Care coordination helps seniors live independently at home

Program cuts hospitalizations, ED visits

Senior citizens are living independently longer and staying out of the hospital and emergency department thanks to client-centered care coordination through two programs developed by UPMC, a large integrated health care delivery system with headquarters in Pittsburgh.

Living-At-Home and Staying-At-Home are offered to older adults who live in their own home, in an assisted living facility, or in a retirement community in Allegheny County.

The Staying-At-Home program is the outgrowth of UPMC's Living-At-Home program, a program that has provided geriatric care management to low-income seniors since 1987.

It started out as a pilot project under a grant from the Robert Wood Johnson Foundation.

"The program showed very positive results, and when the funding lapsed, UPMC continued to support the program even though insurance wouldn't pay for it. Our outcomes data that we collect through random chart audit show that we continue to decrease hospital and emergency department visits and increase compliance with physician visits," says Shikha Iyengar, vice president of geriatric services for UPMC.

Living-At-Home serves low-income seniors in 14 Pittsburgh neighborhoods and is subsidized by UPMC at no cost to the clients.

The Staying-At-Home program, begun two years ago, covers all of Allegheny County and charges a fee to individuals who can afford to pay for the services.

"Most of the clients in Staying-At-Home pay out of pocket, but our cost is lower than that of other case management programs in the country. We like to think we can do more for the clients because we have the backing of the entire UPMC health care organization, and we often make referrals to various geriatric programs within UPMC," says Missy Sovak, MSW, director of the UPMC Staying-At-Home and Living-At-Home programs.

Both programs are served by the same staff and offer the same services depending on the client's needs.

The clinical staff include geriatric care coordinators who have a bachelor's degree in social work or a health care-related field and clinical coordinators who are nurses. Each care coordinator has a caseload of about 100 clients.

"Older adults don't need a nurse every time. Most of the care coordination can be done by health care professionals who understand the needs of an aging population, the health care delivery system, and what kind of support system is needed," Iyengar says.

The nurses are involved in only 30% of the cases. The other 70% are handled strictly by the care coordinators, says Charlotte Birchard, RN, clinical coordinator.

"For most older adults, the need for skilled care is secondary. Their primary needs are support systems and someone who can help them navigate the health care system. The goal of our program is to keep our older patients stable and delay institutionalization," Iyengar says.

The medical director and the geriatric pharmacologist in the program are from UPMC's division of geriatric medicine and work with the nurses and care coordinators to ensure that all of the clients' needs are met.

Staying-At-Home and Living-At-Home are successful because they take a proactive approach to coordinating care for senior citizens, Iyengar points out.

"Our health care system is focused on providing the best care for older adults. If you wait until they get to the hospital to provide care coordination, they will have more complications and complex needs," she says.

Clients are referred to the program by home care nurses, hospital social workers, physicians, individuals in the community, or the clients themselves.

When someone is referred to the program, a geriatric care coordinator visits his or her home and completes a comprehensive assessment that includes demographic information, information on the patient's physical condition, the client's psycho-support system, the client's living situations, and all the medications the client is taking. All clients also are screened for depression and referred for whatever interventions they may need.

The care coordinators stratify clients into one of two levels of care.

Clients on Level 1 don't have pressing clinical needs but may need social support. The care coordinators contact them by telephone or in person monthly, or more often if necessary.

Clients on Level 2 have more clinical issues and need more intensive management and assistance with medications.

If the client needs assistance with medication or has complex needs, the care coordinator makes a referral to a nurse, who goes to the home and completes a skilled nursing assessment and medication reconciliation.

In these cases, the care coordinator collaborates with the nurse who handles medication reconciliation and other clinical issues while the care coordinator handles the social needs of the client.

The care coordinators develop a care plan based on the client's strengths, interests, abilities, and capabilities.

"The focus is on prevention and getting to the person before they have a downward trajectory and decline in function," Iyengar says.

The care coordinators set a schedule of when to see or call the clients, depending on the needs of the seniors.

"People who don't require a lot of services and have a support system in place but want to be part of the program in case they do have needs may be visited every three months or receive a phone call every one or two months," says Mark Shaw, lead care coordinator.

The care coordinators help clients make their doctors' appointments and call them and remind them to attend. If the senior needs help, such as housekeeping assistance or help with meals, the care coordinator arranges with community agencies to provide the services.

"Sometimes the needs of the clients are as simple as coordinating doctors' appointments and arranging transportation. We've signed many of them up for transportation assistance and taught them how to order the access van," Shaw says.

The care coordinators are assigned by zip code and get to know the formal and informal services available for seniors throughout the community.

For instance, some churches offer free lawn care service to seniors in the summer months, Shaw adds.

When seniors in the Living-At-Home program need assistance, the care coordinators can call on a volunteers, who make friendly phone calls to older adults, visit with them, help them with grocery shopping, and escort them to doctors' appointments, Shaw says.

When there are compliance issues, the care coordinators drill down to find the reason.

"Cost is often a major factor in nonadherence. The care coordinators and clinical coordinators work with the client and the primary care physician to come up with a medication regimen that can enhance compliance," Iyengar says.

If the senior needs assistance with medication, the nurse gets an order from a physician and pre-fills pill boxes for a two-week period to make sure the client adheres to his or her medication regimen.

The nurses also may pre-fill insulin syringes or give the client B-12 injections so the senior doesn't have to go the physician office, Birchard says.

One of the program's most successful initiatives is the personal health care diary, Iyengar says.

The document contains key information the patient needs when he or she has a doctor's appointment or presents in the emergency department.

The care coordinators enter the information they get on intake into the diary and update it on an ongoing basis. Seniors are encouraged to keep the diary in their purse or pocket and take it with them when they see a doctor.

It includes demographic information, the patient's living situation, contact information for the primary care physician and specialists, contact information for family members and/or other caregivers, activity level, health problems, current medications, and preventive procedures and screenings such as pneumonia vaccine, osteoporosis screening, shingles vaccine, and vision and dental visits.

The diary goes into details on health problems, such as shortness of breath, as well as including detailed information on chronic diseases and conditions, Iyengar says.

"It takes our preventative, proactive approach in managing care to a new level. The diary has everything physicians and paramedics need to treat the patient. It contains contact information for family members and other support that is in place, a list of physicians treating the client, and a list of medication so the paramedics or emergency room staff don't have to look for pill bottles or rely on the senior's memory," Sovak says.

If patients are hospitalized, the care coordinators make sure the hospital health care team has complete and appropriate information about the patient. They work with the hospital case managers on discharge planning to make sure the client is discharged to the most appropriate setting and help with the transition.

If a client is going home with home health services, the nurses work with the home health agency to smooth the transition but don't see the client until the home health regimen is completed in order to avoid duplication of services.

The care coordinators work with the clients and their families to create plans for the future, going beyond health care advanced planning, Iyengar says.

"Since there may be a time that they have to move out of a large home, we educate them on housing options. If they are not able to manage financially, we connect them with an organization that may help with bill paying. We try to help them look ahead so that they aren't so shocked when their living situation has to change," she says.

Clients stay in the program indefinitely.

Some of the clients have been in the program for nearly 20 years, Sovak says.

"We coordinate care for seniors who are well and living at home, through their disease process and to the end of life," she says.