Navigating a complex health system can be overwhelming for a geriatric patient, with communication problems arising about misunderstanding of diagnosis, discharge instruction, and medical management—all areas that the hospital system works diligently to resolve, says Nancy A. Istenes, DO, CMD, medical director for long-term and transitional care services for Summa Health System.
Before implementing its ACE model, hospital officials sought to make improvements in patient care, to avoid a system “that contains the potential for errors,” Istenes says. “There could be situations where a patient doesn’t know who to call, who is in charge, and the medical community may be uncertain which physician has ownership of the patient’s multiple medical conditions” following discharge.
Istenes says the hospital reviewed models of care that focused on “having a transitional coach to help empower patients to take a more active and informed role in their transition from one care setting to another.” In another model, a case management structure was initiated “in which everything was done for the patient—discharge planning and home visit,” she says.
“We blended both programs to ensure patients know who to call if they need help or have questions about their medical care,” Istenes says. “Errors can happen if care is needed and can’t be delivered in a timely fashion. We wanted to bridge that transition from hospital to home.”
The program starts while the patient is in the hospital. Patients meet with a transitional care nurse and schedule a one-time follow-up home visit. A day or two after discharge, a transitional care nurse contacts the patient and his or her family to review discharge instructions, determine if prescriptions are filled, and encourage patients to follow-up with their primary care physicians. The nurse oversight and health coaching from staff continues during the first month after discharge, Istenes says. To reduce costs, Summa Health partnered with SummaCare.
“We see greater enrollment in Medicare and Medicare Advantage; the real cusp of the wave is to come. We’re trying to build a program that will be able to grow in capacity to meet the needs before the real tidal wave,” Istenes says.
The program, known as CK Village, includes discounts and reminders for screening and follow-up on health and wellness programs, and helps members access other services such as transportation, home repairs, and bill paying through a Village Navigator, who can be a nurse or social worker. The hospital charges a nominal membership fee for geriatric patients, their children who may be caregivers, as well as disabled or dependent children over 18.
“Providing personalized concierge-type service for our members is highly appreciated by those who receive the service,” Looby says. “We certainly would like to see the numbers increase, but this service was not launched because it was viewed as an additional source of revenue; it was launched because we believe that it would be a valuable service to the community.”
Different organizations across the country are looking at the village concept, she says. “We’re looking at how we can transition across the continuum of care and identifying ways the Village can help with the transition of care and become a more integral part of providing postacute care services,” she says. Because many of the individuals in CK Village programs are older adults with multiple medical conditions, one of the goals is to target more children of aging parents.
“In the health system and its commitment to geriatric care, we needed to create a program that bridges the gap between inpatient and outpatient care for the elderly,” Looby says. “How do you connect those dots for patients and not have them fall between the cracks?” Crozer-Keystone created an 800 number to provide additional support to patients and their families to have access to community-based services.
“In recognition of the specialized needs of the elderly, the health system also created the ACE unit at one of its hospitals,” Looby says.
“Providing a compassionate service is essential for caring for geriatric patients, she says. We have a responsibility that you don’t treat an 84-year-old the same as 24-year-olds.”
This article appears in the November 2011 issue of HealthLeaders magazine.