Stephen D. Ryan, M.D.

Medical director of ElderONE discusses how this Rochester Regional Health program is an alternative to nursing home. Over 700 seniors participate in it

By Chris Motola

Q: What is ElderONE and how does it function with the rest of the Rochester Regional Health system?

A: ElderONE is described a lot of different ways depending on the audience. I like to describe it as a nursing home without walls, because all of the patients that join have to be nursing home eligible. They receive all of the services that are associated with nursing homes like physical therapy, occupational therapy, nursing, medical, social work, dietary. So that helps some people get a sense of ElderONE. To doctors I describe it as a patient-centered medical home on steroids. Patient-centered medical home is a term that doctors understand means providing a little more care coordination so that patients’ loose ends are taken care of. So it’s not just a doctor’s office, it’s an entire team working toward those aims. The third way I’d describe it is it’s also a health plan.

Q: How so?

A: ElderONE is responsible for coordinating all the care that the 700-plus folks in the program receive in the hospital, out of the hospital, home care, nursing home, durable medical equipment, medication, specialty visits, rehab, all those things get coordinated so that family can be more focused on being family members than keeping track of all the appointments and transportation.

Q: What is the process for getting enrolled in ElderONE?

A: Typically somebody realizes the patient may need help to remain in the community. That call could come from a family member, it could come from the hospital. There’s a several-step process where someone calls in, we get some basic information. We send a team out and see from our perspective if they have real needs, do they meet eligibility criteria set by the state. If they say yes, it has to go to a third party who will look things over again. Then the patient gets to come in, meet people, gets to see if this is a good fit, do they like what they see? And then they can sign up. You can sign up on the first of any month, and they’re also able to leave at the first of any month, although it’s pretty rare that, once people join, that they leave.

Q: So it’s not a program that’s typically used for temporary nursing home needs?

A: Yeah, it’s meant to be an alternative to ending up in the nursing home. So some people will join who have been getting rehabilitation after a hospital stay. They need to go home, but they realize they need more help than they needed before. ElderONE lets them return to the community while still getting help.

Q: How have patients and families responded? Are the outcomes generally positive?

A: There are a lot of outcomes over time. Some are more medically focused. ElderONE is an example of a PACE [Program for All-inclusive Care of the Elderly] program, so some of the numbers I cite come from Rochester General, some from national data. But in general enrolled folks will go the hospital for preventable conditions less often. They’ll stay in their home longer. They’ll get more and longer periods of therapy. They’ll reduce the number of medications they’re taking. Here in Rochester we’ve been able to reduce falls and falls with injuries. In terms of satisfaction, around 95% of individuals would say enroll again or recommend it to a friend or family member. And that’s a pretty high level of endorsement.

Q: What’s the average age for enrollment?

A: The average is around 77. The federal rules around it are that you have to be 55 years or older. You have to be able to live safely in the community. And you have to be nursing home eligible. Most folks are Medicaid and Medicare eligible, but if they’re not they work with whatever they’re eligible for. But this program is a replacement for all things Medicare and Medicaid-related.

Q: What are the requirements to be nursing home eligible?

A: It’s all functional. You have to require help for accomplishing certain activities of daily living, like help getting in the shower, getting dressed. The state has a very elaborate list of criteria that I can’t summarize, but that determines whether someone is nursing home eligible. New York has a pretty strict standard, so that can vary from state to state.

Q: How many hours of help to ElderONE patients generally need?

A: It varies. We have adult day centers where folks can come to where they can see the doctor, see the physical therapist, meet with a social worker, meet with a nurse, chat with a dietitian or come for activities. Some of those folks will come four or five hours one day a week, or three days a week. Some folks come less often and get more of their services performed by staff who go out to their home. Some live in the home where they raised their family. Some live in senior housing where staff may go floor to floor asking if people need anything.

Q: What is your role like in all of this?

A: I’m the medical director for ElderONE and have been in the role for about 15 years. I supervise all of the doctors, all of whom are board-certified geriatricians, as well as nurse practitioners and physician’s assistants. I’m also responsible for helping monitor and improving the quality of care. And then there are some health plan functions that I’m also responsible for.

Q: What kind of patient is a good fit for this program versus a nursing home?

A: Some folks really want to be in a nursing home. They like the security and having stuff taken care of for them. Those folks are a good fit for a nursing home. Others are more independent. They may have family, they may not, but they want to stay in the community as long as possible. Those folks are a good fit. No one will work harder than ElderONE will work harder to make sure you can stay in the community as long as possible.


Name: Stephen D Ryan, M.D.

Position: Medical director, ElderONE; senior medical director for geriatric medicine, Rochester Regional Health

Hometown: Rockville, Maryland

Education: Medical degree from the University at Buffalo School of Medicine and Biomedical Sciences; residency in general internal medicine, Johns Hopkins University School of Medicine; clinical research fellowship in geriatric medicine and gerontology, Johns Hopkins University School of Medicine; master’s in public health (MPH), Johns Hopkins University School of Hygiene and Public Health

Affiliations: Rochester General Hospital; Unity Hospital

Organizations: American Geriatric Society; National PACE Association; Society for Post-Acute and Longterm Care

Family: Married, four children, four grandchildren

Hobbies: Gardening, time with grandchildren