Seniors stay safely at home with support services

Seniors stay safely at home with support services

Interventions provided at home, senior center

Although all of them qualify for a skilled nursing level of care, 86% of participants in Summit ElderCare are able to live in the community.

Summit ElderCare sponsored by Worcester, MA-based Fallon Community Health Plan is a medical, insurance, and social support program for people age 55 and older that helps participants remain in the community as an alternative to moving to a nursing home. The program is based on the Program of All-Inclusive Care for the Elderly (PACE) model centered around the belief that it is better for the well-being of seniors with chronic care needs if their care is provided in the community. Summit ElderCare is a participating provider in Medicare's Program of All-Inclusive Care for the Elderly (PACE).

Components include a team of professionals specializing in geriatric care who coordinate medical care, social services, and support, and five PACE health centers where seniors can receive medical care and participate in social activities.

"Our mission is to keep participants living in their own homes as long as possible," says David Wilner, MD, a geriatrician and hospice care specialist who is vice president and medical director at Summit ElderCare.

The program is conducted out of five PACE centers, located in central and western Massachusetts. The teams at each PACE center include physicians, social workers, physical therapists, occupational therapists, transportation coordinators, home care nurses, clinical nurses, nutritionists, health aides, nurse practitioners, activity coordinators, and the director of the center. People who apply to join the program undergo an extensive assessment by each member of the PACE team to determine if they meet criteria for the program. "We have people who want to join who are not frail enough or are not functionally impaired," says Karen Longo, MHA, vice president and executive director of Summit ElderCare.

The first step in the process is a home visit by the enrollment nurse who assesses the applicant's living situation, ability to perform activities of daily living at home, and need for skilled services. Then the applicant spends a day at the PACE center, getting to know the staff and being assessed individually by each discipline. Then the interdisciplinary team works with the enrollee and family to develop an initial service plan. The team reviews the medical records, talks to providers, and spends time gaining an understanding of the person's medical, psychosocial and functional history.

"At the point of enrollment, the individual already has had extensive interaction with the interdisciplinary team, and the team has a good working knowledge of the participant, the family and the goals they have. They go beyond the interactions of a multidisciplinary team where each person is focused on their own goals and collaborate closely to prioritize each participant's multiple issues and multiple potential interventions to determine on where to focus first, taking into account their goals and their needs," she says.

Once an individual is enrolled, there are no out-of-pocket expenses beyond the monthly program cost. "Full coverage is provided for all approved services, including hospitalizations, in-home services, medical supplies, medications, and more. There are no financial barriers to providing what is needed to maximize functioning and help the participant continue living in the community," Longo says.

Once the plan is in place, the team meets with the participant and family to make sure they are on board with the plan. "We understand that the participants are at that stage in life when they are struggling with multiple issues and challenges. The services we provide are different for each person and are tailored to the individual's needs and wishes. It is essential to make sure to match the care provided with their goals," Wilner says.

All of the disciplines intervene as needed while collaborating with the rest of the team to take a seamless approach. One team member is the primary contact. For instance, if a patient has multiple medical issues and is in and out of the hospital, the primary contact may be to keep the chronic conditions stable and maximize the person's functional level. In that case, the nurse practitioner may become the primary contact. At the same time, the nurse and social worker may be working on eliminating barriers to getting medication and adhering to the treatment plan. If someone has a wound that hasn't healed, the rehab staff may visit the home to determine any physical or environmental factors that may be contributing to the problem. For instance, the person may be sleeping in a chair or is out of medication and can't get to the pharmacy to obtain more.

The team meets regularly to review the participants' progress and to brainstorm other interventions that could help them remain in their homes.

Members of the PACE team and the nursing staff are available 24 hours a day. The program keeps extensive records on each participant that include medical information, interventions and the team member making them, services and equipment that are in place, social and family support including the role of each family member, advance directives, and the education the participant has received. "When someone calls in after hours, the clinician who answers can pull up the participant's records and provide appropriate support regardless of the time of day. They know what coordination has been done and don't have to start at square one," Wilner says.

Clinicians go to the home and provide medical care when participants are sick and provide care at nursing homes and long-term care facilities.

Summit ElderCare also has transition of care nurses who work with the interdisciplinary team, participants, and family members and act as a liaison between hospitals and post-acute facilities to ensure a smooth transition. The transition of care nurses are not necessarily part of the interdisciplinary team but work with the team, hospitals, skilled nursing facilities, home health agencies, and transportation providers. "They take a checklist approach to make sure all the dots are connected when people move from one level of care to another," she says.

The program has a contract with a hospitalist group to provide day-to-day management of participants in the hospital but the team continues to have oversight. The transition of care coordinator works with the hospital team to provide information that can help with the discharge plan. "We are able to go to the hospital and consult on care issues as needed, as well as coordinating with the hospital, the patient, and family," Longo says.

"One of the significant benefits of the PACE program is that one team coordinates care throughout the hospital stay, a skilled nursing admission, and back to the community. One team knows what is going on and has a checklist of services that need to be in place," Wilner adds.

Participants, on average, spend time at the PACE centers a little more than two days a week. Some come only once a month for a medical visit. Others are there five days a week for adult day activities, rehabilitation, and other medical services.

The centers have transportation coordinators that work with participants and family members to ensure that they can get to the centers when they are scheduled. Some participants are brought to the center by their family members. Others take the center's van.

The team takes a proactive approach to keeping members safe. For instance, when an ice storm was predicted for the area and the centers were expected to be closed, the team made sure there were safe plans for every member and that they had the medications they needed.

Family support is a key to the success of the program, Longo says. If there are no family members nearby, the program can provide the physical assistance that will allow the senior to remain in the home. The team works to engage family members and holds regular family meetings. If the family is out of town, the conferences are by telephone.

"When an individual first enrolls, the team spends a lot of time trying to identify potential support beyond just identifying a spokesperson. We look at whether there are grandchildren, neighbors, or friends that may have something to offer," she says.

The team checks on participants by telephone as needed and is piloting an Internet-based monitoring system that alerts them when the daily routine changes. The alerts can be customized to meet the needs of the participant. For instance, the sensors may be installed on the refrigerator and kitchen cabinets and alert the family or the team when the person fails to open them in the morning.

For more information on the PACE program, visit: www.summiteldercare.org, and http://www.npaonline.org/website/article.asp?id=12&title=Who,_What_and_Where_is_PACE?.