Wellness promotion among elders in community settings and licensed health care facilities

With the implementation of health care reform, care for the elderly at home and in the community will change. One reason is the new emphasis on innovative payment reform models that may improve quality of care and reduce costs. Hebrew Senior Life, a large provider of services to the elderly, has had direct experience with an innovative Medicaid-Medicare partnership model that illustrates the potential for improved care by providing a complete package of coordinated health care and social services for low-income seniors. The model can emphasize wellness, keeping elders independent and out of the hospital because of the way reimbursement is offered. One example involves preventing hospitalizations. All too often older patients end up in emergency rooms, leave the hospital even frailer than when they were admitted, and "bounce back" at alarming rates. I will present an evaluation of Hebrew Senior Life's 3 step approach to addressing this problem and reducing rehospitalizations by 30 percent. It involves rigorous advanced care planning to help patients and their caregivers determine the most appropriate treatment plans; a discharge planning project that counsels patients using a special software program to better understand and comply with discharge instructions; and multidisciplinary patient safety and quality conferences, during which staff analyze the root causes of avoidable readmissions and near misses, encouraging open discussion about what steps can be taken to improve patient outcomes. Once patients are back home, home health-care providers can help reinforce the discharge program's plan and become the eyes and ears for their physicians.