Not-for-Profit Post-Acute Providers are Ideal Partners in Population Health Strategies

February 23, 2016

Older adults are among the fastest growing age groups, and they are at high risk for developing chronic illnesses and related disabilities. Population health is a strategy that can improve their health and health outcomes.

Well-managed care transitioning from one health service setting to another, and care coordination, are two ways to help manage care for this group. These are not new concepts to LeadingAge PA members.

Many senior service providers have been perfecting the concept of population health management for decades through Continuing Care Retirement Communities (CCRC)—a comprehensive array of health services spanning many levels and intensity of care.

LeadingAge PA members have been developing creative partnerships to address not only the health needs of the residents living in their CCRCs and housing facilities, but the needs of the greater communities surrounding their campuses. Population health is a natural extension of the mission of their organizations.

Many of our members were founded by organizations that have treated not only the physical symptoms of aging, but the emotional and spiritual needs, through a more holistic approach.

Every health care entity plays a special role in a healthy population. Diversifying care expertise throughout the care process can only improve patient and resident outcomes.

Senior Housing Health Care Coordinators

For example, Presbyterian Senior Living, an expert in senior housing and services, developed a partnership with PinnacleHealth System. Together, they dramatically improved health outcomes at their affordable senior housing apartment building in Harrisburg through innovative collaborative efforts.

Between 2012 and 2015, this partnership decreased non-urgent emergency room visits by 86.3 percent and 30-day readmissions by 86 percent.

On-site service coordinators are available to assist residents with applications for food and prescription assistance, as well as provide planning support for community activities. A doctor, nurse navigator, and social worker make up the team.

The partnership resulted in improved health outcomes for this vulnerable and disparate population by:

• Reducing hospital admissions/readmissions
• Enhancing medication reconciliation—creating accurate lists of all medications a patient is taking and comparing that list against the physician's admission, transfer, and/or discharge orders
• Creating new access to care

The Presbyterian Senior Living and PinnacleHealth initiative also reduced costs, a key goal in health reform.

Remote Patient Monitoring and Telemedicine

Many senior living providers have health care and social services that extend outside the walls of their campuses and facilities. These providers not only offer support through traditional home and community-based services, but many have implemented technologies that allow for remote monitoring and telemedicine services.

The Madlyn and Leonard Abramson Center for Jewish Life, a member of LeadingAge PA, recently formed a partnership with Intel-GE Care Innovations™ to use a remote patient monitoring solution to assist patients, clinicians, care providers, and family members to improve the care for recently discharged patients.

This system can remotely conduct health sessions, capture vital signs such as blood pressure, weight, and oxygen levels, and other information needed for caregivers to manage care plans, promote medication adherence, and closely monitor patients’ changing health.

The way we provide services for older adults and the way we fund these services is rapidly and significantly changing. Collaborating with providers of the full continuum of services will be essential in this exciting and a little frightening new world.