SAGE Aims to Improve the Health of Older Adults at Risk for Nursing Home Placement
SAGE is a collaboration between an acute care hospital system that owns a health plan and provides adult medical services, the community-based Area Agency on Aging (AAA). The goal is to integrate a comprehensive geriatric hospital-based clinical program with a community aging network to improve the health, functional status, and prevent institutionalization of older adults at risk for nursing home placement.
Summa Health System is an integrated, not-for-profit health care delivery system - including six community teaching hospitals with more than 1,940 beds. The System also offers a provider sponsored health plan (SummaCare) that provides health insurance for over 100,000 lives including a Medicare Advantage plan for 15,000 Medicare beneficiaries. Hospital geriatric services are provided in a consult and support model in outpatient (Center for Senior Health), inpatient (ACE Units and Geriatric Consultation), and long-term care facilities (geriatric rehabilitation units) Services also include community collaboration with skilled nursing facilities through the Care Coordination Network.
Area Agency on Aging 10B’s mission is to develop a responsive network of services and resources to assist older adults and their families in a four county region of NE Ohio. Services include care management, home care services through PASSPORT (Ohio’s Medicaid waiver Community Based LTC program), care coordination, Alzheimer respite program, family caregiver respite program and an elder rights division.
The relationship with Summa and AAA started in the early 1990s. Both organizations identified lack in continuity of care due to communication problems, unmet health and support needs for at-risk populations served by both institutions, and a fragmentation of care delivery.
The first initiative was to develop a referral and communication process. Fax communication tools were developed for referrals to the AAA from all areas of the health system. Another tool was developed for referrals from the AAA to the Center for Senior Health for comprehensive geriatric assessment and geriatric consultation in the hospital. For AAA clients admitted to the hospital, the care manager faxed information regarding the plan of care and services in place to hospital discharge planning staff. Upon discharge, the discharge planning staff faxes new orders, makes phone follow-up calls to the AAA care manager to reactivate services and discusses any further interventions needed.
Building upon this successful communication network, an inpatient AAA RN assessor program was started. This program targets individuals at risk of permanent institutionalization at hospitalization, a known risk factor for NH placement for vulnerable populations. RN assessors are assigned to each of the Summa hospitals to screen patients during their acute stay who may benefit from available services. The RN assessor is an integral member of the hospital discharge planning team and provides direct feedback to acute care staff regarding the eligibility for service.
The RN assessor program has been very successful, increasing referrals to the AAA by 94 percent and PASSPORT enrollment by 725 percent. Other positives of the program are that patients/families are more willing to accept help during an acute stay, the start of services are expedited and there is a decrease in gaps of service. The AAA is able to better target and case find as well as provide improved continuity of care. The health system benefits by strengthening the partnership with the community agency, resulting in enhanced utilization and process of care outcomes for Medicare/Medicaid population, improved utilization and capacity management and improvement in the quality of the continuity of care. The RN assessor program has now been implemented in many other hospitals within the areas served by the AAA as a result of this successful demonstration.
AAA 10B Inc and SummaCare also partnered with and have been supported by an Administration on Aging grant for a demonstration project that helped to integrate care plans between an AAA and Medicare Advantage health plan. By implementing joint care management, it incorporates the strengths of each entity to provide the best care possible. The AAA focuses on the community issues of the care and the care plans are tailored to these needs. SummaCare focuses on disease management and their care plans are tailored to more medical needs. Through joint care management, each agency is aware of what the other is doing and is able to work together to ensure that all of the needs are being addressed and followed up in a timely and appropriate manner.
An effective and efficient communication system was a vital component of the success of integrating care. A secure, web-based software system (CANOPY) allows both sides to have real-time access to consumer information, and can be used for case management services as well as discharge planning. CANOPY allows the AAA care manager to be actively involved as soon as the consumer is admitted to the hospital and to work with the hospital discharge planners and SummaCare staff to return them back to a community setting.
Additionally, CANOPY is a useful tool for ongoing care management services. CANOPY allows the SummaCare staff to see what services and service providers are involved through the AAA and it also allows AAA care managers to communicate any changes in the consumer’s status or condition to the SummaCare care manager. Likewise, it allows the AAA to see what services SummaCare is providing as well as any changes in the consumer status. The shared communication facilitates and ensures that all aspects of care are covered, from disease specific medical issues to functional, behavioral and social issues.
Ongoing collaboration involves a geriatrician advisor for the AAA care management division that meets regularly with AAA care managers within an interdisciplinary team format to review and problem solve difficult and challenging cases. This interdisciplinary collaborative work is based in the Acute Care for Elders Team model. Future steps on the hospital side are to use the Extended Care Information Network (ECIN), a web-based telecommunications discharge planning and care coordination system to electronically notify the AAA RN hospital assessors of all nursing home discharges in the Summa Health System so as to introduce and provide community based long-term care resources and planning for this at risk population.
Contacts:
Annette Ruby
Vice President, Health Services Management
SummaCare
10 North Main Street
Akron, Ohio 44308
Email: RubyA@SummaCare.com
Phone 330-996-8651
Kyle R. Allen, DO
Medical Director, Post Acute and Senior Services
Summa Health System
75 Arch Street Suite G1
Akron, Ohio 44304
Email: allenk@summa-health.org
Phone; 330-375-3747
Carolyn Holder, RN, MSN
Coordinator Geriatric Services
Post Acute and Senior Services
Summa Health System
75 Arch St. Suite G1
Akron, Ohio 44304
Sandee Ferguson, RN, MS
Vice President Managed Long Term Care
Area Agency On Aging, 10B Inc.
1550 Corporate Woods Parkway
Uniontown, Ohio 44685-8797
Nancy Whitelaw, Ph.D.
Director, Center for Healthy Aging
Senior Vice President, National Council on Aging
nancy.whitelaw@ncoa.org