final revisions included and Advisory Council acceptance of Year Two Plan. (August 2015)

Responsible Parties: TiP Partners, Advisory Council, TiP Coordinator

Measures: Year Two TiP Implementation submitted to MeHAF with signed Letters of Commitment and MOU’s


High-level Outline of Plans for Year Two and Three Implementation


*Develop data-driven plan/response from information gathered through key informant interviews and focus groups with underserved participants. Implement plan in at least two towns.

*Expand successful interventions for caregivers, elders, and patients with chronic conditions to three additional towns—Brooklin, Brooksville, and Sedgwick

*Modify/revise program interventions from Year One, based on participant and provider evaluations

*Maintain intervention strategies for partnership and participants in Year One towns—Penobscot, Castine, Stonington, and Deer Isle

*Identify and engage additional community resources and providers for TiP partnership efforts

*Continue robust community outreach through internal and external communication systems/networks

*Formalize data systems, including qualitative measures of progress on TiP intervention and quantitative short term outcomes for patients

*Develop Sustainability Plan, including fundraising/donor development for Thriving Downeast beyond Year Three Implementation



*Review, revise, and implement strategies for underserved participants in two additional towns

*Expand successful interventions for caregivers, elders, and patients with chronic diseases to final two towns in service area—Blue Hill and Surry

*Maintain intervention strategies for partnership and participants in Year One and Two towns—Penobscot, Castine, Stonington, Deer Isle, Brooksville, Brooklin, and Sedgwick

*Continue robust community outreach through internal and external communication systems/networks

*Monitor short and longer term outcomes for patients; determine longer term measures and set up tracking system

*Begin implementation of Sustainability and Fundraising Plan for Thriving Downeast beyond MeHAF funding

*Formalize leadership, roles and responsibilities of all involved in TiP going forward

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