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ST. JOSEPH — The Region IV Area Agency on Aging is pleased to share that the Michigan Health Endowment Fund (MHEF), through its capacity building program, has awarded the agency a $500,000 grant to support the implementation of a new community service, Integrated Care at Home.  The Michigan Health Endowment Fund supports grants that further its goal to help Michigan communities promote older adults’ health through interconnected, meaningful support, informed by the people services reach.   

Integrated Care at Home is a medical provider program that provides physical and behavioral health care and care management services to older adults in their home or the living place of their choosing. Work will integrate and partner with existing home and community-based services to address previously identified care and service gaps and to better integrate social determinants of health into care resulting more fully in better patient health and quality of life outcomes for those served. The Integrated Care at Home model of care is founded on the principle of a ‘one-team’ interdisciplinary approach to care inclusive of medical, behavioral, and social care professionals with the individual receiving services and/or care partners as a central part of the team.

“We are excited to be able to increase in-home care capacity, close gaps in access to care, and support an initiative that will improve physical and mental health outcomes for older adults throughout Berrien, Cass and Van Buren Counties,” shares Christine Vanlandingham, CEO of the RIV Area Agency on Aging. “The launch of Integrated Care at Home shows the power that innovative thought and partnership convening has in ensuring choices for independence is truly accessible and achievable for older adults in our communities.”

Integrated Care at Home is informed by and modeled after an initiative currently supported by Senior Resources (Region 14, Area Agency on Aging). In addition, RIV AAA’s Integrated Care at Home will benefit from a partnership with Senior Resources to have unified Medical Directorship of both programs. While each program will focus on the unique needs of the local areas it is targeted to serve, both will scale to provide integrated clinical services, behavioral health counseling, medical nutrition therapy, and chronic care management in one’s own home.

Integrated Care at Home is founded on the principle of collective impact and partnership.  While RIV AAA will provide the in-home primary medical care, behavioral health counseling, and care management services, ongoing work will integrate with and build upon a vast network of partners to support its overall success and sustainability.  Multi-sector partners from behavioral health, primary care, community-based organizations, federally qualified and rural health centers, public health, consumers, caregivers and over 70+ home and community-based providers are and will continue to be essential to the initiatives long-term success.

The RIV AAA’s Integrated Care at Home initiative began a soft launch at the end of 2022, with the integration of behavioral health counseling for MI Choice Waiver clients and will continue to scale and grow in 2023.  The program has goals of serving 100 community residents in its first full year (2023) with plans for progressive growth to capacity and service reach in the immediate years thereafter.

The development and launch of Integrated Care at Home are supported by grant funding from the United Way of Southwest Michigan and Berrien Community Foundation, in addition to the MHEF, as well as American Rescue Plan Funds and agency program development funds designated and approved by the RIV AAA’s Board of Directors. Additionally, services will be provided through a fee-for-service model that are billable to Medicare and other health plans and insurances.

Integrated health and social care, right in one’s own home!  Overcoming barriers for seniors, Integrated Care at Home brings primary care, counseling, and social supports to improve health, reduce costs, support caregivers, and improve quality of life for vulnerable older adults.