Geisinger Health System’s Living Independently for Elders (LIFE) program provides medical care, therapy, adult day activities, and home visits for elderly patients who meet the medical criteria for a nursing home admission.

• Seniors referred to the program are assessed by a multidisciplinary team that develops an individualized service plan.

• Most participants spend two or three days a week at one of two LIFE centers, facilities with 12,000 or more square feet of space that serve as the hub of the program.

• The program’s home care team makes home visits to participants who need assistance with activities of daily living.

Senior citizens who otherwise would be placed in a nursing home are able to live at home safely thanks to support provided by Geisinger Health System’s Living Independently for Elders (LIFE) program in Pennsylvania.

LIFE Geisinger is open to anyone 55 or older who lives within the service area and who meets the medical criteria for a nursing home admission. Participants typically spend several days a week at a LIFE center, where they receive regular medical care and therapy and can take part in a variety of activities.

Between trips to the center, participants who need help at home are visited by LIFE Geisinger’s home care team for assistance with housekeeping, meal preparation, and other activities of daily living, as well as validating medication compliance.

“The goal of the program is to keep these seniors out of the nursing home and living in the community. We take care of their healthcare needs and keep them active and socialized so they don’t sit at home watching television, becoming debilitated and less able to manage on their own,” says Robert McQuillan, MHA, NHA, associate vice president of LIFE Geisinger/skilled nursing facility operations.

The program provides transportation to and from the facility, primary and specialty physician care, dental care, medication management, nutrition counseling, physical, occupational, and speech therapies, social worker interventions, and recreational therapy. LIFE Geisinger may contract with a home health agency to provide skilled services to participants if needed. The therapists, clinic nurse, and physicians also may visit participants at home if necessary.

Geisinger has two full LIFE centers, one in Scranton, PA and one in Kulpmont, PA. The staff at the Scranton LIFE center oversee the activities at a satellite center in Wilkes Barre, PA.

The centers are staffed by interdisciplinary teams that include managers of direct services and home care, physicians or nurse practitioners, physical therapists, occupational therapists, a pharmacist, a dietician, social workers, and a transportation supervisor. The intake coordinator is a nurse or a social worker.

The LIFE program receives referrals from a wide range of sources including churches, community organizations, state agencies, hospital staff, physicians, and friends or family members of potential participants.

When the program receives a referral, the intake coordinator contacts the patient, explains the program, and finds out what services may be needed. Individuals who are interested in participating have a choice of coming to the day center for a tour or having a staff member, either a social worker or a nurse, come to their home for an initial visit.

“During the initial visit, we try to gather enough information on the potential participant, his or her needs, and the family dynamics and put together an initial plan. We share what services we can provide and offer the participant and family members a trial visit to introduce them to the daily routine of the program,” McQuillan says.

The potential participant stays most of the day during the trial visit and meets members of the team. The team meets the next morning and outlines a service plan. Then, the intake coordinator or center manager calls the family, shares the plan, and asks if they want the senior to participate.

LIFE Geisinger is part of CMS PACE (Program for All-inclusive Care for the Elderly). Many of the people in the program are dually eligible for Medicare and Medicaid.

The program receives a capitated payment for dual eligible participants from both the state and federal programs. Those funds cover all of the expenses of dually eligible participants including home care, medication, supplies, transportation, testing, physician visits, and home modification. Participants who are eligible for Medicare but have too many resources for medical assistance pay a private portion of $4,469.78 a month.

Participants can be enrolled only on the first of the month. “When hospital discharge planners or people in a physician office have someone with an immediate need, we can’t help them until the first of the month,” McQuillan says.

Before participants can be enrolled in the program, the Area Agency on Aging must visit the home and certify that they meet nursing home medical eligibility criteria.

“They agree with us 90% of the time. If we can’t meet the individuals’ needs, we connect them with organizations that can. We don’t leave anyone hanging,” McQuillan says.

On the first day they attend the center, the participants meet individually with the multidisciplinary team. “This gives us an opportunity to verify the information we got on the intake assessment and to get a baseline measurement for therapy. As time goes by, we try to involve them in activities that will help them maintain or improve their performance,” McQuillan says.

Over the course of the first 30 days, the multidisciplinary team members refine the service plan, adding more specific goals and measurements. They review the plan and the participant’s progress again in six months unless there is a significant change in condition.

Participants may come to the LIFE center monthly, but most come two to three times a week. The center staff may assist with the participants’ laundry and bathing, and provide a morning snack, a hot meal for lunch, and food to take home.

“We make sure they have their medication and all the supplies they need for the weekend or in winter when they may have to stay at home because of the weather,” McQuillan says.

The day centers are the hub of the LIFE program. Each program is conducted in a facility with more than 12,000 square feet of space, enough room for activities for all levels of skills and needs. and includes a therapy area, clinic space with exam rooms, an activity room, and dining area. “We utilize technology like telehealth so our participants can see other providers or a specialist for a second opinion, eliminating the need to take patients to another facility,” McQuillan says.