Team focuses on needs of the elderly
Goal is to help seniors maintain independence
By reaching out to community organizations and agencies to collaborate on care management and improve care transitions for its high-risk elderly population, Scottsdale Health System has decreased readmissions and frequent emergency department visits among the area’s senior population.
The goal of the initiative is to help seniors get what they need to maintain their independence and maximize their health. "The elderly have a multitude of issues that cause their discharge plans to fail and drain the resources from the city on multiple levels. They are fragile, many live alone and are isolated, and they have a lot of fears. They make a lot of calls to 911 and have frequent visits to the emergency department. We are working together to look at these individuals and their living situations and to get to the root causes of their problems," says Catherine Holdeman, RN, MSN, system manager for the care coordination program, focusing on patient-centered care and the elderly.
As part of its implementation of patient-centered care initiatives, the three-hospital system brought together all of the community organizations that provide services for the elderly including the fire department, police department, crisis workers, senior centers, the parish nursing program, and adult protective services to talk about how to provide better care for the elderly.
"We wanted to build a strong relationship with other organizations in the community that provide services to the elderly. We understand our population, their chronic diseases, behavioral health issues, and their access to physicians, but we didn’t have good communication with some of the agencies that also provide services to our patients," Holdeman says.
Senior citizens have a tremendous number of issues that can cause the discharge plan to fail and send them back to the hospital, points out Karen Ford, RN, MSN director of case management. "Every time our process breaks down, the seniors either call 911 or go to the senior center for help," she adds.
When representatives from the various agencies began getting together, it was eye-opening to realize how little all the players were talking to each other. "Sometimes patients would call 911 eight or nine times a month. They’d bring them to the emergency department and we’d treat them and send them home, but since we weren’t communicating well, none of us had the full picture," Ford reports.
Representatives from all the agencies work together as a team and collaborate on how to pool the resources of all the entities to benefit the entire community. "The players at the table all have different strengths and different experiences. We all have shared the challenges that our current practices present and are working together to change the way we provide healthcare. We have worked to get the support of leadership from all entities and to determine what we can and can’t accomplish," Holdeman says.
During the meetings, representatives from each organization have educated each other on what goes on in their part of the continuum. "Understanding the roles of each organization and the boundaries they must observe takes the mystery out of what everybody does and helps build relationships," Ford adds.
For instance, the other agencies did not initially understand medical necessity criteria, patient status, and other regulations hospitals must follow, such as the three-day rule for Medicare to cover a stay in a skilled nursing facility. "Until we explained it, everybody asks why we couldn’t just keep patients for three days until they qualify for a skilled nursing facility stay. Agencies often had the perception that the hospital didn’t work in the best interest of the patient and family, and now that they understand the rules we have to follow, they know it isn’t the case," she says.
The group started meeting monthly in early 2011 as an executive group. The meetings have evolved into subcommittees working on different areas and with different focuses, Holdeman says. One group includes representatives from the hospital and the fire department who are working on emergency department issues. Another is concentrating on specific issues that individual seniors face.
Each of the organizations has utilization metrics that it tracks, but until recently, the organizations didn’t combine their data. Now, for instance, the partners can track how many times an individual has been to the emergency department and how many times he or she has called 911. The senior center can use the information to send a social worker into the community to find out exactly what the senior needs. "It could be something as simple as linking the person with the senior center. Sometimes people call 911 because they just lost their spouse, their family lives out of state, and they feel alone," Ford says. Other times, it may be that the best solution for the person may be in an alternative living setting with more support.
The staff from the senior centers or Adult Protective Services can determine what the individual or family needs, whether it’s financial help or setting up Meals on Wheels or housekeeping assistance, and link them with community organizations that can provide services.
In some cases, the staff at a senior center notices that someone who has been coming there regularly is showing signs of dementia or struggling with walking. Then the center’s case manager can link the individual with a primary care physician and make sure he or she sees the physician regularly.
"These relationships and communication links are powerful and invaluable to us as we complete our assessments and discharge plans. Patients often come in and we treat whatever is wrong and they come back. We try to find out what is going on with them outside the hospital walls, but many times people, especially the elderly, say everything is fine at home," Ford says. But sometimes the police or fire representatives report that the patient is showings signs of hoarding, the house is a unsafe, there’s no food in the refrigerator, or they have behavioral problems, she adds.
"The crisis team sees people in their home and can share a wealth of information, such as living conditions or family dynamics while the individual tells us what they want us to hear. These interactions with other agencies help us put the pieces together," Ford says.
Many times now, when patients come into the emergency department or are admitted, the agency that has been working with them sends the hospital case management department an email asking the inpatient case management team and transitional care services to work with them on the discharge. "Now we are covering all the bases. They may give us information that otherwise we would not have known," she says.
In one case, the first responders to the 911 call noted that there was an eviction notice on a patient’s door. "The patient didn’t disclose this, and we wouldn’t have known if the fire department hadn’t put it in the notes. Having this information helped us find an alternative living situation and ensure a healthier transition out of acute care," she says.
The organizations can also intervene when younger, disabled people who consume a lot of resources need assistance, she says. For instance, some people call 911 every night because they need help transferring from a wheelchair to the bed. In these cases, someone from a community agency intervenes to get the person into an assisted living center or set up assistance to help with activities of daily living.
"When everyone talks to each other, it’s advantageous to the city, the patients, their families, and the healthcare system. It also has helped employee satisfaction because everyone works collaboratively and addresses the root causes of the problems so employees feel that they have done the best job they can of helping the individual," Holdeman says.