CMs help MD group keep seniors home
Office staff trained in early intervention
A San Francisco-based medical group wants to prove that case management keeps seniors healthier and more independent. Researchers still are crunching the raw data, but patient satisfaction surveys show the program is already popular with patients referred to Brown & Toland’s Identification and Early Intervention program.
In a survey of 130 Brown & Toland patients receiving help from Seniors-At-Home, 88% said the service helps them feel safer at home. Seniors-At-Home is a community service agency operated by Jewish Family and Children’s Services of San Francisco, the Peninsula, and Marin and Sonoma Counties that provides case management for the group’s at-risk seniors. In addition, 82% report the service helps them remain independent in their own homes, and 97% simply are grateful their doctor’s staff reach out to them.
"We didn’t actually do a pre-intervention study to determine whether our costs for our seniors were extremely high, but there was a strong feeling that we had a growing need to help our seniors remain independent," says Susan Roth, MS, RN, director of geriatric programs for Brown & Toland. The medical group launched its Identification and Early Intervention program just over three years ago to provide preventive social services to at-risk members, and more than 1,300 of Brown & Toland’s 16,000 seniors have received case management services so far, she adds.
More than 50% of referrals come from local hospitals. Brown & Toland receives a daily printout of geriatric admissions to California Pacific Medical Center in San Francisco. The printout provides patient age, diagnosis, and most recent admission date. "That’s important information. If an 86-year-old patient is admitted for a fall and was just in the hospital two months ago, I see red flags," she says.
Brown & Toland also trains members of their physicians’ office staff to act as geriatric resource specialists. "We target physician practices with a high percentage of seniors,"’ Roth says. She holds quarterly training sessions for physician staff members designed to help them identify problems earlier.
The 10-hour training sessions cover the following:
• normal and abnormal signs of aging;
• advance directives;
• elder abuse;
• polypharmacy;
• finances;
• communicating with individuals who have sensory impairment;
• local area services for seniors.
Education is ongoing
Geriatric resource specialists receive a binder of information to help them identify signs of cognitive problems and other frailties common in the elderly. "We don’t give geriatric resource specialists a list of specific red flags.’ I feel there has to be more thinking going on," Roth says. "Not every patient needs a referral." In addition to their initial training, geriatric resource specialists receive a newsletter and quarterly inservices to continue their training.
Brown & Toland patients identified as at-risk are referred to the Seniors-At-Home program for case management. A case manager visits patients referrals within 48 hours to complete a thorough at-home assessment, which includes functional ability, support systems, and health status.
"From that home visit, we make recommendations to Brown & Toland about what services patients need and how long case management should continue," notes Eileen Goldman, LCSW, director of the Seniors-At-Home program. "A patient may have a good social support system and need no more than a meal delivered daily, transportation to the physician’s office, or a good adult day-care program."
The two levels of case management Seniors-At-Home provides for the majority of Brown & Toland patients are:
• Limited risk case management. "A patient who needs limited case management might be a patient who needs a few services, such as meal delivery, but who follows directions well and has a good support system," says Goldman. "These patients are able to manage well with some education, a few home visits, and a referral or two to local services."
Patients in this level typically receive three home visits from a case manager. "We make the telephone referrals to social services and write a final report for the patient’s physician," she says.
• Moderate risk case management. "A patient who needs moderate case management might be a patient with some cognitive or emotional impairment that makes it harder to provide case management for them. This is typically also a person with a weaker support system," Goldman explains.
Patients in this level typically receive five home visits with follow-up telephone calls. "At the end of that time, if we think the patient still needs case management, we can ask the physician to authorize six months of monitoring or to reauthorize case management at the same level," she says. "If a case manager is monitoring a patient, typically that means a monthly home visit and weekly telephone calls."
Researchers at the Robert Wood Johnson Foundation in Princeton, NJ, are analyzing utilization data to determine whether case management services help reduce costs for seniors. "We have a treatment and control group, and we’re looking at target areas such as emergency room use, inpatient days, skilled nursing facility admissions, and home health visits. We hope that the numbers prove that identification and early intervention help control medical costs for seniors," Roth says.
MD recommendation opens doors
Whatever the final numbers show, Roth and Goldman both are confident that the case management services have had a positive impact on Brown & Toland’s seniors.
Goldman recalls one woman who fell in her home and had pain in her leg. "She was being cared for by her two brothers and they were ready to send her to the hospital," she says. Seniors-At-Home arranged to have an X-ray taken in the home. "The X-ray showed the bone wasn’t broken. We arranged some respite care for the brothers and some physical therapy for the patient. The problem was easily managed at home with a good outcome."
"The beauty of this program is that the referrals come from the patient’s doctor," adds Goldman. "It’s often difficult to get seniors to accept social services, but if the recommendation comes from their doctor, the door opens for us to come in."
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