I couldn’t agree more with Nora OBrien-Suric’s blog post on the the John A. Hartford Foundation blog.  No one will ever fill his shoes, but he left in many of us a  the passion and commitment to question, investigate, advocate and create change.  What a legacy!

Claudia Fine, LCSW, MPH, Chief Professional Officer, SeniorBridge

• For health insurer, Geisner, paying nurses to conduct phone follow-ups with chronically ill patients reduced hospital admissions by 18%  and overall medical expenses by 7 percent, according to The New York Times.
• Insurer Health Net of Arizona used a “high-intensity telephone management program” to reduce hospitalizations by 40% and save $1,000 per patient, according to American Journal of Managed Care.

Clearly phone follow-ups (also known as tele-care management) are an important element of keeping the chronically ill healthy and at home.  However, for patients who can’t self-direct their care, phone follow-up has limited value – which is of interest when you consider that the top 5 percent of the population, accounts for 49 percent of health care expenditure.  

That top 5 percent consists of patients who have multiple chronic conditions that are complex to treat.  For these patients and their families, a hospitalization is not only costly, but also takes a profound physical and emotional toll.    The much talked about phenomenon of hospital delirium affecting one in three over 70 is one of a long laundry list of factors.

For these reasons, over the last ten years SeniorBridge has been developing a model of service provision that incorporates a multidisciplinary professional team of health providers who offer care management, caregiving and care monitoring services for those with chronic complex health illnesses.   The data are compelling. 

In a review of SeniorBridge client records that were on service for a year, health outcomes were considerably better than those reported in the general Medicare population.  SeniorBridge clients with chronic illnesses who are 65 years and older have 82% fewer hospitalizations and 92% fewer visits to the emergency room, as compared to Medicare beneficiaries with chronic illnesses  Additionally, SeniorBridge clients have 46% fewer re-hospitalizations than reported in the recent study published in the New England Journal of Medicine.  These outcomes demonstrate that there is both a quality of life and economic benefit to the high-touch approach to in-home care that is provided by a team of healthcare professionals, coordinating care with the physician and the family support system.

The power of a face-to-face home visit by a nurse (photo courtesy of Getty Images)

However, the reality is most family  members are not equipped to follow the tips for a smooth transition.  More importantly, keeping people out of the hospital goes beyond the discharge and involves overseeing their care at home.   While many family members feel they are most equipped to advocate for their  parents, challenge information provided at a hospital and oversee their ongoing care, evidence shows that they can make more informed, thoughtful and effective decisions that keep their parents out of the hospital by partnering with a professional geriatric care manager who will bring perspective, experience and a personal touch.  

For example, a pharmacist who checks a medication list ultimately has no control or insight into preventing medication errors once the patient arrives home, where he or she might be confusing outdated meds with new ones or have cognitive disabilities that disrupt compliance.  On the other hand, care managers can visit the patient at home to understand where medication is kept, see how the medication is administered and dispose of outdated medications.  Care managers assess a patient’s entire constellation of factors including medical, home environment, support system of family and friends, financial and legal situation. These professionals are critical not only in developing a care plan based on needs and personal preferences but also in identifying resources for services many are surprised are not covered by Medicare. 

Given that an AARP survey recently found that 90% of older people want to stay in place as long as possible care mangers can develop solutions to help people stay in their own homes safely.

SeniorBridge care manager, Karen Knutson, and her client of 8 years, Nancy Crawford celebrating 100 years of healthy living

We are incredibly proud of the recognition SeniorBridge has received for our leadership in using technology to improve elder care from organizations including The New York Times and Community Health Accreditation Program (CHAP).  But it’s our coordinated care model that results in 82% fewer hospitalizations of seniors compared to national data that makes the most important difference.

Our mobile electronic medical records, tele-medicine, tele-care management and SeniorBridge Skype programs only empower our geriatric care management team of licensed nurses, licensed social workers and certified in-home caregivers to improve health outcomes and functions.

Thanks, Thomas, for sharing what was ultimately a happy ending and best regards to “Betty”!

 Originally developed in China as a form of self-defense, tai chi is a noncompetitive, self-paced system of gentle physical exercise and stretching—and it requires no physical prowess. More and more medical research is pointing to the wider-ranging benefits of this 2,000-year-old form of exercise. In fact, tai chi is frequently mentioned as a way to improve balance and prevent falls among the elderly population. It also can help overcome problems such as arthritis, rheumatism, back problems, high blood pressure, stress, post-traumatic stress and lack of energy.

Sometimes called tai chi chuan, tai chi involves a series of postures or movements performed in a slow, graceful manner. Each posture flows into the next without pause. Best of all, anyone, regardless of age or physical ability, can practice tai chi. Translated literally to mean “Practicing and Improving the Life Force,” it emphasizes technique over strength. 

When practiced regularly, tai chi can help reduce stress and it offers a number of other important benefits as well, such as:

• Increased flexibility
• Improved muscle strength and definition
• Increased energy, stamina and agility
• Increased feelings of well-being

There are two ways of practicing tai chi, the Tai Chi Form and Chi Gong.
The Tai Chi Form is a choreographed set of moves, similar to a dance. Often this form of tai chi is practiced in parks and outdoors.  Every move flows into the next, with breathing as the leading force.  The exercise set is a continuum of shifting the weight of the body, moving the arms, turning and balancing on one leg or the other. Coordination of these moves takes concentration and focus. Being aware of and practicing the continuous shift of the center of the body through these moves helps develop a greater sense of balance, in turn leading to more confidence in walking and moving around. 

Chi Gong is a set of exercises based on breathing—circulating the life force and focusing the mind. Its benefits include promoting the circulation of energy within the body, and overall enhancement of health.

Tai chi is a physical exercise that focuses the mind, while conditioning the body. Practicing as few as 20 minutes a day can help alleviate stress and reduce stress-related debilities, increase stamina and strengthen the body while creating better balance and confidence.

 As I get older, I find it harder to maintain a regular exercise program, is it really that important?

 As we grow older we tend to become less active. This is often a slow process that leaves us overweight and out of shape before we know it. How can we stop this process? The first step toward a more active, healthy lifestyle is exercise.

As we get older, our bodies change. Muscle size and strength decrease primarily due to inactivity. Bone mass and density decrease, increasing the susceptibility to fractures. Tendons and ligaments become less elastic, making it easy to get overuse injuries. Joint inflammation and cartilage degeneration often occur due to arthritis.

Thirty minutes of physical activity a day can help individuals feel good and prevent some medical conditions. Even individuals with chronic conditions, such as osteoarthritis and osteoporosis, can benefit from a balanced fitness program

 An effective exercise program is made up of several components: aerobic conditioning, flexibility and agility exercises, and strength training,. Before starting an exercise program be sure to talk with your doctor, especially if you are aware of, or suspect an ongoing medical problem.  If you have not had a medical check up in a while, one should be scheduled before starting an exercise program.

 Aerobic Conditioning improves the health of your heart and lungs. It also helps to manage your weight. With aerobic exercise, you move continuously to increase your heart rate and keep it elevated for a sustained period of time. How long you can exercise aerobically will depend on your fitness level. A general guideline is to work up to 20 to 30 minutes a day, three to four days a week.

Choose activities that you enjoy and can do regularly. Common aerobic activities include walking, jogging, bicycling, swimming, low impact aerobic classes, water exercise classes, and dancing. Many people prefer using machines, such as a rowing machine, stair climber, treadmill, elliptical trainer, or stationary bicycle. All forms of dancing — ballroom, social, country western — are another great way to get moving!

If you have arthritis, consider low- to no-impact activities such as water aerobics, swimming, elliptical trainer, Nordic track, stationary bicycle, or rowing machine.

 Flexibility and Agility Exercises are important for increasing your body’s range of motion. They also help lessen muscle tension and soreness, and reduce your risk of injury. We often overlook stretching and range of motion exercises, but they are very important in maintaining overall fitness.

Stretching programs and activities like yoga or tai chi are good examples of flexibility and agility training. Balance training is important and may help prevent falls and, therefore, fall-related fractures.

Tai chi is a program of exercises, breathing, and movements based on ancient Chinese practices. Seniors who practice tai chi or yoga have fewer falls and less fear of falling. These classes can also increase self-confidence and improve body balance.

 Strength Training improves muscular capacity and bone density. Stronger muscles and bones make it easier to do everyday activities like carry shopping bags or do yard work.

The most common strength training methods are working with free weights, resistance rubber bands or weight machines. It is very important to avoid strength imbalances by working all the major muscle groups, including the muscles in your arms, chest, back, stomach, hips, and legs.  If you have osteoporosis or loss of bone calcium, you will need to talk with a doctor before beginning a strength training program.

 Below, are 7 good reasons for seniors to continue exercising:

•  A safe, effective exercise program can help reduce some of the aches and pains that are a part of getting older. It can also slow down the progression of conditions associated with aging.
•  Keeping active helps you maintain your ability to walk, which is especially important to maintain your independence.
•  Exercise can improve and maintain balance and posture, reducing your risk of falling.
•  Exercise can improve your strength, endurance and flexibility. It promotes bone strength. Repeated mild stress on our bones helps them maintain their calcium content and structure.
• Exercise also helps to maintain muscle mass and tone. After age 30 we start losing muscle mass. Exercise stimulates muscle growth and slows this process. Muscle also uses more calories than fat tissue. As we increase or maintain our muscle mass we create a better ‘metabolic machine’ for burning calories.
• Exercise is also important for joint health. Repetitive motion promotes the body’s natural process of lubricating joint surfaces. This may help lessen joint stiffness and achiness.
• The stronger your muscles are, the more weight and stress they can handle.  Stronger muscles protect your joints. As we age our joints begin to gradually weaken from typical wear and tear.  Stronger muscles take weight and stress away from your joints.

Dr. Michael Gross is the founder and director of Active Orthopedic and Sports Medicine.  He is the section chief of sports medicine and the orthopedic director of the Center for Sports Medicine at Hackensack University Medical Center.  Dr. Gross has written numerous articles and book chapters on sports injuries. He has taken care of some of Bergen County’s finest athletes, from weekend warriors to professional athletes. Dr Gross can be reached by e-mail at: drgross@activeorthopedic.com, and his web site is www.activeorthopedics.com.

Rona S. Bartelstone

LCSW, BCD, CMC, C-ASWCM

Traditionally, physicians have been the point person for primary care. But with diseases today being mostly chronic illnesses requiring a range of health, social, emotional, environmental and physical services in addition to medical care, private care management has emerged as a leader in guiding families through the caregiving process.

A successful partnership between the care manager and the family, as illustrated below, facilitates the coordination of appropriate care, at the appropriate time, in the right setting and in accordance with individual needs and resources.

Care Management at Work
Living away from their family, Mr. and Mrs. Chasser (not their real name) were beginning to deal with multiple care decisions. They were a worldly couple who had saved enough money to meet their retirement needs.

Though relatively healthy, Mr. Chasser was beginning to experience some memory loss and asked his wife to take over the daily money management. Mrs. Chasser, 80, had a heart condition as well as osteoporosis; she was becoming increasingly anxious that her husband was becoming senile. Mrs. Chasser had never been responsible for money management, investments or legal issues and was afraid to ask her husband for guidance, fearing she might upset him.

After a trip to visit their grandchildren, Mrs. Chasser had a stroke, causing her to become weak and unable to speak. Although she would regain some of her mobility and speech, she would never be as active again. While Mrs. Chasser was in the hospital and rehabilitation center, Mr. Chasser realized he could not manage at home alone. He was unable to take care of the shopping, meal preparation, laundry or housekeeping. He also had difficulty dressing himself and frequently became frightened, knocking on neighbors’ doors at all hours.

A concerned neighbor called the couple’s son, Brian, who was unaware of the extent of his father’s memory loss and his inability to manage at home alone. When his mother was going to be discharged from the hospital to a long term care facility for rehabilitation Brian flew in to visit his parents. Upon arriving at their home, Brian found his father sitting in the dark crying because he could not remember when his son was coming and he thought his wife had already been moved, though he could not remember where. In the unkempt house, Brian found no food and dirty clothes; he suspected that his father hadn’t bathed in several days.

While a hospital social worker was able to assist Brian with his mother’s care, she was unable to help with his father because he was not a patient. She suggested hiring a private care manager who would be able to help coordinate the care of both parents. A care manager could also help integrate the different services and payer sources to provide the optimal plan.

Brian hired a care manager who soon discovered there were several levels of need and sources of support. After a comprehensive assessment, she helped Brian determine the best short term and long term plan of care for his parents.

At the rehab facility, Mrs. Chasser’s care was covered by Medicare and supplemental insurance policies for two weeks. If more care was deemed necessary, the couple’s long term care policy would cover the cost.

Mr. Chasser needed extensive care as well. The care manager felt his cognitive losses and anxiety were being exacerbated by the stress of his wife’s illness. She arranged for a complete neurological and psychiatric work-up, resulting in a diagnosis of probable Alzheimer’s disease. The diagnosis qualified Mr. Chasser for home care benefits under his long term care policy.

The care manager placed a temporary, 24-hour aide in the home. She also arranged community services for Mr. Chasser, including a daycare program with stimulation and socialization, and brought a medication dispenser to the Chassers’ home to assure compliance with medication routines. Grab bars and a shower seat were added to the bathroom and a personal emergency response system (ERS) was installed that could eventually reduce the hours the aide was needed. The care manager worked with Brian to help him understand how the long term care policy would work and how to allocate its use so that the pool of funds would not be depleted too quickly. This was a particular concern since Mr. Chasser could live with his dementing illness for many years.

The care manager worked with the family to bring Mrs. Chasser home after rehab. With the ERS in place, the couple could be alone for 14 hours each day. Gradually, as Mrs. Chasser became more frail and Mr. Chasser more forgetful, 24-hour care was reinstated. Eighteen months later, when Mrs. Chasser died, the care manager helped support Mr. Chasser through his grief and eventually helped move him to an Alzheimer’s-specific assisted living facility. After a brief adjustment, he began to flourish in the new residence.

Brian was grateful to the care manager for helping his family navigate a complex, fragmented system of health and social services. He also was relieved that in spite of using his parents’ financial resources to pay for their care, there were still financial resources that would help pay for his children’s college education. In fact, a result of the heart-wrenching experience, Brian began to work on his own financial, insurance and legal plans.

A Successful Partnership
The entire Chasser family benefited from the partnership with their care manager. Brian was able to visit his parents as planned, instead of always in a crisis mode. Mr. and Mrs. Chasser were able to be cared for in their own home using a combination of private insurance, community resources, entitlement programs and emotional support from the care manager. The physician, who received regular reports from the care manager, was confident that his plan of care would be carried out in the home to assure the best treatment possible in a safe environment. And finally, when it was appropriate, Mr. Chasser was able to move into assisted living that catered to his specific needs.  
]]> http://blog.seniorbridge.com/2009/09/21/parterning-with-a-care-manager/feed/ 4 SeniorBridge rona http://blog.seniorbridge.com/2009/09/21/health-reform-and-care-of-the-chronically-ill/ http://blog.seniorbridge.com/2009/09/21/health-reform-and-care-of-the-chronically-ill/#comments Mon, 21 Sep 2009 19:42:02 +0000 SeniorBridge http://blog.seniorbridge.com/?p=61 ]]> Eric C. Rackow, M.D.

 The widespread concern among senior citizens about controlling the cost of health care is well founded. The discussion about cost control often centers on controlling the growing cost of Medicare.  However, our seniors are worried that cost control means less health benefits for them as the means by which overall health care cost will be contained.  Seniors know that as they grow older they need more, not less health care.  In an age of unprecedented advances in medicine, our country is growing older.  And the older we get, the more we develop disabilities and chronic health conditions.  In addition, baby boomers will start to enter the ranks of Medicare beneficiaries in 2011 and will almost double the number of citizens who are 65 years or older over the next two decades. 

Maintaining the quality of health care for seniors while at the same time controlling costs must be part of any successful health care reform program.  The single most important issue that helps solve this conundrum is the quality and effectiveness of caring for people with chronic illness.  Four out of every five Medicare beneficiaries have a chronic illness.  Medicare spends two-thirds of its budget on beneficiaries who have five or more chronic illnesses.  A substantial portion of this spending is related to frequent hospitalization.  Although older adults over the age of 65 years comprise 12 of the United States population, they account for 38% of all hospital admissions and 44% of the national hospital bill, approximately $350 billion per year.  Without a clear path too improving the treatment of chronic diseases, these costs will continue to increase.

Since hospitalization is the most costly part of caring for people with chronic illness, the single most important way to control these costs is to avoid hospitalization.  The solution is better coordination and provision of care outside of the hospital.  For example, currently 20% of Medicare beneficiaries are re-hospitalized within 30 days of discharge from the hospital.  It has been demonstrated that coordination of care by advanced practice nurses when elderly patients transition from the hospital to home can reduce re-hospitalizations.  For example, the rate of re-hospitalization for SeniorBridge patients with care management is only 8.5%.

There is also compelling evidence that long-term coordination of care at home for people with chronic illness is effective.  Licensed nurses and social workers who “manage” care at home can improve the quality of treatment, avoid costly hospitalizations, and allow seniors to remain safely at home. Care management for the chronically ill must be part of health care reform.

Claudia Fine, LCSW, MPH – EVP

The good news is that we are living longer; the bad news is there are many health issues to tackle, and it all has to be paid for somehow. Understanding the alternatives to managing long term care can be confusing to understand. According to an AARP study, most Americans have no idea how much long-term care costs and believe that Medicare pays for all of it. People are shocked, disappointed, and frightened to realize that Medicare doesn’t cover chronic, custodial care at home, in assisted living faculties, or in nursing homes. Individuals and families are increasingly faced with the challenge of trying to provide long-term support for individuals with progressive cognitive and functional decline Creative, customized approaches and varied levels of clinical skills are necessary to maintain people at home as deficits increase. But care must also address important aspects of an individual’s and family’s values, preferences, and resources if it is to maintain the quality of life for the older person and the family. At a time when the media is filled with concerns about healthcare coverage – why are we not addressing how we can provide long-term, customer valued care for people with long-term health problems?