Executive Summary
A new initiative addressing healthcare needs of an aging population has resulted in a 50% reduction in admissions for enrolled seniors, according to those in charge of the program.
• The program is a collaboration by health systems and has recently completed a three-year period for a grant.
• In starting the robust care management program, project leaders worked to not use more than existing resources.
• The program targeted seniors with chronic medical conditions or who were considered at risk.
As America’s aging population increases, there’s pressure on the nation’s healthcare industry to develop care models and best practice programs that will improve seniors’ health.
One initiative by Sharp Rees-Stealy Medical Centers of San Diego resulted in a 50% reduction in admissions for seniors engaged in the program. Also, seniors reported a 40% increase in their confidence, knowledge, and skills for self-management.
The health system joined more than 20 other health systems in a program that started July 1, 2012, and recently completed its three-year period for a grant from the Centers for Medicare & Medicaid Services (CMS), says Scott Heimer, project coordinator at Sharp Rees-Stealy Medical Centers.
“We enrolled our first patient in May 2013,” Heimer notes. “It took a year to get everything up and running.”
Sharp Rees-Stealy has had a robust care management program that focused on patients with chronic illnesses, including diabetes, coronary artery disease, and chronic obstructive pulmonary disease (COPD), says Christine Tedeschi, MS, RN, CDE, manager of ambulatory disease management programs at Sharp Rees-Stealy Medical Centers.
“This opportunity focused on the senior population and created a care model for seniors in order to determine, number one, what their needs were, and, two, what type of patient-centered changes took place to increase their efficacy and quality of life,” Tedeschi explains.
The program looked at whether seniors had depression and how the team could connect with them to improve their overall health status, she says.
“This fit in well with Sharp Rees-Stealy’s philosophy,” Tedeschi notes. “Our leadership wanted us to integrate these ideas into our existing programs, and we had a mandate of not increasing resources, so we couldn’t hire anybody extra to manage and take care of this program.”
The challenge proved to be a wonderful experience, she says.
“The overseeing organization was an outside organization of medical groups, and we took their guidelines and incorporated them into what we already had in place,” Tedeschi says.
The health system’s team would meet with the other participating medical groups in collaborative sessions, Heimer says.
“We’d share our experiences and learn a lot from them, as well,” he notes. “We had the key players in our organizations figure out how to best implement and layer it into what we’re already doing to have as little disruption as possible and to make it easier for nurses to keep track of what needed to be done for this particular program.”
The following are some of the steps they took:
• Define the program’s focus. “Our program focused on senior patients, including those with chronic medical conditions and individuals who were thought to be at high risk,” Tedeschi says. “We already had disease management in place, so our high-risk seniors in those programs became eligible for this program, as well.”
Since the health system had a successful disease management program with complex case management, patients in this additional initiative were able to be part of an existing structure, she notes.
“We also had high-risk seniors who didn’t fit into any other programs who could come over and have their care managed by an RN and social worker who were devoted to that senior population,” she adds.
The program required a face-to-face visit, which was integral to its requirements. “It also taught us a lot about how people engaged and how they saw patients on a face-to-face basis to gather consent,” Tedeschi says.
Nurses also called patients and some people were seen in the hospital, but home visits were a part of the program, she says.
• Focus on connecting with patients. “During those face-to-face visits, we worked hard to identify — especially in conversations — how to make a connection with patients to establish what their immediate needs were,” Tedeschi says. “There also was a requirement that we continue to have an engagement with patients and have at least a monthly contact.”
Even the most thorough assessment by phone or in a healthcare setting might miss the patient’s underlying issue, such as the patient’s worry about a family member, she notes.
“It’s all about identifying the immediate needs,” she says.
“For this particular population, these small requirements were helpful over time, so that if a patient needed something, even something as small as a medication refill, we could help,” Tedeschi adds. “This began to be seen by the patient as a special connection.”
There was one patient who would tell her family, “These are my people calling me,” she recalls.
“She was engaged with the care and able to move forward,” Tedeschi says. “All of us were focused on the total care of the senior patient.”
• Assess for mental health and social support needs. “Assessments included clinical and psychological needs, and we used an activation measure and quality of life and depression measure, as well,” Tedeschi says.
“Many patients would be connected with mental health services,” Tedeschi says. “These included depression screening and connecting patients to other programs that might help them.”
For instance, there was one man who needed knee surgery. He lived on a boat, so the nurses worked with him to find housing on land. They were able to find a place for him to live, making it easier for him to have the surgery, she recalls.
“He couldn’t have had the surgery and lived on a boat,” Tedeschi says. “Those were the kind of issues identified over and over again.”
• Use the right staff. “We learned early on that it made a difference who we had making phone calls and outreaching to patients,” Tedeschi says. “We have case managers and care specialists — unlicensed staff members who assist case managers in their work on a daily basis.”
Care specialists can reach out to patients and obtain informed consent by telephone, Tedeschi says.
While the actual assessment was done by the care manager, they found that there were individuals who had a gift for connecting with patients, whether on the phone or in person, Tedeschi says.
“These are the individuals who just have a knack for engaging with patients in person and telephonically,” Tedeschi says. “We think these people are very vulnerable.”
“One of the stars on the staff is able to help with patients who need to reconnect with the medical group,” Tedeschi says. “She has a knack for making that person feel accepted and embraced, and she is very, very engaging; we look for the warmth to come through for every level of outreach.”
• Measure results. “The patient population improved across the board — quality of life scores, depression, as well,” Tedeschi says.
“It was very interesting to look at data and see if the patient was moderately depressed,” she notes. “We were really surprised to find that in both measures having to do with quality of life, we had increases in health-related quality of life.”
They’re refining the process to re-evaluate the patient activation measure, Heimer notes.
“Right now, it’s really subject to the care manager’s opinion whether people need to be challenged,” he says. “It makes sense if you have seniors with multiple chronic conditions, then some will need help for the duration, but the outcomes were positive.”
The key to the program’s success has been the philosophy and regular contact with the patient, Heimer says.
“They develop relationships with their nurse or social worker,” he explains. “It goes back to patient-centered care and how sometimes they’re worried about their cat, and until their cat is okay, you can’t worry about other things.”
A new initiative addressing healthcare needs of an aging population has resulted in a 50% reduction in admissions for enrolled seniors.
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