Full Circle America Case Study

Full Circle America Case Study:
Aging in Place and Community

Interview with Allan Teel
By Jean Galiana and William A. Haseltine

ACCESS Health United States
December 2015
Our vision is that all people, no matter where they live,

no matter what their age, have a right to access
high quality and affordable healthcare.
www.accessh.org
Copyright 2015 ACCESS Health International

ACCESS Health International, Inc.
845 UN Plaza, Suite 86A
New York, New York 10017-3536
United States
Introduction
Seniors around the world are demanding better options for care and support.
That demand is driving impressive and disruptive innovations in the delivery of
person centered care. The Full Circle America home and community care
program is one such innovation. Full Circle America links technology, people,
and clinical processes in a holistic care setting across the care continuum.
Dr. Alan Teel is the founder of Full CircleAmerica. Dr. Teel is one of the early
pioneers of aging in place and community andhealthcare at home in the US.
Aging in place is the ability of an older person to stay in their homes as long as
possible. Aging in community refers to an older person remaining connected to
his or her community assets, including libraries, senior centers, companies that
offer senior discounts, Young Mens Christian Associations (YMCAs), and
churches. Aging in community also refers to an older person having knowledge of
and access to their community supports and services, such as transportation,
meal delivery, and volunteer opportunities. Healthcare at home is a broad range
of health supports given to those who need care at home. This care could include
chronic care management, disability support, mental health support, and
postoperative rehabilitation and recovery. Healthcare at home serves people of all
ages.
The outcomes of the Full Circle America care model include large cost savings,
increasedaccess to care, better healthcare delivery, better health outcomes, and
dramatically better quality of life for participants. Dr. Teel uses computer and
monitoring devices to stay connected. Bliss CONNECT, designed by Pankaj
Khare, is the technology platform supports the Full Circle America care model.
Mr. Khare spent seven years designing the coordinated care platform, which
enables healthcare, aging in place and community, long term care, and disability
support at home.
The Full Circle America vision is to offer the integration of health and wellness,
safety and security, purpose and communications, lifelong learning, and
community engagement in one easy to use technology platform. The secure video,
phone calling, and chat features are HIPAA (Health Insurance Portability and
Accountability Act) compliant. Bliss CONNECT enables contact with a virtual
support team of warm community health workers, nurses, and doctors, along
with selected family, friends, and volunteers, from within the homes of frail
elderly and adults with disabilities living in the community.
FULL CIRCLE AMERICA CASE STUDY: AGING IN PLACE AND COMMUNITY

A clients Full Circle America care plan exists in tandem with the clients existing
doctors, much like if the client was in an assisted living home. Full Circle America
is like virtual assisted living, with the addition of sophisticated technology housed
in one place. The model also divides the care burden into manageable pieces by
connecting to the clients local supports and services and volunteers.
The homepage of the Bliss CONNECT platform is much like a social networking
website, allowing an older or disabled person to connect with others. Users can
chat and share photos in a Facebook style communication board, use a Gmail
style email, shop at online stores, and reference a calendar.There are apps that
are customizable to the users interests. The endless choice of apps ranges from
favorite old movies, to recipe books, news, sports, weather, music, Kindle, and
pizza delivery.
From the first social page, users can connect to their care teams. They can see
photos of their care circles, which include a doctor, a nurse, a case manager, and
all others involved in their care, such as family and community volunteers. This
page is used to video conference and teleconference, or chat electronically with all
in the care network. The page also has a panic call option. Stored on page two are
all of the clientselectronic health records, complete health record, insurance
records and required documentation for third party billing, a place to store
documents, and a place for the healthcare team to document their care and set
up medication alerts. The user can choose who has access to this page.
Full Circle America uses passive video monitoring devices and motion sensors,
combined with protocols, to provide peace of mind for loved ones living at a
distance. The specifics of monitoring vary with the need of the person aging in
place or receiving care at home.
All of the health monitoring devices can be connected to a tablet. Health results
will be sent directly to the care team and stored on the Bliss CONNECT
platform. Full Circle America has a service menu that ranges from twenty to
eight hundred dollars per month. This menu is tailored each clients needs.
In this interview, Dr. Allan Teel describes his thirty years of experience enabling
aging in place and community to his patients. Dr. Teel offers his insights into
elder care and the Full Circle America care model. The Full Circle America model
cuts costs of care substantially and provides equity of access while improving
health outcomes and quality of life for clients.
About Allan Teel

Allan S. Chip Teel, MD, graduated from
Dartmouth College and the University of
Vermont Medical College. He trained at the
Family Medicine Residency at Lancaster
General Hospital in Lancaster, PA. He now
resides in Maine. He has been a family
physician in private practice in Damariscotta
since 1988. He holds a Certificate in
Geriatrics. He has been the medical director
and provided patient care at nursing homes
and assisted living facilities. In 1995, he
cofounded the nonprofit ElderCare Network.
The ElderCare Network owns several small
assisted living homes in Lincoln County, Maine. In the mid 1990s, Dr. Teel was
an original incorporator of the multispecialty Miles Medical Group. In 2003, he
became the founding partner of Full Circle Family Medicine. In 2011, he started
Full Circle America to provide home based elder support on a larger scale.
Interview
Jean Galiana (JG): What inspired you to start an aging in place and healthcare
at home organization?
Allan Teel (AT): It has been a long road. I was the medical director of a nursing
home when the nursing home moved from the top floor of the hospital to its own
building, in the early 1990s. I tried to modernize the care model for the nursing
home. Over a few years, it became apparent that my efforts were not enough. This
fact was most pronounced in the skilled care unit, where I was a physician for
many people in rehabilitation who wanted to go home.
Some home health agencies had sprung up. These agencies tended to only a small
slice of the services that a fragile or frail person needs to stay at home. These
agencies would help manage wound care or maybe listen to your heart and lungs
and make sure you were taking your medicines. Older and frail patients, who

were often recovering from an illness or surgery, needed more comprehensive
home healthcare. There were really no options.
The most disgusting part of this whole story is that the medical supports were
primarily, and still largely are, available only for people who are completely
homebound. If you left your house to have your hair done, to go to church, to go
over to a family members home for a meal, you were not considered homebound;
you did not qualify for Medicare nursing services. Everyone at the time
recognized that these activities were part of living and could potentially aid and
speed your recovery. This limitation in Medicare policy disqualified people from
care they needed in a perverse way.
I wanted a model to treat those who were falling through the cracks and trying to
deal with a Medicare regulatory environment I spoke about, which was anything
but holistic. Honestly, at times, I became quite exasperated by having to tell very
old, very determined people that they could not go home because they did not
have the support system in place.
Early on, it became crystal clear to me that neighbors and friends had
to be a big part of the solution, especially if the healthcare system was
not stepping up.
I started working on a case by case basis to try to solve this need. My initial
efforts were quite rough and informal. I would enlist a neighbor or friend to do
something a bit more comprehensive then what they had been doing in the past.
Early on, it became crystal clear to me that neighbors and friends had to be a big
part of the solution, especially if the healthcare system was not stepping up.
Eventually, I began experimenting with an early version of what would now be
called home sharing. There were many older individuals in my practice. I saw
them downsizing within their own house by closing off the second floor, closing
off half of the first floor, and perhaps not driving. They were effectively living in
their condo of one or two rooms at the center of a big house.
At the same time, other patients of mine were parents with a newborn who
struggled to afford a place to live, or a newly divorced woman who did not have

enough income to buy her own place. It quickly occurred to me that we could find
ways to match people who needed housing with people who had excess housing.
In the mid 1990s, I created a small home sharing pilot project with about a dozen
different couples. Some of the participants became really excellent caregivers.
The sharing worked in both directions: an individual or couple could move into
the elders house, or the elder would move into the spare bedroom of the couples
house. Very often, the sharing arrangement was economically viable.
There might be a woman or man who wanted to be a stay at home parent with his
or her newborn. This option was more desirable than the option of going back to
work for entry level wages while having to pay for childcare. It was more cost
effective and rewarding to stay home and get paid the effective assisted living
rates for having an older person living in your house. The older person acted as a
surrogate grandmother or grandfather.
In theory, the sharing arrangement could be win/win for everyone, but there
were only a few highly successful matches. I underestimated how quickly older
individuals situations might change. I had not factored in the difficulty of a
younger person taking care of someone who could become paranoid or combative
as she aged.
That was my first foray into seeking a way for seniors to age in place and in
community. Another sobering issue was and is that many older people are poor.
To maintain a house or to move into someone elses house and pay rent was not
affordable.
My next step was a five or six year detour where I started a small network of
affordable, home like assisted living facilities. The goal of finding a way for people
to stay in their own homes was always in the back of my mind. From 2001 to
2003, I began to reexplore the use of technology to help people stay at home.
Cell phones were becoming more of a staple than they had been just a few years
earlier. Having an easily accessible communication tool for isolated elders
opened the door to new possibilities. That led to my understanding that the
solution had to be a combination of high tech and high touch. It was not truly
high tech or high touch, but it was more technology than what the elder
community was using at the time. That was the beginning of what inspired me to
start Full Circle America.

JG: At that time, were other organizations providing aging in place or healthcare
at home?
One cannot pick up any periodical and not find stories about how old
we are becoming as a country, and how much worse it is going to be in
the next ten to twenty years if we do not innovate our care delivery.
AT: Ambulatory care was growing, but there were no comprehensive aging in
place options. Today, there still is nothing comprehensive. I expected enormous
growth in the field of aging in place and community. Over the last decade, and
more so every year, one cannot pick up any periodical and not find stories about
how old we are becoming as a country, and how much worse it is going to be in
the next ten to twenty years if we do not innovate our care delivery. Given the
demographics, the economics, and the potential opportunity, I expected many
players to become comprehensive home health providers. I was quite surprised
that even though everyone was talking about home health, very few were entering
the field.
There were pioneers in different areas. I was fortunate enough to meet a couple
of them. One was originally from the Silicon Valley area. Another one came from
North Carolina via India. They both lived in my neighborhood in Maine. They
spent a few years experimenting with technology to enable elders to stay in their
own homes. They convinced Time Warner to give them their patent research
space so they could continue to design their technologies. They had a number of
patents and a prototype that I think would even wow people today. At that point,
there was no bandwidth. There was still no community wide internet to access.
They were ahead of their time and ahead of internet accessibility. Even seven
years ago, when I was trying to provide video monitoring services to someone in a
town nearby, one street had internet and another street did not. You could not
really build a business without internet access. This remains the sad case in much
of rural America today. Those were some of my initial hurdles.
Xanboo was another small home health video monitoring platform. Xanboo
would compete against anything in the market today. I started using some of

their equipment. I worked with some of their engineers to design fancier things
than what they had envisioned.
Quiet Care was another company that pioneered much of the artificial
intelligence around motion sensing. If someone went in and out of the
refrigerator and moved around the kitchen, the technology would tabulate all of
those movements. If it sensed a half an hour or forty five minutes of activity
around the kitchen, it would label that activity lunch. If a client just opened and
closed the refrigerator and then moved to another room, that was labeled
snacking.
Quiet Care designed several things that would enable us to determine common or
unusual behavior for an individual. I used devices from both Xanboo and Quite
Care in the same houses to learn where they were complementary and where they
were at odds with each other. I was able to learn what motion sensors and video
monitoring accomplished. I began to design a care model around those
capabilities.
There were a number of companies experimenting in the field. I had the chance
to communicate with and occasionally be courted by people who were doing work
with Bell Labs and AT&T. AT&T was starting a digital division. Verizon was
experimenting with what now is their webcam for homecare. Cisco was dabbling
in the field also.
Interestingly, all of the business communities were looking at this area primarily
through the lens of home security and not necessarily people security. I had my
points of view solicited by many fairly big players. They all thought that I was too
much of a dreamer.
More importantly, their business model was to make a gadget that they could
charge a recurring revenue fee for and be done. The idea of human interaction
and dealing with the messy daily lives of people was more liability and more
complexity than they wanted to take on. That was discouraging.
AT& T had some very forward thinking people in their digital division, but, at the
end of the day, they said very pointedly to me that they would rather see if I
succeeded and buy my company for one hundred million dollars, five years from
now, than give me five hundred thousand dollars to help me get started. Their
business model was to buy the providers that were left standing rather than to

help pioneer the work that needed to be done. I think that was illustrative of
other challenges I have faced.
The Birth of Full Circle America

JG: Did you approach the Centers for Medicare and Medicaid Services for
support?
AT: Yes. In 2011, I had been fortunate to cross paths with Doris Buffet, Warren
Buffets sister. She has a summer place in Maine. I approached her and gave her a
copy of my book, Alone and Invisible No More. 1 Several months later, she gave
me the funds to compete for a grant from the Centers for Medicare and Medicaid
Services.
In 2012, the Centers for Medicare and Medicaid Services were accepting
applications for programs that would address the needs of their frail and elderly
beneficiaries in a way that would reduce costs of care and improve quality of life.
I thought Full Circle America was a perfect fit. The Centers had several billion
dollars in total and were giving away ten to thirty million dollar grants.
I began hiring a team of people and building a platform. I created a group that
could bring the fledging model that I had developed over the preceding five or six
years to a number of other communities. Our proposal was ambitious. I wanted
to replicate this model in twenty five communities in year one, one hundred
communities in year two, and another five hundred communities in year three. It
was clearly absurd in some respects.
If we enrolled fifty people in each of those five hundred communities, and we
kept growing at that rapid pace for a decade, at the end of a decade, we would
have reached one half of one percent of the target population. The ambitious
proposal was not based on my megalomania. It was based on the fact that this
was the scale of work we had to do if we really wanted to address the aging
tsunami that we are facing.
The reviewers at the Centers for Medicare and Medicaid Services must have been
intrigued enough by the proposal. The reviewers replied with a five page critique
of my one hundred page proposal. In summary, they said that they hoped it
would succeed, but it needed much more refinement. The proposal needed to be
conducted on a much smaller scale first.

The reviewers doubted that elders could embrace technology. They doubted that
volunteers could play a significant role in the lives of elders. The summation
sentence was that they turned down my proposal because I was thinking outside
the box for an innovation grant. At that point, I was quite discouraged. I did not
have a strong Plan B. At least we had fleshed out what we would do if we had
funding. We then just continued to refine the model within whichever
communities agreed to provide some funding and supportive services.
By that time, my book, Alone and Invisible No More, had been picked up by a
national publisher. Many people were interested in the Full Circle model of care
delivery. The book inspired many people around the country who, I am
convinced, are absolutely ready to implement a model of home health like Full
Circle America.
Many sent me heartwarming stories about how they planned to retire from their
day job and make elder care their second career. Nurses expressed that person
centered elder care is why they went into careers in healthcare. People from
religious communities and younger people wrote that they had become inspired
to work in elder care. There were many affirmations that we do have a potential
workforce and service sector that is absolutely primed to make aging in place and
community a reality for our elderly.
Developing Metrics
JG: Have you developed standardized assessments for your clients?
AT: Yes. That came out of expediency and necessity. Most of the caregiving
agencies wanted to know how to know if somebody qualifies for the services we
offer and how we know it will help them. It was reasonable to develop a common
language to assess the situation and design a care plan collectively. I created the
Independent Living Assessment. The assessment informs the scope of the care
plan. Data show that addressing the activities of daily living effectively reduces a
persons healthcare spending and enables her to stay in her house longer.
My assessment has the acronym BFAMES: be famous (See Appendix). It stands
for the different components of living independently. The B stands for bathroom
and bathing needs and capabilities, including dressing, doing laundry, showering
or bathing, shaving, teeth brushing, and hair washing and brushing.
F represents activities having to do with food, such as remembering to eat
regularly, cooking, meal planning, eating, and cleaning up. A represents activities

like walking, getting in and out of the car, climbing stairs, and getting in and out
of a chair. M stands for memory, money, medications, and keeping track of the
basics. It gives me insight into the level of cognition. E is everything to do with
equipment, including operating the toaster, the stove, the refrigerator, the
washing machine, the television, the computer, and running the vacuum.
S is everything to do with support, including having neighbors, friends, or family
that are interested. Is the family estranged or living far away? Has the client
alienated his care team because he has been such a curmudgeon? It works very
well. The client and I can have a five minute conversation and that will enable me
to reassure the family members that I have a good idea what the clients care
profile will look like.
The Katz Index of Independence in Activities of Daily Living2 is an assessment
that is being used by state agencies to decide how much to reimburse facilities for
the amount of care they provide. It is used primarily in long term care facilities.
My assessment was designed to understand the clients situation and to
determine what the client needs in order to stay in his home.
JG: What health outcomes do you measure and how do you measure them?
AT: Before my Centers for Medicare and Medicaid Services rebuff, my metrics
were simply, if one wanted to stay in his own home and did not have much
money, we would make it possible at a lower cost than other options. I thought
that enabling people to stay at home and receive high quality care at a
substantially lower cost were the only metrics needed.
The financial metrics in terms of Full Circle America virtual assisted living have
always been compelling. When I tally up a clients expenses here in Maine,
including housing and the basics, and add to that expense a three or four
hundred dollar monthly support package of technology and targeted homecare
from Full Circle America, I come up with a total monthly expense of 1,500 to
2,500 dollars a month. Assisted living facilities charge ten to thirteen thousand
dollars a month, depending upon what part of the country one is living in. The
savings are somewhere between seventy and eighty percent of what assisted
living would be. Even if I am off by a factor of two, it is still a sizable difference.
In terms of the other metrics, I recently created what I call the Chronic Care
Vulnerability Index. In January 2015, the Centers for Medicare and Medicaid
Services published their Chronic Conditions Data Warehouse.3,4 At this time, the
10

Centers began to offer reimbursement for chronic care management. The
reimbursement allows for people who provide for chronic care needs to be paid a
monthly chronic care management fee. The goal of the reimbursement was to
encourage primary care doctors to care for individuals with chronic needs.
There are three parts to my original vulnerability index: What diseases does the
client have? What healthcare services has he or she used recently? What are the
clients social determinants? These make for a rather complicated scoring system.
It is something that should be validated over time. It addresses the triple aim of
Centers for Medicare and Medicaid Services: better quality of life, better quality
of healthcare, and reduced costs. The index was another way to demonstrate that,
since most older individuals are poor, we need to have third party payment from
Medicare and Medicaid. Third parties are interested in how to translate various
factors into a relatively easy scoring system that many people can use.
The metrics that I added to my original vulnerability index include the
independent living assessment that I described earlier, the Healthy Days
Measure,5 and a Quality of Life Scale6 These are validated instruments that have
been around for twenty years, but I never found anyone in healthcare in the US
who uses them. They are used in other parts of the world. The Quality of Life
measures have been validated in twenty to thirty countries, with people in all
populations and of all ages.
The Healthy Days Measure is a series of simple questions: How would you rate
your health: good, bad, or miserable? How many days in the last month has your
mental health kept you from doing what you want to do? How many days in the
last month has your mental health been good? How many days in the last month
has your physical health been good or bad? How many days in the last month has
your physical or mental health kept you from doing something you wanted to do?
The assessment takes less than a minute to administer. It is a fairly easy way for
us to be able to track outcomes using instruments designed by other players, like
the National Institutes of Health, the Centers for Disease Control and Prevention,
and the World Health Organization.
We administer each of these instruments on a staggered basis over the course of a
year so that we can gather outcomes over time, without taxing the individual. One
of the hardest measures is healthcare dollars spent. There is no easy way to access
data on an individuals past healthcare spending. As a provider, I need to have a
working relationship with an insurance company, with a Medicare regional office,
11

and with a Medicaid state office to determine a clients pre enrollment and post
enrollment spending. This information is useful in proving that the Full Circle
America model creates substantial cost savings.
JG: Can you request shared savings from the insurers?
AT: Absolutely. We could make an arrangement to take on the highest users in a
neighborhood and agree on goals. We could share the profits and the risk. The
insurers would not have to pay us if we do not deliver. If we deliver savings, then
the insurers share that with us. It seems like it would be appealing to insurance
providers to have a partner who is willing to make that agreement.
JG: Would the provider using your care model then be able to have a profitable
program?
AT: Definitely, yes. I should note that the goal is different for the client and for
the family. We offer peace of mind to the family that lives far from their loved
ones. They are interested in finding someone to look after their mom or dad.
Oftentimes, the care burden is too great, even for the siblings and children who
live in close proximity to their relative. There can be a profound sense of isolation
on the part of the adult sons and daughters. Family members often do not know
where to turn for help. It is surprising how many adult children of aging parents
have tears of gratitude when they find a supportive partner in us and the local
supports and services that we connect them too.
Financing Aging in Place and Community

JG: How do most of your clients pay for your services?
AT: Most of them pay privately. I have a few clients who are on state assistance
and are under a Medicaid program called Money Follows the Person.7 Money
Follows the Person is a program sponsored by the federal government. The
program takes people who have been residents of nursing homes for a relatively
short period of time and returns them to live in the community. The program will
end in another year or two.
The federal government will pay one hundred percent of the transition costs and
one hundred percent of the first year costs to get people back in the community.
On year two, the payment declines to ninety percent, and year three, to eighty
percent.
12

For this program to work, states must realize that they will spend less in the long
run through this program than what they would have to pay for Medicaid nursing
home costs. The Money Follows the Person placements have mostly been for
disabled younger adults rather than for elders. Much of that has to do with the
array of support systems that many disabled younger adults have in place. In the
case of an eighty five year old woman who is in a nursing home, one of the main
reasons she is in a nursing home is that she did not have a social support system
in her community. Reconfiguring existing community assets that is, the
resources and supports available in the community is important in enabling
aging in place and community.
Several of the long term care insurers will allow people to submit their invoices
from Full Circle America as part of their payout benefit from their plan. Only
about eight percent of elders in America have a long term care insurance policy.8
Most long term care provider policy writers have stopped writing policies because
they cannot control the payout and the cost of the payout.
We have created a model whereby the annual payout is three hundred dollars a
month or 3,600 dollars a year, which is far less expensive than senior living and
nursing facilities. If an at home solution like Full Circle America and a defined
benefit payout produces an affordable premium for the client and a return on
investment for the insurance companies, we could revitalize the long term care
insurance market. It is a triple win. The providers make a profit, the insurance
companies can make a desirable return on their investment, and people can
afford long term care insurance. This development has the potential to change
the dynamic. Today, the only long term care payout available is for residential
care in a nursing home. Residential care is an exorbitant expense for insurance
providers.
JG: Is it a challenge to find experienced caregivers? Do you use caregivers of
various skill levels?
AT: One does not need an advanced degree to be able to identify that a client is
sitting on the couch, walking around the house, or eating at the kitchen table.
One does not need healthcare credentials to gather that useful information. One
just has to be organized.
An ideal employee is a part time mom who wants to do this kind of work. Since
the services are web based and easily distributed, a stay at home mom could work
three or four hours a day, a few days a week, to be a part of the Full Circle
13

America support system. I have mothers of newborns that are doing some of our
client monitoring around their parenting duties. There are many nurses, social
workers, and other caregivers who went into healthcare to do something more
holistic. I have a file folder filled with resumes of people who would love to
participate in the Full Circle America program. I do not think that there will be a
labor shortage in this model of care.
Tapping Community Assets

JG: Could you talk about the peer to peer volunteer component of Full Circle
America?
If we consider each elder client to be a volunteer for someone, each

client is a care recipient as well as a caregiver.
AT: If we consider each elder client to be a volunteer for someone, each client is a
care recipient as well as a caregiver. This arrangement makes almost everyone
who is enrolled as a participant a potential volunteer. One of the biggest issues
for frail elders is isolation and loneliness. There is hardly anyone who cannot
participate to some degree. For example, how many elders do you know who are
unable to talk with someone on the telephone once or twice a month for five
minutes?
Many adult sons and daughters do not have forty hours a week to devote to their
parents care. If you ask them for a targeted hour or two throughout the course of
the week, it is manageable. I start looking for volunteers within the clients own
circle first. Then, I find others who are already in the care network, such as
friends, neighbors, relatives, and church mates. Working outward from there, we
can fill a fairly substantial care grid. Finally, we access the at large local volunteer
supports and services.
We make the volunteer opportunities commensurate with peoples interests and
abilities. Some want to be a fireman of sorts and help out when there is a crisis.
They are not the volunteer for playing checkers or bridge once a week. A lot of the
volunteering is about making those sticky connections. Once you do, that person
is regularly reminded how important they are. Part of our job is to continue to
14

remind people that they are relevant and needed. Volunteers want a connection
to their community as much as an isolated elder does.
JG: How do you involve the local supports and services within your clients
community?
AT: I reconfigure existing community assets. I look for infrastructure that
already exists and try to build that into the connected support system. These
supports are all housed for our clients on the Bliss CONNECT software platform.
There are many different ways to facilitate relationship building within the
community that do not cost much. We find local organizations that provide what
our client needs.
Local churches have an established network. Churches are trying to grow their
congregation and make it more intergenerational. Churches have community
outreach arms for transportation, meals, and companionship. We use their
untapped capabilities as part of the clients care team. We ask them to be a part of
the care ecosystem by emailing, texting, phone calling, or otherwise reporting on
their occasional interaction with our client. This makes them an integral part of
the support solution.
We also engage other local supports. There are approximately ten thousand
communities in the United States of around fifty thousand people that make up
our population of three hundred million. There are more than ten thousand
Young Mens Christian Associations (YMCAs) in the United States.9 There is a
YMCA for almost each pod of fifty thousand people. YMCAs have a wonderful
array of facilities with a variety of programs.
The YMCAs were not initially designed to take care of the older population, but,
over the years, many have morphed into community based resources. The YMCAs
have fitness classes and social events for seniors. The intergenerational
interaction is beneficial for all members. The YMCAs are dabbling in chronic care
management, obesity prevention, diabetes control, and arthritis programs. Many
YMCAs offer seniors a twenty dollar monthly membership. I defy anyone to find
as great an array of resources for twenty dollars a month.
Most communities have libraries. Libraries are generally comfortable places for
seniors. We make libraries part of our clients support network. Most towns have
junior high schools. If they are serving four hundred students for lunch, having
five more lunches for elders is not a tax on their resource. If we at Full Circle
15

America can arrange for our client to enjoy a five dollar lunch and be around the
buzz of youthful energy and kids, we create social connection with a bit of
entertainment.
Once you put people in those environments, often you have some of the kids
taking a shine to some of the elders and asking them if they will come back to
their English class and talk about what it was like during the depression because
they are reading Grapes of Wrath or go back to their art class and pose for the
class to be a model for a portrait. If you do this once a month for an elder who
rarely gets out of his house, it has great impact on loneliness. It does not work for
everyone everywhere, but I have done it enough to know that local schools are a
resource that should not be overlooked.
We take the local community supports that are acting as independent silos and
connect them to our clients. We are now able to join these supports together into
an easily captured network. I have just begun to use the Bliss CONNECT 10
software that houses all of a clients support within what I call the Circle of
Caring.
JG: How do you find local supports and services for each client?
AT: I found that it takes us at Full Circle America somewhere between an hour
and two hours to completely mine what a clients community has to offer. There
is a methodology to that process. We look for churches, libraries, schools, senior
centers, YMCAs, community colleges, interfaith action programs, meal providers,
volunteer transportation services, and lifelong learning institutions.
Bliss CONNECT and the Role of Technology

JG: How does the Bliss Connect platform work within your care model?
AT: Pankag Khare, the designer of Bliss CONNECT, has a team of about fifty
engineers and people in India that supplement the business support group in
North Carolina. This platform addresses all of the nonmedical and medical needs
in a sophisticated way.
In the past, Full Circle America had a robust video monitoring platform, but that
was all it did. The video monitoring platform did not have a way to host secure
multiparty video conferencing. The platform did not have a way to notify and
collect secure, active communications among all members of a care team. The
platform did not have the ability for multiple members of the care team to be
16

notified about different things. The platform did not have the ability to give alerts
and reminders to our clients. The platform did not have the ability to connect
clients to blogs and social networking. The platform did not have the ability to
shop online. The platform did not have the ability to integrate personal
entertainment like music videos. The platform did not have a way for clients to
create end of life or emergency preparedness plans, or keep medical and other
important documents in one secure and accessible place.
An example of one of the noteworthy capabilities of Bliss CONNECT is that when
a client visits an emergency room in another town, she or her children can use a
tablet to access her advanced directive and medical records from her primary
doctor. Bliss CONNECT also provides the ability to fax the hospital and doctor
the information stored in the secure vault on the platform. It is a common
concern among people that they do not have an easy way to carry around their
health records.
JG: What devices do you use for remote monitoring and how do they incorporate
the Bliss CONNECT platform?
AT: We use active and passive devices. For our passive devices, our clients do not
have to press buttons or have any computer literacy. Passive devices include
video and motion monitoring systems. These involve a couple of webcams, a
couple of motion sensors, and a door sensor. These cameras and sensors are all
connected to a central hub. The cameras create live video and stored snapshots
that are date and time stamped. That information can quickly identify whether a
clients pattern is the same as any other daily pattern or whether it is unusual
behavior.
It is hard to convey to people who have not done this how much we all
are creatures of habit.
It is hard to convey to people who have not done this how much we all are
creatures of habit. It is hard to convey how informative it can be to have someone
looking at the camera in your living room for two minutes, once a day. We can
determine whether something is out of place or everything is exactly the same as
what it was before.
17

Often, our task is as basic as noticing that a client isnt sitting in the particular
chair that he or she always uses. We could also observe that the mail is on the
side table and it is always in the kitchen. We could observe someone in their
bathrobe at noon while their regular pattern is to be dressed by 6 or 7 am. A
client could be telling us that he has not had company in weeks while the video
tells us there have been many people visiting him. In that case, the client does not
remember or does not have a sense of time. Passive video monitoring gives us a
phenomenal amount of information.
The client must participate one way or another with the active devices. The active
video or interactive video is important. Our clients confirm that having a video
conversation is a richer experience for them than a phone call. Video connection
helps to address loneliness and isolation. We make the video connection process
easy for our clients, including frail elders. Clients only need to tap a touch screen.
To ensure ease of use, Full Circle America uses technology that requires a one or
two step process. Anything more than two steps has the potential to overwhelm a
person who is not used to using computers.
We are morphing Bliss CONNECT into an expansive care team that coordinates
care and information through one secure location. We are able to bring the whole
care team, medical and nonmedical, into our clients house via a video call.
This capability enables us to do telemedicine and telecare. Telecare allows the
nurse, social worker, physical therapist, occupational therapist, and medical
assistant to communicate with our client in the same way. The care team
members all have access to an electronic health record that is stored on the
platform. The members of the care team all have a way to play on the same team
and break down the isolated silos that typically exist, either in the healthcare
world and, just as importantly, in the informal care community. Using Bliss
CONNECT is the game changer for Full Circle America expansion.
JG: Are there any other devices that you use as monitors?
AT: We put together a chronic care kit that includes a blood pressure cuff, a pulse
oximeter, a peak flow meter, a pedometer, a glucometer, and a scale. The
monitors can either be manual, which is cheaper, or Bluetooth enabled, which
sends information directly to the platform. The clients take the reading and give a
number to store in the device. A client can either read that number to me when I
talk to her, or her caregiver can enter it into the her file on the Bliss CONNECT
platform. Monitoring blood pressure several times a week rather than once every
18

three or four months is a big improvement in managing a clients cardiovascular
status.
The impact of remote monitoring is impressive with diabetes. Diabetes
management is far ahead of other fields. There are many improvements in
glucose monitoring because of active consumers in that field. In terms of elder
care, there is not the same amount of advocacy. I can put together a kit that
includes a pulse oximeter, pedometer, blood pressure cuff, scale, and a peak
expiratory flow meter for around seventy five dollars. That price should be within
the budget of every healthcare plan because it allows us to measure heart and
lung health and to manage chronic disease. The Bliss CONNECT platform has the
ability to store and graph the monitoring data. Bliss CONNECT can also send
alerts when appropriate.
Another aspect of chronic care management is the correct use of medications.
Medication errors are a common cause of hospital admissions. Roughly fifty
percent of people over sixty five are taking their medications incorrectly.11 Failure
to adhere to recommended prescription doses and schedules are the cause of over
eleven percent of hospital admissions.12 When you consider the contribution to
healthcare spending, anything we can do to improve medication adherence
should be a big part of all providers chronic care solution.
JG: How do you address the issue of adherence to medications?
AT: The way we address correct medication adherence ranges from simple to
exotic. We use a little seven compartment flip top device that organizes a clients
daily medications. Our computer platform can remind our clients to take their
medications by email, text, or automatic phone call. With Bliss CONNECT, we
can send and receive alerts when they have not taken their medications at the
correct time.
Sometimes, we use the electronic medication management device called
MedFolio.13 MedFolio is an electronic device that sends alerts to clients to remind
them to take their medication. If our client has not taken his medications within
thirty minutes of the scheduled time, MedFolio starts to beep. If our client has
not taken his medications thirty minutes later, MedFolio phones them. If our
client hasnt taken his medications another thirty minutes later, MedFolio calls
me. The device is very efficient. We can even change the programming online. We
also do a medication review from time to time.
19

Problems related to medications in the over sixty five population create health
system costs that rival the individual costs of Alzheimers disease, cancer,
cardiovascular disease, and diabetes.14 Another issue is what is prescribed.
Benzodiazepines that the American Geriatric Society has listed as an
inappropriate drug for older people since 2012 are still widely prescribed. The
British Medical Journal (now known as the BMJ) linked the use of
benzodiazepines to an increased risk of Alzheimers disease.15
We do periodic reviews to ensure that our clients are not overmedicated. It is
increasingly apparent to most in the healthcare world that blood pressure,
diabetes, and cholesterol medicines are used too aggressively in treating seniors.
There is a plethora of data about the overmedication of the senior population.
One statistic estimates that seniors sixty five to seventy nine years of age receive
over twenty seven prescriptions for new drugs per year.16 We need a different
guideline for prescription medications for seniors. Today, seniors are medicated
using the same guidelines of the younger healthier population.
JG: Are your devices interoperable?
AT: Yes, our devices are interoperable. They use a Linux operating system. The
system can easily integrate the communication from any other tools or devices
that use the common operating system. The only limitation that exists between
the tablet device and its operating system is when they are working with a vendor
that does not want to share information. It is possible for the Bliss CONNECT
system to integrate with others, but there are players who have proprietary
technology and do not want to integrate. If they do not share their machine, the
machine communication, or operating system abilities, we are locked out.
JG: How do your clients access all of this stored data?
AT: The data is all web based. Our clients communicate via the internet, through
their home computer or through a tablet. We have chosen a tablet or a mini
personal computer that is affordable and works well.
JG: Do you provide the devices for your clients?
AT: If our client has a tablet that he is fond of, he uses that. If he has nothing
already, we will sell him a preloaded, preconfigured system for approximately
four hundred dollars. With that, we can provide a robust Android device that is
preconfigured with all of the components. Clients can either pay up front or pay
20

twenty five dollars a month until it is paid off. We try to make it easy to obtain
and use.
JG: Who makes up the care team other than you, the doctor?
AT: At the core of the Full Circle America care team is an angel. An angel is our
term for someone whose job it is to be a surrogate son or daughter, a good friend
and confidant, and a fitness coach. The angel is someone who stays closely
connected to the client through a phone or video call, at least once per week.
We also use a case manager, who organizes the logistics of the workload for each
angel. The caseload of each angel ranges from one to forty to one to eighty
customers. We have three angels to every nurse and two nurses for every doctor.
The doctors load is anticipated to be approximately one per five hundred.
This structure allows us to provide a team on a regular basis for each client, for an
average of three hundred dollars, per client, per month. Bliss angels spend a
minimum of a half hour per week with each client. Nurses spend around an hour
a month with every client. The doctor spends a half hour per month with every
client. Our clients can have a virtual doctor visit and a nurse visit every month,
along with a half hour of a support person every week for three hundred dollars a
month. That is a good price.
JG: Do you coordinate your services with the clients primary care team?
AT: Absolutely. It is important to connect with the clients medical providers
early in the enrollment process. We have a nurse or doctor call the clients
doctors office to tell them that their patient is enrolled in one level of our care
programs. We invite the doctor and other care team members to be as involved
with our support of their patient as they like. Health and treatment information is
shared fluidly with the existing medical team.
JG: Do you foresee health insurers funding your services and this kind of aging
in place care?
AT: Eventually. I do not see the tide turning very quickly. That just has not been
the experience that I have had to date. I think the missing link is a strong
grassroots movement. The pressure will come from individuals and communities
clamoring for this.
21

If Full Circle America can establish a handful of very successful, very visible
community efforts, things may change quickly. If we wait for the Accountable
Care Organizations and the typical healthcare policymakers to come around, we
are going to be waiting for a long time.
JG: Wouldnt insurers push for your model of care?
AT: Insurers could realize financial gain. Yet, the Medicare Advantage plans are
having a record year, in terms of profits. They are making so much money that
even though they are giving lip service to the triple aims of cost cutting, better
health outcomes, and more access along with shared savings, they do not have an
incentive to change. I wish I had a rosier outlook, but congressmen do not listen
to stakeholders who have a financial gain in this. It can appear to policymakers
that I am advocating only to profit from my model of care.
Reimbursing for Full Circle America and others home healthcare and support
services has the potential to save insurers a lot of money. As long as insurers are
making as much money as they are making right now, I do not think that they feel
any sense of urgency to reimburse any differently.
JG: What are your plans for the future of Full Circle America?
AT: I hope to inspire grassroots movements. I am going to southern Rhode
Island next week to begin building a team and to establish a care network for new
clients. We are also preparing for a pilot program in Steuben County, New York.
The Steuben County Office for Aging, the Senior Services Fund, the churches, and
a fleet of other service providers in the area are prepared to promote and support
a Full Circle America pilot program. Together, the local support and service
organizations have put together their action plan and a timeline for broadly
rolling out Full Circle America and letting the work of Full Circle America define
a good part of the work of their organizations. The work these organizers have
put in toward launching this pilot program shows their level of commitment to
the community and their dedication to their elderly population.
JG: Is there anything you would like to add to our discussion?
AT: Internet connection is still an issue in rural America There is a telecom
initiative to provide internet to every library in Steuben County. There are about
fifteen or twenty libraries scattered throughout the county. There are several
initiatives, through the rural telecom carrier networks, working to provide
22

broadband coverage to the remotest parts of America.17,18,19 Many of those
initiatives are looking for what services they can run through their lines to justify
their investment. I try to convey to them the advantages of delivering
telemedicine and video medicine support to the community.
Having the Bliss CONNECT software platform is important in encouraging
companies to run internet connections to rural neighborhoods. The ability to
bring the visiting nurse, the social worker, the physical therapist, the
occupational therapist, the doctor, and other specialty medical support into the
homes of elders could be compelling enough to bring in better internet
connectivity. Better connectivity could transform the ability of underserved areas
to get such specialty care, from rheumatology to psychology to neurology,
cardiology, pulmonology, and renal specialists. Once you have a system for other
players to work through, the possibilities are limitless.
JG: Thank you for this very interesting discussion.
AT: Thank you.
23
Appendix
Full Circle America Metrics Summary
Name:
Date of Birth:
1) Member Goals and Aspirations (Taken from intake/interview form)
a).
b).
c).
2) Member Financial Outcomes (Some items from member, rest of financial
data from third party insurers)
a). Out of pocket healthcare costs
b). Living expenses
c). Family support ($ or in kind)
d). Emergency department expenditures
e). Hospital costs
f). Skilled nursing facility costs
g). Long term care residential costs
h). At home support costs
24

3) Independent Living Assessment
INFORMANT:
DATE ASSESSED:
BY WHOM:
1
ACTIVITY/SCORE
(CHECK APPROPRIATE
BOX)
(CAN'T DO AT
ALL)
(CAN DO SOME
(CAN DO MOST OF
OF THE ACTIVITY
THE ACTIVITY
MOST OF THE
MOST OF THE TIME
TIME)
WITHOUT HELP)
TOTAL SCORE
BATHROOM TASKS
FOOD TASKS
AMBULATION
MENTAL HEALTH
EQUIPMENT
SUPPORT/SAFETY
4) Healthy Days Measure

a) Would you say that in general your health is excellent, very good, good, fair or
poor? _______
b) Now thinking about your physical health, which includes physical illness and
injury, how many days during the past thirty days was your physical health not
good? _______
c) Now thinking about your mental health, which includes stress, depression, and
problems with emotions, how many days during the past thirty days was your
mental health not good? ________
25

d) During the past thirty days, approximately how many days did poor physical or
mental health keep you from doing your usual activities, such as self care, work,
or recreation? _______
5) World Health Organization Quality of Life Questionnaire
1. How would you rate your quality of life?
1 Very Poor/ 2 Poor/ 3 Neither/ 4 Good/ 5 Very Good
2. How satisfied are you with your health?
1 Very Dissatisfied/ 2 Dissatisfied/ 3 Neither/ 4 Satisfied/ 5 Very Satisfied
How much you have experienced the following things in the last two weeks?
3. To what extent do you feel that physical pain prevents you from doing what
you need to do?
1 Not At All/ 2 A Little/ 3 A Moderate Amount/ 4 Very Much/ 5 An Extreme
Amount
4. How much do you need any medical treatment to function in your daily life?
1 Not At All/ 2 A Little/ 3 A Moderate Amount/ 4 Very Much/ 5 An Extreme
Amount
5. Do you have enough energy for everyday life?
1 Not at all/ 2 A Little/ 3 Moderately/ 4 Mostly/ 5 Completely
6. How well are you able to get around?
1 Very poor/ 2 Poor/ 3 Neither Poor Nor Well/ 4 Well/ 5 Very Well
7. How satisfied are you with your sleep?
1 Very Dissatisfied/ 2 Dissatisfied/ 3 Neither Satisfied Nor Dissatisfied/ 4
Satisfied/ 5 Very Satisfied
8. How satisfied are you with your ability to perform your daily living activities?
26

9. How satisfied are you with your capacity for work?
10. How much do you enjoy life?
1 Not At All/ 2 A Little/ 3 A Moderate Amount/ 4 Very Much/ 5 An
Extreme Amount
11. To what extent do you feel your life to be meaningful?
1 Not At All/ 2 A Little/ 3 A Moderate Amount/ 4 Very Much/ 5 An
Extreme Amount
12. How well are you able to concentrate?
1Not At All/ 2 Slightly/ 3 A Moderate Amount/ 4 Very Much/ 5 Extremely
13. Are you able to accept your bodily appearance?
1 Not At All/ 2 A Little/ 3 Moderately/ 4 Mostly/ 5 Completely
14. How satisfied are you with yourself?
15. How often do you have negative feelings such as blue mood, despair, anxiety,
depression?
1 Never/ 2 Seldom/ 3 Quite Often/ 4 Very Often/ 5 Always
16. How satisfied are you with your personal relationships?
17. How satisfied are you with your sex life?
27

18. How satisfied are with the support you get from your friends?
19. How safe do you feel in your daily life?
1 Not At All/ 2 Slightly/ 3 A Moderate Amount/ 4 Very Much/ 5 Extremely
20. How healthy is your physical environment?
1 Not At All/ 2 Slightly/ 3 A Moderate Amount/ 4 Very Much/ 5 Extremely
21. Have you enough money to meet your needs?
1 Not At All/ 2 A Little/ 3 Moderately/ 4 Mostly/ 5 Completely
22. How available to you is the information that you need in your day to day life?
23. To what extent do you have the opportunity for leisure activities?
24. How satisfied are you with the condition of your living place?
25. How satisfied are you with your access to health services?
26. How satisfied are you with your transportation?
Score: ____________%
28

6) Combined UCLA / DeJong Gierveld Loneliness Scales
Total Score: ____________
Marital status: a) single or b) married;
Living arrangements: a)lives alone or b) not alone.
How often do you..... Hardly Ever (1 pt), Some of the Time (2 pts), Often (3 pts)
a) feel a general sense of emptiness?
b) feel that you lack companionship?
c) feel left out?
d) feel isolated from others?
e) feel there is someone I can rely on when I have a problem?
f) feel your neighborhood is safe?
g) volunteer? > one hundred hours a year? How many? ___
h) provide or receive any kind of family help?

1 http://www.amazon.com/Alone-Invisible-More-Grassroots-Technologies/dp/1603583793
2
http://consultgerirn.org/uploads/File/trythis/try_this_2.pdf
https://www.ccwdata.org/web/guest/home
4
https://www.ccwdata.org/cs/groups/public/.../ccw_userguide.pdf
3
http://www.cdc.gov/hrqol/pdfs/mhd.pdf
http://www.who.int/substance_abuse/research_tools/whoqolbref/en/
7
http://www.medicaid.gov/medicaid-chip-program-information/by-topics/long-termservices-and-supports/balancing/money-follows-the-person.html
6
http://www.aplaceformom.com/senior-care-resources/articles/long-term-care-costs
http://www.ymca.net/history
10
https://blissconnect.com/bliss/
11
http://www.aplaceformom.com/blog/10-30-13-common-medication-mistakes-to-avoid/
12
Marek, K.D., Atle, L (2008). Patient safety and quality: an evidence based handbook for nurses.
Agency for Healthcare Research and Quality (U.S.).
13 https://www.medfoliopillbox.com
9
29
14 American Society of Consultant Pharmacists Fact Sheet. https://www.ascp.com/articles/aboutascp/ascp-fact-sheet

15
Billiotti de Gage, S, Moride, Y., Ducruet, T., Kurth, T., Verdoux, H., Tournier, M., Pariente, A., &
Bgaud, B. (2014). Benzodiazepine use and risk of Alzheimers disease: case-control study. British
Medical Journal, 349:g5205.
16 Beveridge, R., MD (2014). Many senior citizens take too many medicines heres how to fix it.
Forbes Pharma & Healthcare, Dec. 10.
17 https://www.fcc.gov/general/telecommunications-service-rural-america
18 https://www.fcc.gov/news-events/blog/2014/11/20/closing-digital-divide-rural-america
19 https://www.whitehouse.gov/the-press-office/2011/02/10/president-obama-details-plan-winfuture-through-expanded-wireless-access
30
ACCESS Health International works to help provide high quality, affordable care
for the elderly and the chronically ill. Our method is to identify, analyze, and
document best practices in managing the elderly and chronically ill patients and
to consult with public and private providers to help implement new and better
cost effective ways to care for this population. We also encourage entrepreneurs
to create new businesses to serve the needs of this rapidly expanding population.
At present, ACCESS Health works on these issues in high income countries,
including Singapore, Sweden, and the United States. ACCESS Health is working
to expand this work to low and middle income countries, including India and
China.
According to estimates from the US Department of Health and Human Services,
people aged sixty five and older will represent nineteen percent of the population
by 2030, up from just over twelve percent in 2000. And a 2013 survey by the Pew
Research Center found that seventy five percent of adults in this age group are
living with a chronic condition, such as high blood pressure, diabetes, or heart
disease. With four in ten Americans currently tasked with the care of their elderly
and chronically ill relatives, the US healthcare system urgently needs to adjust to
meet the rapidly growing demand for high quality and affordable elder and tong
term care. ACCESS Health United States helps practitioners and policymakers
locate, learn from, and scale up pockets of excellence in elder and long term care.
Learn more at www.accessh.org.

Full Circle America Case Study

Uploaded by

Document Information

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

Full Circle America Case Study

Uploaded by

Copyright:

Available Formats

Full Circle America Case Study:

Aging in Place and Community

By Jean Galiana and William A. Haseltine

Our vision is that all people, no matter where they live,

Copyright 2015 ACCESS Health International

About Allan Teel

FULL CIRCLE AMERICA CASE STUDY: AGING IN PLACE AND COMMUNITY

FULL CIRCLE AMERICA CASE STUDY: AGING IN PLACE AND COMMUNITY

The Birth of Full Circle America

FULL CIRCLE AMERICA CASE STUDY: AGING IN PLACE AND COMMUNITY

Financing Aging in Place and Community

Tapping Community Assets

If we consider each elder client to be a volunteer for someone, each

Bliss CONNECT and the Role of Technology

FULL CIRCLE AMERICA CASE STUDY: AGING IN PLACE AND COMMUNITY

FULL CIRCLE AMERICA CASE STUDY: AGING IN PLACE AND COMMUNITY

FULL CIRCLE AMERICA CASE STUDY: AGING IN PLACE AND COMMUNITY

4) Healthy Days Measure

FULL CIRCLE AMERICA CASE STUDY: AGING IN PLACE AND COMMUNITY

FULL CIRCLE AMERICA CASE STUDY: AGING IN PLACE AND COMMUNITY

FULL CIRCLE AMERICA CASE STUDY: AGING IN PLACE AND COMMUNITY

14 American Society of Consultant Pharmacists Fact Sheet. https://www.ascp.com/articles/aboutascp/ascp-fact-sheet

FULL CIRCLE AMERICA CASE STUDY: AGING IN PLACE AND COMMUNITY

You might also like