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Senior living and elder care: Testing a team approach

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Officials from Lancaster General Health/Penn Medicine were looking for local senior communities that could help them deliver quality care after patients left the hospital and keep them from being readmitted, John Sauder said.

Sauder is president of Mennonite Home Communities in Lancaster County, which cares for 850 patients at Mennonite Home and its nearby Woodcrest Villa communities.

Mennonite Home is among the 10 skilled nursing/retirement facilities in Lancaster County that began a partnership more than a year ago with Lancaster General Health/Penn Medicine to improve the transition of older patients from the hospital to nursing homes.

And he’s encouraged by the results of the partnership, saying it is already having a positive impact.

The partnership, called a “Preferred Provider Network,” increased coordination between the retirement facilities and the Lancaster-based health system. And it comes at a time when having to readmit senior citizens to hospitals is being viewed as a major problem in health care. The federal Medicare program has created incentives for hospitals to lower their readmission rates.

Discharged patients often bounce back to hospitals because there is little coordination of care between hospitals and senior homes, there are changes in a patient’s clinical status or there are medication errors, health officials say.

About 16 months after it started, the LGH partnership appears to be reducing readmission rates and improving other health statistics, both LGH and retirement-community leaders said.

And there’s also a fringe benefit, one health care leader added: Hospitals are gaining a newfound appreciation for senior-living communities as partners in health care.

Matt Oathout, senior vice president for operations at Luthercare in Lititz, noted that hospitals in the past didn’t always view retirement communities as valuable health care partners. One of Luthercare’s three communities, Luther Acres in Lititz, is part of the new network.

Oathout sees the partnership with LGH as an “exciting thing that can improve the quality of care for our residents, plus the quality of training and the resources that the hospital brings to us.”

In addition to Luther Acres and Mennonite Home, other senior communities working with LGH in the new effort are: Conestoga View; Landis Homes; ManorCare Health Services-Lancaster; Masonic Villages; Moravian Manor, Pleasant View; Quarryville Presbyterian; and Willow Valley Communities.

Reducing readmissions

The partnership’s goals include reducing “avoidable readmissions” of people living in the senior communities that are partners in the effort, plus reducing how long patients stay in the senior communities’ skilled facilities, said Stacey Youcis, LGH’s senior vice president for service lines and population health.

When the effort began, nearly 20 percent of seniors from the participating retirement communities who left the hospital had to be subsequently readmitted, for a variety of reasons. That figure has now fallen by more than half, to 8.6 percent, Youcis said.

And the average length of stay for patients also shows encouraging signs, she continued.

The average stay for patients from the participating retirement communities recovering from a fractured hip has fallen by about half, from 32 days to 16.7 days, with no increase in readmissions and no drop in quality of patient care, Youcis said.

Nationally, the federal government’s readmission penalties on hospitals are believed to be at a new high, as Medicare is expected to withhold more than $500 million in payments and punish more than half of U.S. hospitals that have higher-than-expected readmission rates, according to a report from Kaiser Health News, a news service that covers health policy issues.

According to government findings, the most common reasons for hospital readmissions include non-hypertensive heart failure, septicemia (life-threatening complications from an infection), pneumonia and chronic obstructive pulmonary disease.

Coordination, communication

Like Sauder and other senior-community officials, Youcis credits the improved rates to better communication and coordination of care between LGH and the senior facilities in the partnership.

The partnership between a hospital/health provider and its regional senior communities is not unusual, Youcis said. But what is unique, she said, is that LGH did not want a “top-down” relationship in which it dictated to the member facilities what it wanted in the partnership, but instead wanted to meet with them as equals.

Teams from the partner organizations meet regularly to discuss aspects of the post-hospital care issue.

“At the end of the day, the overall aim is to deliver a high-quality care and improved quality at a lesser cost, and I think that collaboratively, with these teams working together, we’re on our way to doing that,” Sauder said.

Youcis said many larger health systems are focusing attention on “post-acute space,” or what happens during the time after a patient is discharged from the hospital: “We chose instead to put our hand out (to the senior communities) and say, come to the table with us, and let’s figure out how we’re going to do this together.”

In one example of changes brought about by the partnership, the hospital now use case managers to keep in close touch with patients after their hospital stays and to “offer support when the patient is transitioned back to their home environment” in the senior community, said Phyllis Wojtusik, LGH’s director of post-acute care.

LGH used several criteria to identify who it wanted to be a part of the network. Specifically, “we needed to have the facilities the patients were going to when they are discharged from Lancaster General,” Youcis said.

All but one of the 10 participating facilities use an LGH geriatrician as its medical director. Youcis said this is important to delivering consistent care, since the medical director, along with the director of nursing at skilled nursing facilities, is the person who “can most influence and change how care is delivered.”

The 10 participating facilities also are geographically distributed around Lancaster “to make sure we had adequate coverage across the county, and we wanted people who were creative and interested in performing care transformation,” Youcis said.

Youcis is the executive-level coordinator of the project, so she spends much of her time with executives at the participating facilities.

Committee members who meet regularly to address specific topics (such as medication management or transitions of care), she said, are seeing “this process in a very positive light, because they feel we’re listening to what they have to say. And the facilities are listening, and improving in more substantial ways than they’ve seen before.”

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David O'Connor

David O'Connor

Dave O'Connor covers York County, manufacturing, higher education, nonprofits, and workforce development. Have a tip or question for him? Email him at Follow him on Twitter, @DaveOC_CPBJ.

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