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Seniors·At·Home conducts ongoing geriatric research and training to improve health care results for seniors and increase cost savings for health care providers. We accomplish this by integrating medical care with much needed social services to improve patient care and health care outcomes. This approach significantly reduces avoidable emergency room visits, ambulance calls, physician office visits, and inpatient and skilled nursing facility days.
Training the Front Line
Seniors·At·Home trains geriatric professionals (for example, front office staff in physicians' offices) in order to improve senior care and to expand our ability to assist more seniors and families in need for years to come.
One program trains geriatric resource people in physicians' offices to identify at-risk seniors and alert physicians to concerns. Course participants spend 10 hours learning how to become the human "communication link" among the Seniors·At·Home program, the primary care physicians, case managers and seniors themselves. The Nurse/Training Coordinator uses a curriculum developed specifically for this program (and certified for continuing education by a local California university), to emphasize knowledge, sensitivity and awareness of geriatric issues. They teach participants to recognize outward signs of frailty that a patient may display in the office or community. They also 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. The program is funded by grants from the Evelyn and Walter Haas Jr. Fund, the Retirement Research Foundation and the California HealthCare Foundation.
Research in the Field:
Social Services Models of Care
To address rising costs and perceived poorer healthcare outcomes, in 1993 California Pacific Medical Service Organization (CPMSO) initiated a system of care for senior HMO enrollees to expanded the scope of care offered to seniors. The system identified at-risk seniors during routine visits to physicians and at hospital discharge, and assigned Seniors·At·Home to address the non-medical needs of patients that might adversely affect their health. 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. When the 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. The results also showed that that the intervention lowered costs to the medical groups by decreasing unnecessary hospital visits and emergency room, skilled nursing facility and ambulance usage. The research indicated that issues like depression, decreased income or loneliness can affect a patient's ability to stay well as significantly as diseases do. These initial results are limited and the results provide a basis for further evaluation of the effects of IEI.
Research in the Field:
Case Management Intervention
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 study grant to investigate:
- The efficacy of the case management intervention
- The value of the geriatric resource intervention in relation to patient outcomes
- 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.
Independent Research
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% of patients were satisfied with the services provided by Seniors·At·Home.
The results of a 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.
A full 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 patients.
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