In addition to the care Seniors·At·Home provides to seniors and their families today, we are training other geriatric professionals to expand our ability to assist more seniors and families in need for years to come. Seniors·At·Home believes that by coordinating specialized geriatric training, we can make better use of front office staff in physicians' offices to improve senior care. One of the Seniors·At·Home programs, funded by grants from the Evelyn and Walter Haas Jr. Fund, the Retirement Research Foundation and the California HealthCare Foundation, trains geriatric resource people in physicians' offices to identify at-risk seniors and alert physicians to concerns. During a 10-hour course certified for continuing education by a local California university, these individuals learn how to become the human "communication link" among the Seniors·At·Home Program, the primary care physicians, case managers and the seniors themselves. Using a curriculum developed specifically for this program, the Nurse/Training Coordinator emphasizes knowledge, sensitivity and awareness of geriatric issues and recognition of the outward signs of frailty that a patient may display in the office or community. Geriatric resource persons learn how to describe the major normal changes of aging, better identify "at-risk" seniors, identify and describe the major indications of cognitive failure, and identify factors related to safety, rehabilitation and nutrition. Program participants receive a training manual that will help them easily reference the lessons learned. In addition, the program purchases Commission on Aging Resource Guides for each program participant.
Seniors·At·Home's ongoing independent and collaborative research projects clearly demonstrate the effectiveness of this social services model of care. To address rising costs and perceived poorer healthcare outcomes, in 1993 California Pacific Medical Service Organization (CPMSO), the predecessor to Brown and Toland Physician Services Organization (BTPSO), initiated a system of care for senior HMO enrollees that expanded the scope of care offered to seniors. The system identified at-risk seniors during routine visits to physicians and at hospital discharge, and included contracting with Seniors·At·Home to address the non-medical needs of patients that might adversely affect their health outcomes. The system also trained front office staff in primary care physician offices to identify and refer at-risk seniors, and was paid for entirely by the Medical Group. The Program's unique components (community-based, social work case management, trained front office staff, physician education, and sophisticated management information systems/analysis) were intended to be complementary and are dependent on one another for improved health and cost related outcomes. In 1994 the Robert Wood Johnson Foundation agreed to fund a cost-benefit analysis of the program.
The Foundation-funded study was completed in 1997. Initial results indicated that the Identification and Early Intervention Program (IEI) may reduce costs for seniors enrolled in Medicare risk programs. Surveys of patients and physicians participating in IEI also indicated substantial satisfaction with the program. In addition, the results showed that that the intervention lowered costs to the payor (the medical group) by decreasing unnecessary hospital visits and emergency room, skilled nursing facility and ambulance usage. The study's research indicated that issues like depression, decreased income or loneliness can just as significantly impact a patient's ability to stay well as organic disease processes. These initial results were limited, however, and the results provide a basis for further evaluation of the effects of IEI.
In October of 1998, California HealthCare Foundation awarded Seniors·At·Home, in collaboration with Brown and Toland Physician Services Organization and the Division of Geriatrics at the University of California in San Francisco, a three-year grant to study the efficacy of the case management intervention, the value of the geriatric resource intervention in relation to patient outcomes, and the overall effectiveness of the intervention in reducing health care costs. The study is being implemented to allow robust quasi-experimental evaluation: half of the primary care practices will implement the program during the first year and half during the second year. Thus, the effects on costs and outcomes will be assessed both by comparing a group with the program to a group without the program, and by evaluating a group over time before and after implementation of the program. The study will determine the effects of the program's intervention on medical care costs and health outcomes in Medicare at-risk programs.
Seniors·At·Home also conducts its own research on an ongoing basis to ensure the satisfaction of patients and referral sources. A patient satisfaction survey conducted by Watson Wyatt in November 1997 and again in 1998 indicates that 90% were satisfied with the services provided by Seniors·At·Home. The results of the March 1999 survey among referral sources indicated that 85% of physicians want Seniors·At·Home to continue providing social work case management services to their senior patients. An impressive 100% of geriatric resource persons believe that Seniors·At·Home provides them with more resources and knowledge for accessing care for seniors. Of the hospital discharge planners surveyed, 100% will continue referring to the program in the future.
Recently, Seniors·At·Home's partnership with Health Net California, a health care delivery system, was honored as one of two recipients of the prestigious 2001 Award for Innovation and Quality in Managed Care, sponsored by the American Society on Aging (ASA) and Pfizer, Inc. The Health Net/Seniors·At·Home partnership effectively shares responsibility for identifying, assessing, enrolling, and following up with patients who are members of Health Net Seniority Plus, a Medicare+Choice HMO, in the Seniors·At·Home care program. Health Net care managers or medical groups identify frail seniors eligible for the program while Seniors·At·Home performs a complete assessment, recommends an appropriate plan of care, visits seniors in their homes to implement the plan and carefully reports and tracks the patients' progress and outcomes. Launched as a pilot program in the San Francisco Bay Area, the collaboration will be expanded to Sacramento and Southern California. |
