Community Partnership for Chronic Care Improvement:
helping elders remain where they most want to be – at home
John and Mary Smith* are in their 80s and both have multiple chronic health conditions, yet they want to remain together and in their own home. Mary’s conditions include dementia, and she needs assistance with daily activities. She was admitted to an in-patient facility for rehabilitation of untreated traumatic leg fractures. At discharge questions arose: Who would help with her care? Could the Smiths continue to live in their own home?
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| Nurse Case Manager Susan Harrison conducts a home visit to check on a patient's respiratory status. | Enter Susan Harrison, RN, the nurse case manager for the Community Partnership for Chronic Care Improvement Program of Cornerstone Adult Services. Susan worked with the couple and their physician to monitor and adjust critical medications, address John’s health problems, arrange for in-home health services to meet Mary’s needs, and help John manage both his own medical needs and his caregiving duties. With Susan’s help, Mary and John were able to remain where they most wanted to be – at home.
The Smiths are just two of the 137 patients who have benefited from the first nine months of this Foundation-funded program that enables Cornerstone to work with primary care physicians to implement a patient-centered medical home model of primary care. The program’s goals: improve health outcomes of older persons with chronic conditions and raise the level of patient/caregiver satisfaction.
“We want to get doctors to think about community-based services,” states Roberta B. Merkle, executive vice president of strategic initiatives of the Saint Elizabeth Community and immediate past president/CEO of Cornerstone Adult Services. “All too often, we see people come to services too late…when they’re facing a crisis.”
After learning about the Chronic Care Sustainability Initiative, another Foundation-funded project working with larger physician practices, as well as other programs throughout the country, Merkle brought Maureen Maigret, RN, MPA, on board to research the possibility of aligning with smaller practices.
“For us, it (the patient-centered medical home model) fits. It’s really about meeting people where they are,” Merkle explains.
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| Drs. Tim Manown and D. B. Hebb flank Susan Harrison, nurse case manager. | For the program’s first year, Warwick-based Cornerstone is working with five physicians in two practices in Kent County: Drs. Tim Manown and D. B. Hebb at Coventry Primary Care and Drs. (Herbert) Brennan (Charles) Cronin and (Richard) Del Sesto in East Greenwich. Harrison, the nurse case manager, is “embedded” in the practices and assists in bringing a seamless, comprehensive approach to care coordination/care management.
“The program is very flexible in terms of meeting the patients’ needs…in a very holistic way,” Maigret explains, noting one focus of the program is on “transitions” – when a person is, for example, discharged from a hospital – while another focus is on patient education and outreach.
Owen Heleen, the Foundation’s vice president for grant programs who recommended the grant to Cornerstone for this program, states, “The patient-centered medical home tends to connect patients with services in the community. When we do a good job of handing off the baton (when a patient transfers from one service to another) we see much better patient outcomes. Programs that utilize the patient-centered medial home model provide the continuity of care – and awareness of patients’ needs – that is so critical to these positive outcomes.”
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| Drs. Richard Del Sesto, Charles Cronin, and Herbert Brennan review patient records with Kathy Coon, practice manager. | Merkle agrees. “What often happens without these interventions are more emergency room visits and hospitalizations,” she says, with Maigret adding that statistics show that one out of every five elders discharged from the hospital is re-admitted within 30 days.
Cornerstone targets high-risk elders, with almost one-fourth of the patients 85 and older. “Just the fact you’re 85 or older puts you at high risk,” Maigret states, noting other participants in the program are older adults who recently have been discharged from the hospital and those with multiple chronic conditions.
Eighty percent of older adults suffer from at least one chronic condition; the average 75-year-old has three chronic conditions and uses more than four prescription medications. The chronic condition seen most frequently in Cornerstone’s program is diabetes, followed by heart disease and dementia.
Cornerstone works with a myriad of care providers – Coventry Senior Services, West Bay Community Action Program, Kent Hospital, the Department of Elderly Affairs, home care providers, and visiting nurses, among others – to assure program participants receive the services they need.
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| Nurse Case Manager Susan Harrison points out services available to a patient at Coventry Primary Care. | “You just can’t isolate health when you have other issues that affect the person getting well,” Merkle explains, adding, “The need is great. We’d like to be able to bring the program to more practices so more elders have access to integrated health services and social services.”
The bottom line, Maigret concludes: “The program helps assure that each patient’s quality of life is better.” John and Mary Smith are just two examples of the program’s early success.
* Patient names have been changed to protect their privacy.
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