The 2019 Award for Excellence in Program Innovation, given by the Archstone Foundation and the Aging & Public Health Section of the American Public Health Association, recognizes Lifespan’s Community Care Connections service as a “best practice model in care for older adults.”
Community Care Connections integrates Lifespan’s services for older adults with medical systems of care to reduce unnecessary ED visits and hospitalizations among people 60 and older. As evaluated by the New York Academy of Medicine, ED visits among 1,225 patients decreased by 28% 90-days post service, hospitalizations decreased by 29% and observation stays decreased by 23%.
The service accepts referrals from health care organizations for patients who struggle with medical adherence, have multiple illnesses, difficulty navigating healthcare, a history of missed appointments, low health literacy and/or no caregiver or stressed caregiver.
Lifespan’s social workers visit with patients and/or caregivers to assess needs and link them to supportive services. In a new role, Lifespan’s healthcare coordinators, LPN nurses, help patients schedule appointments and transportation, attend appointments with patients, conduct medication reconciliation in homes and provide health education. Community Care Connections social workers and nurses communicate findings and progress to the referring medical organizations.
The evaluation also identifies which community service connections make the greatest difference in decreasing ED use and hospitalizations. The analysis showed that in addition to Lifespan’s in-home care management, linking older adults to bill paying, home delivered meals, transportation, health management workshops and minor home modifications helped reduce medical utilization.
“We’ve always believed that integrating services, like Lifespan’s, with medical providers would enhance care for older adults. Why? Because it’s vital for physicians and other providers to know what’s influencing a person’s health outside of the healthcare door. Do they have enough money to pay for prescriptions? Do they have a reliable caregiver? Do they have transportation for appointments? Where are they living? Do they understand their diagnoses? These are the factors we uncover with our assessments and home visits,” notes Ann Marie Cook, president/CEO of Lifespan.