Senior Care Service Contract

					    Senior Care
Community Partnership
Progress toward service integration



       F E B R U A R Y   2 0 0 5
Senior Care Community Partnership
Progress toward service integration

February 2005




Prepared by:
Cara L. Bailey, Nicole Martin, and Greg Owen

Wilder Research Center
1295 Bandana Boulevard North, Suite 210
Saint Paul, Minnesota 55108
651-647-4600
www.wilder.org
Contents
Executive summary............................................................................................................. 1
Project background and purpose......................................................................................... 7
     The partnership ............................................................................................................... 7
     Living at Home/Block Nurse Program ......................................................................... 11
Evaluation methods........................................................................................................... 12
Findings............................................................................................................................. 14
     Partner interviews ......................................................................................................... 14
     Hospital staff interviews ............................................................................................... 17
     Clinic staff interviews ................................................................................................... 21
     Participants’ results....................................................................................................... 24
Participants’ stories........................................................................................................... 28
Participants’ stories........................................................................................................... 29
     Irene and Joe ................................................................................................................. 29
     Donna and Martin ......................................................................................................... 31
Conclusions and issues to consider................................................................................... 33
     Progress toward systems change................................................................................... 33
     Participant outcomes..................................................................................................... 34
     Considerations for the SPICE-Bridge partnership........................................................ 35
Appendix........................................................................................................................... 37
     Clinic staff survey responses ........................................................................................ 39
     Participant survey responses ......................................................................................... 40
     Services and contacts summary .................................................................................... 43




Figures
1.       Grant-supported activities of SCCP........................................................................... 8
2.       Hospital staff members’ awareness of services provided through the Living at
         Home/Block Nurse Programs and their requests for the Programs to provide the
         services for their patients ......................................................................................... 20




           Senior Care Community Partnership                                      Wilder Research Center, February 2005
            Progress toward service integration
Acknowledgments
The authors would like to thank Arlene Pine, SCCP project coordinator, for assisting with
the design of this evaluation, as well as providing us with access to contact information
for the individuals interviewed in this report. The authors would also like to thank the
SCCP participants, United Hospital staff, United Family Practice Health Center staff, and
SCCP partners who agreed to participate in the interviews.

The following Wilder Research Center staff also contributed to the creation of this report:

Mark Anton
Jacqueline Campeau
Marilyn Conrad
Phil Cooper
Louann Graham
Nathan Holm
Ginger Hope
Margaret Langmo
Ryan McArdle
Margaret Peterson
Deborah Sjostrom
Daniel Swanson
Karen Ulstad




       Senior Care Community Partnership               Wilder Research Center, February 2005
        Progress toward service integration
Executive summary
The goal of the Senior Care Community Partnership (SCCP) was to create a new model
of improved care for older adults that would enable them to continue living
independently in their own homes for as long as possible. The strategy of SCCP was to
integrate community-based services and supports with large health care systems through
a structured partnership with the goal of strengthening the connections and
communication between these entities. Under this program, 95 older adults received
continuous community support in their transitions into and out of the clinic, hospital,
rehabilitation center, nursing home, and home.

Partnership activities and the Living at Home/Block Nurse
Program
SCCP successfully completed a number of grant-funded activities including:

   Established common protocols and forms that were implemented by the four
   participating Living at Home/Block Nurse Programs (Highland Park, Macalester-
   Groveland, Summit Hill, and West Seventh)

   Initiated a program to educate, assist, and encourage participants to complete Health
   Care Directives

   Worked with United Hospital and United Family Practice Center (referred to as the
   clinic) to implement a “flagging” system to identify patients eligible for Living at
   Home/Block Nurse Program services

   Facilitated communication between health care providers at the hospital and clinic
   and the Living at Home/Block Nurse Program staff

   Implemented a 24-hour phone/fax referral line principally used by hospital discharge
   planners when setting up medical care and support services for patients being
   discharged to home

   Assigning a third year resident from the clinic to the project as part of the community
   service requirement of the residency program




       Senior Care Community Partnership      1       Wilder Research Center, February 2005
        Progress toward service integration
Living at Home/Block Nurse Programs

The Living at Home /Block Nurse Programs are nonprofit neighborhood-based
organizations that use both professional and volunteer services of local residents to
provide information, health care, social, and support services for older, frail adults,
enabling them to continue living in their own homes. Living at Home/Block Nurse
Programs mobilize resources such as individuals, churches, businesses, and schools to
provide social and community supports as well as contract with certified home care
agencies to provide skilled nursing services. Living at Home/Block Nurse Programs
provide case management services and coordinate Meals on Wheels, adult day services,
transportation services, chore services, homemaking services, and other services, if needed.

For the SCCP project, the four participating Living at Home/Block Nurse Programs
served a combined total of 95 participants and their caregivers over the partnership’s
three year period.

Findings

Participant outcomes

A statistically significant (p < .05) correlation was found between medication
management problems noted and the number of hospital admissions participants had after
enrollment. This finding points to the importance of conducting the medication
management review and implementing medication management practices in terms of
preventing hospital admissions for participants.

Other important participant outcomes for SCCP that exemplify progress toward
smoothing participants’ transitions in and out of the clinic, hospital, rehabilitation center,
nursing home, and home include:

   96 percent of participants (care recipients and caregivers) “agree” or “strongly agree”
   that finding out about available services, scheduling their first appointment, and
   setting up needed services was easy

   87 percent of surveyed caregivers reported feeling relief from their caregiving
   responsibilities as a result of the services their care recipient received from SCCP

   43 percent of participants completed Health Care Directives




       Senior Care Community Partnership      2          Wilder Research Center, February 2005
        Progress toward service integration
  When asked about the most important benefits they experienced as a result of their
  participation, 35 percent of participants mentioned the reassurance given by the nurse,
  and 13 percent each mentioned help with transportation, receiving information about
  services, and being checked on by the nurse

  Nearly all (96%) of the participants interviewed said they did not have any problems
  setting up services

  All (100%) of the participants said they would recommend Living at Home/Block
  Nurse Program services to others in a similar situation

Systems outcomes

  Improved communication between the clinic, hospital, and the Living at
  Home/Block Nurse Programs resulting in smoother transitions for participants
  between health care settings and home, as exemplified by:

     Use of a dedicated referral line by clinic and hospital staff; 41 referrals were made
     by clinic staff (SCCP referral source database) and 12 referrals were made by
     hospital staff (stakeholder interview; three are noted in the SCCP referral source
     database)

     Improved communication between clinic and hospital staff and Living at
     Home/Block Nurse Program staff; 13 of the 16 partners interviewed said they
     “agree” or “strongly agree” that SCCP had achieved its goal of improved
     communication among the Living at Home/Block Nurse Programs, the clinic, and
     the hospital

     Partners reported that participants benefited from SCCP because it provided for
     improved communication among health care providers, improved access to
     services, and advocacy on their behalf with health care and other organizations

     United Hospital and United Family Practice Center implemented a “flagging”
     system to notify providers of eligible patients

     In-home evaluation has become part of the patient chart, giving clinic and hospital
     staff a more holistic picture of the patient’s situation

  Progress made toward direct reimbursement, as demonstrated by:

     Three health plans served as technical advisors to the project and provided
     guidance regarding reimbursable services (usually services, such as fall
     prevention and medication management, that may reduce health care costs)


     Senior Care Community Partnership      3        Wilder Research Center, February 2005
      Progress toward service integration
       One Living at Home/Block Nurse Program reached an agreement to receive
       reimbursement of select services

       Two health plans are in discussion with Living at Home/Block Nurse Programs
       regarding reimbursement of select services

   Education, as demonstrated by:

       Hospital and clinic staff received periodic in-service training about the Living at
       Home/Block Nurse Programs

       Hospital staff became advocates for the Living at Home/Block Nurse Programs
       through their participation in SCCP

   Spillover effects, as represented by:

       Although many Living at Home/Block Nurse Program participants were not
       enrolled in SCCP (n=144), they were able to experience the processes,
       relationships, and education programs of SCCP

       Clinic and hospital patients who lived outside the geographic scope of SCCP had
       opportunities to attend health education sessions, to receive short-term
       interventions from Living at Home/Block Nurse Programs, and to receive medical
       consultations with the clinic resident

Evaluation methods
For the two-year project implementation period (2002-2004), evaluation of the
effectiveness of SCCP involved telephone interviews with 62 eligible participants (90%
response rate) from the four Living at Home/Block Nurse Programs, 19 United Hospital
staff (58% response rate), 11 United Family Practice Center staff (55% response rate), and
16 SCCP partner representatives (87% response rate). The evaluation also included
analysis of administrative data that examined the following:

   Client Services and Contacts forms that tracked Living at Home/Blocks Nurse
   Program service usage

   Hospital admissions and emergency room utilization tracked by United Hospital

   Missed clinic appointment data tracked by United Family Practice Center




       Senior Care Community Partnership      4        Wilder Research Center, February 2005
        Progress toward service integration
Issues to consider

No “presence” at the clinic

SCCP was unable to complete one planned activity, which was to create a “presence” at
the United Family Practice Center, also known as the clinic. According to SCCP, this
activity remained incomplete because of several process and physical limitations. First,
although clinic personnel were supportive of the idea of having SCCP staff on-site, they
were coping with several changes of affiliation and some changes in upper management,
which resulted in their not being able to vigorously assess the process and find a way to
integrate SCCP staff into their routine practice. Second, the clinic staff expressed
concerns related to clinic routine and patient privacy and confidentiality. Third, the clinic
had a shortage of space in which to house an on-site SCCP representative. Lastly, the
clinic management had expectations that the on-site SCCP representative be a community
resource for all clinic patients and not be a resource for older adults only, which was
beyond the scope of SCCP.

Clinic physician participation

Some of the findings from the clinic staff survey corroborate findings from the hospital
staff surveys and partner surveys. For example, several clinic staff members mentioned
that the Living at Home/Block Nurse Program should be easier to contact, which is
consistent with the suggestions made by the respondents in the other surveys. In
addition, these respondents’ comments indicate the value they see in community-based
care, both in terms of comfort for the patient and also in terms of efficiency in service
provision.

Referral line

SCCP set up a dedicated fax/voice mail referral line for health care providers to arrange
for health care and support services for their patients. However, users of the fax/voice
system were not comfortable leaving messages or using the fax as the only means of
contact; they preferred to speak with a person instead. As part of the SPICE-Bridge
partnership, which is a continuation and expansion of SCCP, a dedicated referral line will
be answered by a person 24 hours a day.




       Senior Care Community Partnership      5         Wilder Research Center, February 2005
        Progress toward service integration
Administration of standard assessments

The Living at Home/Block Nurse Programs’ service coordinators may want to consider
routinely administering the medication management review, the falls prevention
assessment, home safety check, blood pressure screening, depression screening, and the
Alternative Care/Elderly Waiver eligibility screening. Not only would consistent record
keeping improve evaluation efforts, but routine screening would likely yield improved
quality of service. Furthermore, routine screening of Alternative Care/Elderly Waiver
eligibility may lead to a higher number of participants for whom the Living at
Home/Block Nurse Programs may receive direct reimbursement for services. Lastly, the
data maintained by the hospitals should include readmission data as well as hospital
admissions data. Readmission data will facilitate measurement of the effectiveness of the
hospital-to-home transition.




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        Progress toward service integration
Project background and purpose

The partnership
In 2000, a collaboration of health care providers and community-based Living at
Home/Block Nurse Programs came together to attempt to serve older adults in a more
integrated, or “seamless,” way. Together these organizations formed the Senior Care
Community Partnership (SCCP). They launched a three-year pilot study with residents
of the southwest quadrant of Saint Paul. The members of the partnership included:

   United Hospital (hospital)

   United Family Practice Center (clinic)

   Four neighborhood Living At Home/Block Nurse Programs: Highland, Macalester-
   Groveland, Summit Hill, and West Seventh Community Center

   The Elderberry Institute

Additionally, representatives from several group health care plans and providers serve in
an advisory capacity to the partnership. This includes representatives from UCare,
Medica, HealthPartners, and Evercare.

Overall, the Living at Home/Block Nurse Programs and the United Family Practice
Center serve a varied, but typically moderate and low income, patient population.
However, for this project the partners focused their services on frail persons age 65 years
and older.

Partnership goals
The mission of the partnership was

   To make system changes that improve communications between community, clinic,
   and hospital, resulting in improved transitions for elders

   To demonstrate the value of Living at Home/Block Nurse Program services to health
   plans resulting in reimbursement for services

   To improve the quality of life and quality of care for older people in our communities




       Senior Care Community Partnership      7        Wilder Research Center, February 2005
        Progress toward service integration
The activities shown in Figure 1 were supported by the Saint Paul Foundation, Mardag
Foundation, Bigelow Foundation, Medtronic Foundation, and the Public Welfare
Association.

1.    Grant-supported activities of SCCP

                                                                               Number of persons
                                                                          (participants, partners, and
                                                                            hospital and clinic staff)
Activity                                                Status                impacted by activity
Living at Home/Block Nurse Programs               Completed             97 participants
(LAH/BNPs) established common protocols
                                                                        7 partners
and forms.
                                                                        75 staff (estimated)
Monthly partner meetings held to improve          Continuing as part    233 elders served by 4
communication, refine and/or revise services,     of SPICE-Bridge       LAH/BNPs (including 97
and problem-solve.                                (next phase of the    participants)
                                                  project)
                                                                        7 partners
                                                                        75 staff (estimated)
The United Hospital (hospital) and United         Completed             41 referrals from the clinic
Family Practice Health Center (clinic)
                                                                        3 referrals from hospital
developed systems to identify patients eligible
for Living at Home/Block Nurse Program
services.
A “Release of Confidential Information” form      Completed             97 participants
was adopted allowing hospital, clinic, and
                                                                        75 staff (estimated)
Living at Home/Block Nurse Programs to
share information necessary to provide
optimal service.
Living at Home/Block Nurse Program staff          Completed 8 in-       60 staff (estimated)
provided training to both clinic and hospital     service training
                                                                        233 elders
staff regarding program services for older        sessions
adults, how those services relate to medical
care, and how to make a referral.
Living at Home/Block Nurse Programs and           Completed             20 participants
the clinic jointly sponsored education
                                                                        75 staff (estimated)
programs about resources and Health Care
Directives to older adults.




       Senior Care Community Partnership          8         Wilder Research Center, February 2005
        Progress toward service integration
1.    Grant-supported activities of SCCP (continued)

                                                                                  Number of persons
                                                                             (participants, partners, and
                                                                               hospital and clinic staff)
Activity                                                  Status                 impacted by activity
A third-year resident physician was                Continuing as part      200 community members
assigned to the Living at Home/Block Nurse         of the clinic’s         (estimated)
Programs as part of the clinic’s community         resident training
                                                                           3 family practice residents
service training. The resident provided            program
consultation to staff, education to seniors,                               8 LAH/BNP staff
and medical services through home and
clinic visits.
Establish a “presence” at the United Family        Incomplete              Not applicable
Practice Health Center; in other words, have
space available at the clinic for SCCP
activities.
Replication: Partners presented “From Home Completed                       4 partners
to Clinic to Hospital with Ease” at the 2004
                                                                           35 attendees (estimated)
Age Odyssey Conference sponsored by the
Minnesota Board on Aging. The presentation
included information on the model and forms
being used to track program activities and
outcomes. The presenters distributed copies
of all forms and followed up with electronic
copies by request.
Program evaluation, Year 1: Evaluation of          Completed               Interviews completed with 19
stakeholders’ perceptions of the partnership.                              stakeholders; interim report
                                                                           completed
Program evaluation, Year 2 and Year 3:             Completed               Interviews completed with:
Evaluation of stakeholders’ perceptions of
                                                                                 13 partners
the strengths and limitations of the
partnership and achievement of partnership                                       19 hospital staff members
goals and expected outcomes.
                                                                                 11 clinic staff members
                                                                                 62 program participants
                                                                           Analysis of 95 Services and
                                                                           Contacts forms*, hospital
                                                                           admissions, emergency room
                                                                           visits, and missed clinic
                                                                           appointments

*Note.      Two participants were not enrolled long enough to complete Services and Contacts form.




         Senior Care Community Partnership          9           Wilder Research Center, February 2005
          Progress toward service integration
Expectations for the Senior Care Community Partnership

After the first year of planning, partners were interviewed about their roles and
expectations for the partnership. They were asked: “Why did you become involved in the
Senior Care Community Partnership?” For the most part, partners said they became
involved because they wanted to improve communication between providers and bring
resources together in order to streamline the process for program participants. Their
responses were reported in July 2003, as follows.

       To bring available resources together            To find funding for system change

       To collaborate with others with a                To improve communication
       similar mission
                                                        To streamline the process
       To remedy gaps in the continuum of
       care                                             It is a part of my job/position duties

       To change the system


Examples of typical comments

Block Nurse         We recognized major gaps between the hospital and health care
Programs            agencies and the LAH/BNP prior to becoming involved in SCCP.

                    In the past, communication between the hospital and clinic and our
                    services was almost non-existent. After some attempts to find the
                    right people to join with us to improve this, we learned that
                    Elderberry was working on a similar idea. So we started talking and
                    finally the SCCP was formed.


United              We want to bring all available resources to bear for clients upon
Hospital or         discharge.
Clinic
                    Our organization has an interest in changing public policy to build this
Other SCCP          kind of model into the mainstream of how we provide eldercare. We
Partners            hope that HMOs will build this kind of case management into their care
                    packages in the future.




      Senior Care Community Partnership         10         Wilder Research Center, February 2005
       Progress toward service integration
Living at Home/Block Nurse Program
Living at Home /Block Nurse Programs are nonprofit neighborhood-based organizations
that use both professional and volunteer services of local residents to provide
information, health care, social, and support services for older, frail adults, enabling them
to continue living in their own homes. Living at Home/Block Nurse Programs mobilize
resources, such as individuals, churches, businesses, and schools to provide social and
community supports. They also contract with certified home care agencies to provide
skilled nursing services. Living at Home/Blocks Nurse Programs provide case
management and coordinate Meals on Wheels, adult day services, transportation services,
and chore and homemaking services, if needed.

For the SCCP project, the four Living at Home/Block Nurse Programs served a combined
total of 95 participants and their caregivers over the partnership’s three-year period.1




1
    Although 97 participants were enrolled in the program over the three-year project period, two
    participants did not remain in the program long enough to receive service (i.e., death occurred prior to
    receiving service).


        Senior Care Community Partnership            11          Wilder Research Center, February 2005
         Progress toward service integration
Evaluation methods
For the two-year project implementation period (2002-2004), evaluation of the
effectiveness of SCCP in meeting its mission involved stakeholder telephone interviews
and analysis of administrative data that includes: client Services and Contacts forms that
tracked service usage, hospital admissions and emergency room visit data tracked by
United Hospital, and missed clinic appointment data tracked by United Family Practice
Center.

Stakeholder surveys

In fall 2004, Wilder Research Center interviewed 62 of 69 eligible participants2 (90%
response rate) from the four Living at Home/Block Nurse Programs, 19 United Hospital
staff (58% response rate), 11 United Family Practice Center staff (55% response rate),
and 16 SCCP partner representatives (87% response rate). The interviews asked a
different series of questions depending on the stakeholder group. Participants were asked
about the effectiveness of the Living at Home/Block Nurse Programs in meeting their
medical and support needs under the enhanced referral system implemented by the
partnership; hospital and clinic staff were asked about the ease of referring participants
under the structure of the partnership; and partners were asked about relationships among
the members of the partnership and their impressions as to whether the SCCP met its
goals of providing seamless care for older adults residing in the southwest quadrant of
Saint Paul. All respondents were assured that the interview would be treated
confidentially; therefore, names and other identifying information have been removed
from the responses.

Services and Contacts forms

The Living at Home/Block Nurse Programs maintained a “Services and Contacts” form
for each program participant. This form included the following types of information:

    Participants’ program-related goals

    The number of home visits, contacts, and services (nurse visits, home health aide visits,
    clinic advocacy contacts, health advocacy contacts, other advocacy contacts, staff
    contacts with client, volunteer services, transportation to clinic) provided, by quarter

2
    The names of 75 currently enrolled participants were provided to Wilder Research Center by SCCP,
    but only 69 participants were considered eligible to participate in the survey; the 6 ineligible
    participants were considered ineligible, because a case manager was the designated contact person,
    they could not be contacted, or language was a barrier. Participants include caregivers and care
    recipients.


       Senior Care Community Partnership           12          Wilder Research Center, February 2005
        Progress toward service integration
   Connections to community services made (including referral and follow-up with
   Meals on Wheels, blood pressure screening, LifeLine, chore/homemaking, screening
   for Alternative Care and Elderly Waiver eligibility, and occupational or physical
   therapy)

   Safety and health monitoring related to falls prevention, medication management,
   activities of daily living, home safety, depression screening, and vulnerable or
   suspected abuse assessment

   Participants’ status in completing Health Care Directives

This type of data provided us with information about the clients’ program-related goals,
levels of service received, the need for and implementation of medication management,
completion of falls risk assessment, and home safety checks. With this data, we were
able to explore the relationships among these variables and the participants’ outcomes
related to hospital admissions, emergency room visits, and the number of missed clinic
appointments.

Hospital and clinic data

United Hospital provided Wilder with the participants’ number of hospital admissions
and emergency room visits prior to and after enrollment in the SCCP project. United
Family Practice Center provided the number of kept and missed clinic appointments prior
to and after participants’ enrollment in SCCP. This data allowed us to examine the
difference in the number of hospital admissions, emergency room visits, and missed
clinic appointments prior to and after enrollment in SCCP.




       Senior Care Community Partnership      13      Wilder Research Center, February 2005
        Progress toward service integration
Findings
This section reports the results of: 1) the stakeholder surveys, and 2) an analysis of
participant outcomes, such as the number of hospital admissions, the number of emergency
room visits, and the number of missed clinic appointments after enrollment in Living at
Home/Block Nurse Programs participating in SCCP.

Partner interviews
Sixteen SCCP partners completed a survey in November and December 2004 about their
experiences participating in the partnership.

Referral process

When asked how they make referrals to the Living at Home/Block Nurse Program, five
partners said they make referrals by phone and no partners said they make referrals by
fax or in any other way. Of the five partners who said they make referrals, three said it
has been easy to make referrals, one said it was not easy, and one partner refused to
answer the question. When asked what would make it easier to make referrals, one
partner suggested having someone there all the time to answer the phone and another
partner suggested that they would like to be able to make immediate referrals instead of
leaving messages.

Perception of progress toward goals

Partners were also asked to rate how well they feel that SCCP has achieved its goals. The
first goal is: to make system changes that improve communication between community,
clinic, and hospital, resulting in improved transitions for elders. Of the 13 partners who
answered this question, nine “agree” and four “strongly agree” that SCCP achieved this
goal. The second goal is: to demonstrate the value of the Living at Home/Block Nurse
Program services to health plans, resulting in reimbursement for services. Of the 11
partners who answered this question, five “disagree,” five “agree,” and one “strongly
agrees” that SCCP achieved this goal. These findings indicate mixed feelings among
participants. It appears that overall the goal of system changes has been more successfully
achieved compared to the goal of demonstrating the value of Living at Home/Block
Nurse Programs to health plans and/or obtaining reimbursement for services.




       Senior Care Community Partnership      14       Wilder Research Center, February 2005
        Progress toward service integration
When asked to give one example of the type of progress made by SCCP or an
improvement that is in progress in smoothing the transition between care setting and
home, partners gave the following responses:

       A client is dying of cancer. Hospice care was set up. Several people
       collaborated and talked with each other so the man got what he needed. Now he
       has his hospice set up at home.

       Block Nurse Program needs to do a better job of letting people know what
       services are available. Also, need to get reimbursed. They are working on this
       issue but have a way to go. They can probably get reimbursed for independent
       living skills, walker, and senior companion. Other organizations use these
       workers and get reimbursed.

       United Hospital has incorporated into the computer system a way to identify
       people that qualify for the program.

       There are intake sheets for Health Care Directives in the patient’s home and clinic.
       We, at the hospital, can access the file at the clinic and that is very helpful.

       We did a good job on assessment tools that we developed. The tool is given to
       hospitals and doctors.

       Assessment tool and flagging system have worked very well. Much improved
       communication and referral improved.

       They took the initiative to seek out our organization and find out how we do our
       intake process and adapted to us. They were very open and receptive.

       We were called about a woman being discharged by the hospital. We set up
       rides, nursing, and home health aides. We had not had any contact with her
       before. We became her support system. She is an example of how the
       participants working together can change seniors’ lives for the better.

       The care setting was a Transition Care Center (TCU) and the discharge planner
       called me directly to let me know the patient was going home. I was invited to
       her discharge planning. Rather than getting involved after the discharge, we
       were involved before they even left the nursing home. I think this led to a greatly
       improved transition for the patient from TCU to home.

       Learning how the hospital discharge planner can refer to Block Nurse Program
       when discharging someone.

       Better referral process for service providers is in progress. Referring directly
       through a person instead of voice mail should improve participation rate. Also,
       trying to improve response time to one hour or less.

       SCCP now has a new referral line process that is better than the old one.

       I really don’t think I can answer that. I’m not in a position to see that.


       Senior Care Community Partnership         15         Wilder Research Center, February 2005
        Progress toward service integration
In addition, partners were asked to describe the one or two benefits that participants have
experienced as a result of SCCP. The most common responses were:

   The partnership improved communication between health care providers
   (8 responses)

   The partnership improved senior care through better access to services and better
   advocacy (6 responses)

   SCCP more efficiently connects resources for seniors (3 responses)

   It is helpful to connect with providers who work in seniors’ neighborhoods
   (1 response)

   More knowledge of where the patient has been (1 response)

   More contact with patients’ families; ease of transition to and from hospital
   (1 response)

   Increased case management for patients, including better follow-through on tests and
   procedures the patient needs (1 response)

   Continued care after hospitalization (1 response)

When asked how SCCP has helped them in their role, the partners’ responses included
the following:

   Improved familiarity and communication between health care entities and providers
   (6 responses)

   They gained an increased understanding of community resources that are available to
   them (3 responses)

   They were able to provide more direct patient care (2 responses)

   More formal systems in place for health monitoring and service coordination
   (1 response)

   Broadened perspective about what will help clients (1 response)

   Working on how the Block Nurse Program can work more closely with payer
   (Medicare/Medicaid) (1 response)

   Better distinction of services so different organizations do not replicate services
   (1 response)


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        Progress toward service integration
The results on these items support the conclusion that SCCP has been more effective at
system changes in terms of improving communication between providers to ease
transitions for older adults, which is related to the first goal of SCCP, than it has been
with attaining reimbursement for services and demonstrating its value to health plans,
which is the second goal of SCCP.

Finally, partners were asked to describe one or two things they felt did not work well for
SCCP. There were no comments made by more than three partners each. This indicates
that there were not any significant or overarching problems with SCCP that were
universal for partners. However, the comments provided by partners can shed some light
on challenges faced and possible improvements that can be made to the program. Three
partners said that high staff turnover and transitions at the clinic created some challenges.
Two partners each said that there was insufficient information about the program
dispensed to other health care providers, that the program was not open all the time and
in cases when someone was needed for an immediate referral, and that the quantity of
referrals from the hospital or clinic was less than expected. Other comments made by
one partner each include: some health care providers did not make SCCP a priority, the
program coordinator needs to be more “take-charge,” need to make better use of the
timeline, it is a slow process to develop relationships between health care entities, need to
improve relations with the clinic, and much documentation is required.

Hospital staff interviews
Nineteen hospital staff completed interviews in November and December 2004 regarding
their experiences with the Living at Home/Block Nurse Program. When asked how they
learned about the program, eight hospital staff said they found out about the program at
an in-service or care coordinator meeting, four heard about it in job training, and two said
they found out about the program through a patient who was already connected to the
program. In addition, hospital staff found out about SCCP through: vendors putting
information in staff mailboxes, from being in social work, and from administration input.

Making referrals

Nearly two-thirds of the hospital staff who participated in the survey (12 of 19
respondents) said they have made specific referrals to the Living at Home/Block Nurse
Program in the past. Eleven of these respondents provided the referral by phone (and the
twelfth respondent did not answer this item). When asked specifically what kind of help
they were looking for in making the referral, hospital staff gave the following responses:

   Skilled nursing care (5 responses)



       Senior Care Community Partnership      17        Wilder Research Center, February 2005
        Progress toward service integration
   Nursing assessments or visits (4 responses)

   Unskilled services (4 responses)

   On-going help with medication (3 responses)

   Physical therapy for a client (2 responses)

   Wound care for a client (2 responses)

   On-going education (1 response)

It appears that most of the referrals made by hospital staff were related to a need for
skilled nursing care or assessments.

Of the 12 hospital staff who said they had provided referrals to SCCP, 11 said that they
received the type of help they were looking for. (The twelfth respondent said they “don’t
know.”) In addition, four respondents who provided referrals said it was “very easy” to
make the referral and five said it was “somewhat easy.” Only one respondent each said it
was “somewhat difficult” or “very difficult” to make referrals to the Living at
Home/Block Nurse Program.

When asked for suggestions as to how the referral process might be made easier for
hospital staff, five respondents provided suggestions. (Three respondents said there is
nothing that can be done to improve the referral process or that they do not have any
suggestions.) Four respondents suggested that there should always be someone at SCCP
to answer the phone and one respondent suggested that more information be provided
about how the program works and what services the program offers.

Direct patient care

Over three-quarters of hospital staff members who completed the survey (15 of 19
respondents) said that the Living at Home/Block Nurse Program has worked directly with
their patients. Of these 15 respondents, 14 said that the program has been helpful to their
patients (and one respondent said that they “don’t know”). Specifically, hospital staff
members said the program helped their patients in the following ways:

   Gives their patients the option to stay in their homes and be independent and that it
   keeps them out of the hospital (4 responses)

   Helps their patients get more information about available services or actually gets
   them more services (4 responses)



       Senior Care Community Partnership      18        Wilder Research Center, February 2005
        Progress toward service integration
   They (hospital staff) are more closely connected with a community provider who will
   know when patient needs arise (4 responses)

   Provides nursing services their patients need (2 responses)

   Gives family members a sense of ease (1 response)

   Provides patient assessments and medical services (1 response)

   Patients get care before they reach a crisis point (1 response)

   Gives B12 shots (1 response)

   Arranges transportation for patients (1 response)

   Keeps doctors and hospital informed (1 response)

Health Care Directives

When asked if the Living at Home Block/Nurse Program helped patients to understand
Health Care Directives, nine hospital staff members said they “don’t know,” eight said
“no,” and two said “yes.” Furthermore, none of the hospital staff who participated in the
survey said that the program had helped patients to complete Health Care Directives.
(Ten respondents said they “don’t know” and eight said “no.”) This result does not align
with the number of completed Health Care Directives recorded on the participants’
Services and Contacts forms.

Specific services provided by the Living at Home/Block Nurse Programs

Hospital staff members were asked about their awareness of specific services provided by
the Living at Home/Block Nurse Programs. They were subsequently asked if they have
ever asked the program to arrange the service for one of their patients. It appears that
over half of the hospital staff members who participated in the survey were aware that the
Programs provide these services. Hospital staff members were less aware that the
Programs provide help with Health Care Directives or living wills. All but one
respondent is aware that the program provides help with medical follow-up after a patient
is discharged from the hospital (see Figure 2).




       Senior Care Community Partnership      19       Wilder Research Center, February 2005
        Progress toward service integration
2.    Hospital staff members’ awareness of services provided through the Living
      at Home/Block Nurse Programs and their requests for the Programs to
      provide the services for their patients (n=19)

                                                                           Number who asked
                                                        Number who          the Programs to
                                                        are aware of       provide the service
Service                                                  the service        to their patients
Help with medical follow-up when a patient is
discharged from the hospital                                 18                      12
Help in monitoring health problems                           18                      10
Arrange for Meals on Wheels                                  17                       6
Set up LifeLine or other emergency contact system            17                       5
Arrange for transportation                                   16                       6
Provide relief from loneliness or isolation                  16                       3
Help to prevent unnecessary clinic visits                    16                       3
Help with non-medical follow-up when a patient is
discharged from the hospital                                 15                       6
Help with long-term care planning                            15                       5
Help with Health Care Directives or living wills             11                       1


Benefits of the program

When hospital staff members were asked about the biggest benefit of having Living at
Home/Block Nurse Programs available in Saint Paul neighborhoods, the responses were
as follows:

     Trust of the Programs and the comfort of patients with the Programs – the increased
     likelihood that patients will use a resource if it is community-based (5 responses)

     The continuity of care the Program facilitates (3 responses)

     Increased ability to observe problems with patients both before and after
     hospitalizations (3 responses)

     Support to keep people in their homes (2 responses)

     The additional services available through the Program that are not available through
     Medicare (2 responses)

     The Programs are less expensive than if the same services were provided through an
     agency (1 response)

        Senior Care Community Partnership          20    Wilder Research Center, February 2005
         Progress toward service integration
   Being able to make connections with providers that have enough knowledge about the
   patient to make referrals (1 response)

   The patients does not have to be acute to get help (1 response)

Suggestions for improvement

When asked what they would do if they could do one thing to improve the Living at
Home/Block Nurse Program, 12 of the 19 hospital staff who participated in the survey
gave a response, although none of the comments were given by more than two
respondents each. Their suggestions for improvement included:

   Have one contact person with knowledge about all services a patient is receiving

   Make the referral process easier and the program easier to contact

   Expand to more neighborhoods

   Use health fairs and churches to get out more information about the programs

   Clarify how the services are paid for

   Increase resources available for patients

SCCP has addressed the suggestions to make the referral process easier and to expand to
more neighborhoods through its continuation and expansion through the SPICE-Bridge
partnership. In addition, SCCP in its expanded form as SPICE-Bridge should consider
doing more outreach through health fairs, churches, and other community organizations.

Clinic staff interviews
Eleven clinic staff members completed surveys during November and December 2004
about their experiences with SCCP. Five of these staff members said they found out
about the program because SCCP staff members come to provider meetings, three staff
member found out about the program through their work, one found out about the
program because they were a part of the team that helped develop the program, one staff
member found out about the program through their patient, and one found out about the
program through West Seventh Community Center.

All but one of the respondents said the Living at Home/Block Nurse Program had worked
directly with their patients. All 11 of the respondents had contact with staff members of
the Living at Home/Block Nurse Programs.


       Senior Care Community Partnership       21     Wilder Research Center, February 2005
        Progress toward service integration
Home evaluations

Three-quarters (73%) of clinic staff respondents said they have seen Home Evaluations
done by program staff for some clinic patients. The clinic staff members who have seen
a Home Evaluation were asked about the various uses of the Home Evaluations, in terms
of how they help clinic staff. The uses and helpfulness of the home evaluations are listed
below:

   Six respondents said the Home Evaluation helped staff get to know participants
   better; three thought this evaluation was “very helpful” and one thought it was
   “somewhat helpful”

   Three respondents said the Home Evaluation made it easier to complete a diagnosis;
   one thought this evaluation was “somewhat helpful”

   Five respondents said the Home Evaluation made it easier to develop a treatment
   plan; two thought this evaluation was “very helpful” and one thought it was
   “somewhat helpful”

   Six respondents said the Home Evaluation provided a good snapshot of the
   participant’s home situation; three thought this evaluation was “very helpful” and one
   thought it was “somewhat helpful”

   Five respondents said the Home Evaluation helped identify potential services or help
   that the participants may have at home or in the community; one thought this
   evaluation was “very helpful” and two thought it was “somewhat helpful”

   Six respondents said the Home Evaluation increased staff’s comfort about the
   participant’s ability to live in their current housing; three thought this evaluation was
   “very helpful” and one thought it was “somewhat helpful”

   Five respondents said the Home Evaluation increased staff’s confidence that
   participants’ needs will be attended to when they return home; three thought this
   evaluation was “very helpful”

Accompanying patients to the clinic

Fifty-five percent of clinic staff respondents said they have had a patient who was
accompanied to the clinic by a Living at Home/Block Nurse Program staff member. All
six of these respondents felt that it was helpful to their patient to have the program staff
there. The reasons clinic staff mentioned for why it is helpful for their patients to have a
Living at Home/Block Nurse Program staff member with them at their clinic
appointments include:


       Senior Care Community Partnership      22        Wilder Research Center, February 2005
        Progress toward service integration
    Living at Home/Block Nurse Program staff members provide support and good
    communication for the patient (3 responses)

    Program staff can answer questions for the patient (2 responses)

    They can answer questions about the home environment (1 response)

    Improved coordination of care (1 response)

    Transportation (1 response)

    They helped to organize the patients’ medical care (1 response)

The five clinic staff respondents who had not had any patients accompanied by Living at
Home/Block Nurse Program staff all felt that it would be helpful to the patient to have
program staff with them at their clinic visits for the following reasons: more
communication between staff and the patients (5 responses), increased safety and comfort
for the patients (3 responses), and reinforcement of medication changes and
recommendations for treatment (2 responses).

Referrals to the Living at Home Block Nurse Program

Sixty-four percent of the clinic staff members who participated in the survey have made
specific referrals to the Living at Home/Block Nurse Programs. All of the referrals were
made by phone. The respondents who made referrals were looking for the following
types of assistance: case management (4 responses), in-home evaluations (3 responses),
environmental safety or accessibility (2 responses), and help with financial issues (1
response). All seven respondents who made referrals said they received the type of help
they had requested. Four respondents rated the referral process “very easy” and three
said it was “somewhat easy.”

Specific services provided by the program

Clinic staff members were asked if they are aware that the Living at Home/Block Nurse
Programs provide various services, such as transportation and Meals on Wheels, if they
are aware that the program provides the service, and if they have ever asked the program
to arrange the service for one of their patients. It appears that over half of the clinic staff
members who participated in the survey were aware that the programs provide these
specific services. See the Appendix for clinic staff members’ awareness of services
provided through the Living at Home/Block Nurse Programs and whether or not these
staff have asked the programs to provide the specified services for their patients.




       Senior Care Community Partnership       23         Wilder Research Center, February 2005
        Progress toward service integration
Benefits of the program

When asked to describe the biggest benefit of having the Living at Home/Block Nurse
Programs available in Saint Paul neighborhoods, respondents gave the following
comments:

   Helps seniors stay in their own homes; stay independent (5 responses)

   Living at Home/Block Nurse Programs provide services efficiently (2 responses)

   Coordination of care (1 response)

   Increased stability for patients (1 response)

   Community-oriented care is more user-friendly (1 response)

Suggestions for improvement

When asked what they would do if they could improve one thing about the Living at
Home/Block Nurse Programs, five respondents provided comments. Two respondents
said the program should be easier to contact, one respondent said that communication
between the physician’s staff and the program regarding available services could be
improved, one respondent said the program should be made available to more clients, and
one respondents suggested that the name of the program be shortened.

Participants’ results
At the end of the three-year project, 75 program participants were available to be
interviewed. Sixty-two participants completed interviews, seven of whom were
caregivers, such as spouse or adult child. If a caregiver was interviewed, they were asked
questions about the relief they may have experienced as a result of the program. If a care
recipient was interviewed, they were asked about the benefits they derived from
participating in the program. All participants (caregivers and care recipients) were asked
about the ease of accessing services, the helpfulness of specific services, and their overall
satisfaction with the Living at Home/Block Nurse Program. In addition to interviewing
program participants, all participants’ (n=95) Services and Contacts forms were analyzed.

Satisfaction with services

All (100%) of the participants said they would recommend Living at Home/Block Nurse
Programs to others in a similar situation.




       Senior Care Community Partnership      24        Wilder Research Center, February 2005
        Progress toward service integration
Accessing services

A vast majority of participants felt that Living at Home/Block Nurse Program services
were easy to access:

   96 percent said they “agree” or “strongly agree” that it was easy to find out about the
   services that were available

   94 percent said they “agree” or “strongly agree” that the services scheduling process
   met their needs

   96 percent said they “agree” or “strongly agree” that it was easy to set up services

Source of referrals

Forty-one referrals were made by clinic staff and 12 referrals were made by hospital staff.
About half of the referrals made to the SCCP project by clinic and hospital staff were
made using the dedicated referral line. One-third of the participants were enrolled in
SCCP after a hospitalization.

Types of services received

Assessments

The Living at Home/Block Nurse Programs either assess or confirm that an assessment
has been conducted for the following:

   Activities of daily living

   Falls prevention

   Medication management

   Blood pressure

   Home safety check

   Alternative Care/Elderly Waiver eligibility

   Depression screening




       Senior Care Community Partnership      25       Wilder Research Center, February 2005
        Progress toward service integration
All of the above except the depression screening should be completed routinely with the
consent of the participant. Based on the information available through the Services and
Contacts forms, the activities of daily living assessment is completed most frequently
(81%), followed by the falls prevention assessment (75%), and medication management
review (67%). About half of the participants received blood pressure screenings and
home safety checks, one-third of the participants were screened for Alternative
Care/Elderly Waiver eligibility, and less than one-third were screened for depression. In
addition, a review of vulnerability or suspected abuse is not routine, but a substantial
proportion of participants (39%) were reviewed for being a vulnerable adult or for
suspected abuse.

Advocacy, support, and health care services

The Living at Home/Block Nurse Program staff made clinic, health, or other types of
advocacy contacts on behalf of about half of the participants.3 About 40 percent of the
participants received nurse visits or assistance from volunteers, and one-third of the
participants received support services such as transportation to the clinic or chore and
homemaking services. Additionally, one-quarter of the participants received Meals on
Wheels or home health aide visits and one-fifth or fewer received LifeLine or
occupational or physical therapy.

Problems noted

About one-quarter of the participants had “falls” noted and 14 percent had “medication
management problems” noted in their Services and Contacts forms. When compared
with the frequency of hospital emergency room visits after enrollment in SCCP, there is a
statistically significant correlation (p < .05) between medication management problems
and emergency room visits after enrollment. This correlation is not surprising; it suggests
that participants not taking their medications correctly tend to have a higher frequency of
hospital admissions. A number of factors may be involved, but this correlation points to
the important role of medication management in maintaining frail older adults
independently in their own homes.



3
    Health advocacy contacts include any health-related contacts other than clinic contacts. Examples
    include advocating on behalf of the participant with health plans, ancillary health care providers,
    pharmacies, therapists, hospitals, nursing homes, transitional care units, and mental health workers.
    Other advocacy includes advocating with non-health-related contacts such as lawyers, banks, cleaning
    services, accountants, credit card companies, and retail stores. An average clinic advocacy contact
    required 0.5 hours, an average health advocacy contact required 0.4 hours, and an average other
    advocacy contact required 0.4 hours of Living at Home/Block Nurse Program staff time.


        Senior Care Community Partnership          26          Wilder Research Center, February 2005
         Progress toward service integration
Health Care Directives

One of the primary objectives of the SCCP project was to have participants complete
Health Care Directives that would remain on file at the clinic. According to the
information contained in the Services and Contacts forms (n=95), 43 percent of the
participants “completed” Health Care Directives, 10 percent had Health Care Directives
“in progress,” and 33 percent of the participants were in a “preliminary discussion” about
Health Care Directives with their Living at Home/Block Nurse Program. Two percent of
participants “refused” to complete Health Care Directives and 4 percent of participants
did not have any information recorded.

Helpfulness of services

Participants, both care recipients (n=55) and caregivers (n=7), reported that the services
or assistance received from the Living at Home/Block Nurse Programs was beneficial to
them. For all services, over 90 percent of participants reported that the service was either
“somewhat helpful” or “extremely helpful.” See the Appendix for complete results.

Care recipients

The most frequently reported benefit of the Living at Home/Block Nurse Program (given
by 35% of care recipients) is that the “nurse”4 gives them reassurance, talks to them about
services, and gives them a sense of security. The next most frequently reported benefits
(given by 13% of care recipients each) are: assistance or help with transportation,
receiving information about services, and being checked on by the “nurse.”

Caregiver relief

Nearly all (6 out of 7) caregivers said they “agree” or “strongly agree” that the Living at
Home/Block Nurse Programs relieved some caregiver burden, specifically in the areas of
feeling relief from care-giving responsibilities and feeling less stressed. Most (5 out of 7)
caregivers also said they “agree” or strongly agree” that the services they received
through the Living at Home/Block Nurse Programs allowed them to have time to pursue
personal interests and helped them to be able to go to work. Four caregivers said they
“strongly agree” and three said they “agree” that they were satisfied with the Living at
Home/Block Nurse services overall.




4
     Participants often refer to Living at Home/Block Nurse Program staff members as the “nurse,”
    although the visiting staff member is not always a nurse.


       Senior Care Community Partnership           27          Wilder Research Center, February 2005
        Progress toward service integration
The most frequently mentioned benefits that caregivers saw for care recipients as a result
of the Living at Home/Block Nurse Program services are: receiving medical care, having
meals delivered, and support of their caregivers.

Impact on hospital admissions, emergency room visits, and missed
clinic appointments

By smoothing the transition from hospital to home and between clinic and home, one of
the expected outcomes of SCCP was a decrease in the number of hospitalizations,
emergency room visits, and missed clinic appointments for participants. However, the
number of hospital admissions, emergency room visits, and missed clinic appointments
increased. Possible explanations include the fact that some of the participants had
conditions that were expected to worsen over time. For example, a participant with
terminal cancer had one hospitalization prior to enrollment and five hospitalizations after
enrollment. A better measure of the impact of Living at Home/Block Nurse Program
services would be to collect the number of hospital readmissions. Hospital readmissions
would indicate a poor transition from hospital to home, because this measure reflects a
second hospitalization for the same event within 30 days.




       Senior Care Community Partnership      28       Wilder Research Center, February 2005
        Progress toward service integration
Participants’ stories                      5




Irene and Joe
When you stop by Joe and Irene’s home for a visit, Irene cheerfully ushers you into their
living room. They are quick to offer you a seat, but not before they settle into their
favorite spots near the window. It’s pretty clear that this is a room they like to spend a lot
of time in, and you can see why. It’s the very definition of a quaint and cozy family
room, filled with soft cushions and soft lights. And it’s the center, literally and
figuratively, of their home, where they can just relax and talk about the events of the day.

Joe and Irene have lived in their home on Erie Street in the shadow of the old Schmidt’s
Brewery for more than 60 years. To put that in perspective, Irene recalls the sacrifices
they had to make when first settling into their new home during the war – World War II
that is. Today, the house is beginning to show its age, but it’s still home. It’s their home.
It’s where they raised their six children and where so many memories that they now
treasure were born.

Not surprisingly, Joe and Irene hope to stay in their home for as long as they can. But
lately, it hasn’t been easy. Joe, who is 86 years old, has been in poor health recently. He
is fighting cancer, and the deterioration of his hips makes it difficult for him to walk or
get up out of a chair, let alone take on any of the other tasks of owning a home. But
amazingly, Joe still shows flashes of his mischievous sense of humor. When you ask
Irene about her health and how she’s coping with their situation, she’ll tell you she’s
doing O.K., but she does need some help caring for Joe and managing her depression and
anxiety.

But in the next breath, Irene tells you about Mary – and she smiles. It’s clear that Mary is
someone pretty special. Mary, in fact, is a home health aide from the West Seventh
Living at Home/Block Nurse Program who lives just a few blocks from Joe and Irene and
who has come to their house twice a week to check in on Joe and assist him with his
bathing and various other health-related needs. But that’s not all. Irene says that Mary
also helps with things like cleaning the kitchen floor or taking out the garbage when
Irene, who is 81 years old, doesn’t have the energy to do it herself. It’s made all the
difference in the world.

“I couldn’t do it without Mary. I just need her help in caring for Joe, and it’s so nice
knowing I have someone who will come right here to the house and do that,” Irene says.

5
    These participants agreed to a release of confidentiality in order to share their stories.


        Senior Care Community Partnership              29           Wilder Research Center, February 2005
         Progress toward service integration
Irene and Joe have been receiving services from the West Seventh Living at Home/Block
Nurse Program for the past three years. They originally learned about the program from
one of their daughters who lives out of state and knew her parents could use some help.
In addition to the weekly visits they receive from Mary, another nurse at the West
Seventh Block/Nurse Program, Sue H., stops by once a month to check Joe’s heart, assist
him with his medications, and check his weight among other things.

“Without a doubt, Joe would not be able to stay at home without our services. He would
absolutely be in a nursing home,” says Dana, care manager for the West Seventh Living
at Home/Block Nurse Program. “I would say they have certainly benefited from the
Block Nurse Program.”

Irene agrees. “I never thought I could get someone to help us like this, to come right to
our home, so that we can stay in our home. I just didn’t know what I’d do about Joe. It’s
so hard for him to go out. He needs help right here,” she says. “The nurses and other
people who have been helping us are just a godsend.”




       Senior Care Community Partnership      30      Wilder Research Center, February 2005
        Progress toward service integration
Donna and Martin
Donna laughs when she remembers how her husband, Martin, spent last summer cruising
around the neighborhood in his electric wheelchair.

“He just buzzed all over the neighborhood, right past all the driveways he used to shovel,
just because he loved to shovel snow. Sometimes he would even shovel our yard!”
Donna says.

However, as the cancer that forced Martin to use that wheelchair progressed, he no longer
felt up to making his rounds through the neighborhood. And as the weather began to turn
colder (which Martin used to look forward to because he knew shoveling time was just
around the corner), it became extremely difficult for him to leave the house at all. That
was a problem. You see, not only is Martin (who is 76 years old) fighting cancer, but he
also underwent quadruple heart bypass surgery last summer. Of course, it goes without
saying that he needs regular medical checkups and his condition needs consistent
monitoring, regardless of the temperature outside.

“When it got cold enough, he wouldn’t even dream of going out,” Donna says.

Considering the circumstances, it should come as no surprise that Donna felt
overwhelming relief when she learned that the Summit Hill Living at Home/Block Nurse
Program would send a staff person to their home to check on their needs. Sue B., the
service coordinator with the Program, calls or checks in on the couple each week to see
how things are going and discuss any changes in Martin’s condition.

“It’s just so very, very helpful. I don’t know what I would have done without her,” Donna
says. “I just couldn’t take care of him myself any longer. Having the help of the Block
Nurse Program just made everything so much easier.”




       Senior Care Community Partnership      31      Wilder Research Center, February 2005
        Progress toward service integration
Today, Martin spends his days resting peacefully by the large, west-facing window of
their home just south of West Seventh Street in Saint Paul. Just outside the window there
is a veritable ladder of bird feeders – nearly a dozen in all – that provide constant
entertainment. Inside, it’s often just as busy. It’s not unusual to find several of Joe and
Donna’s seven grown children stopping by to visit with mom and dad, to see how things
are going and just spend time together.

“The love that Donna and Martin and their children show for each other is just so
profound,” Sue B. says. “Even though his cancer has spread, Martin’s attitude is just
amazing. It makes it a joy to visit him.”

Whether it’s her family or the staff from the Summit Hill Block/Nurse Program, Donna is
clearly grateful for the support she has received during her husband’s illness. It’s made a
hopeless situation feel much more manageable. More importantly, the Program has
helped both she and Martin enjoy their remaining time together and appreciate all they’ve
built over their 55-year marriage.

“I was really surprised when I learned that you could still find a nurse that would come
right to your home,” Donna recalls. “When you are stuck at home all the time, it’s nice
to have somebody visit – to know someone cares.”




       Senior Care Community Partnership      32       Wilder Research Center, February 2005
        Progress toward service integration
Conclusions and issues to consider

Progress toward systems change
According to the results of the surveys with the SCCP partners as well as the staff at
United Hospital and the United Family Practice Center, some changes have occurred in
the procedures or methods by which care is provided for older adults living in the
community. In particular, progress was made in implementing a common identification
system for hospital and clinic patients who are eligible to be Living At Home/Block
Nurse Program participants. Common assessment protocols and service and contact
tracking forms were also implemented by the four participating Living at Home/Block
Nurse Programs and partner meetings were held regularly to facilitate communication
and ease problem-solving. In addition, materials were developed and presented for future
replication of the project. Most notable, however, is the expansion of the project as the
SPICE-Bridge partnership (including more Block Nurse Programs and partners), funded
by a State of Minnesota Community Service Grant.

As with any attempt to reform any complex and well-established system, there are some
issues for future consideration as the project moves forward.

Issues to consider-Partners

Partners see the primary benefits of the program in improved care coordination, a
streamlined referral process, and improved services to frail, older adults. However,
partners do not see a significant impact in reimbursement policies or procedures as a
result of this project. Furthermore, one of the biggest challenges partners report is the
difficulty of building strong relationships with large health care entities. Another
comment that surfaced several times in the partner survey is related to the need to have
someone available at all times to answer the SCCP phone and provide immediate
referrals. In response to these concerns, as a part of the next phase of this project, known
as SPICE-Bridge, a 24-hour phone service has been implemented and the partnership has
expanded to include Regions Hospital and Regions Senior Clinic and Evercare.6




6
    Evercare is a geriatric specialty program that provides and coordinates Medicare, Medicaid, and
    Elderly Waiver benefits. Evercare enrollees living in the community and receiving community-based
    care are assigned a care manager who provides care coordination with the enrollee, their family,
    community support providers, and medical providers. Evercare receives a capitated monthly payment
    and assumes full risk for all hospital, skilled nursing, and community-based service expenditures that
    are medically necessary and assist the enrollee with living as independently as possible.


        Senior Care Community Partnership           33          Wilder Research Center, February 2005
         Progress toward service integration
Issues to consider-Hospital staff

Hospital staff members feel that the main value of the Living at Home/Block Nurse
Programs is the Programs’ ability to provide needed medical care and services to older
adults in their homes. As in the partner survey, some issues were raised by hospital staff
about their difficulty in contacting SCCP on a 24-hour basis for referrals and needed
services, but this problem has been addressed in the expanded program model (SPICE-
Bridge).

Issues to consider-Clinic staff

Some of the findings from the clinic staff survey do corroborate findings from the
hospital staff surveys and partner surveys. For example, several clinic staff members
mentioned that the Living at Home/Block Nurse Programs should be easier to contact,
which is consistent with the suggestions made by the respondents in the other surveys. In
addition, these respondents’ comments indicate the value they see in community-based
care, both in terms of comfort for the patient and also in terms of efficiency in service
provision.

Participant outcomes
The primary participant outcomes for SCCP include:

   96 percent of participants (care recipients and caregivers) “agree” or “strongly agree”
   that finding out about available services, scheduling their first appointment, and
   setting up needed services was easy

   87 percent of surveyed caregivers reported feeling relief from their caregiving
   responsibilities as a result of the services their care recipient received from SCCP

   43 percent of participants completed Health Care Directives

   When asked about the most important benefits they experienced as a result of their
   participation, 35 percent of participants mentioned the reassurance given by the nurse,
   and 13 percent each mentioned help with transportation, receiving information about
   services, and being checked on by the nurse

   All (100%) participants would recommend Living at Home/Block Nurse Program
   services to others in a similar situation




       Senior Care Community Partnership      34       Wilder Research Center, February 2005
        Progress toward service integration
Issues to consider-Participants

The participant file review, which showed some missing information, suggests that more
could be done to standardize the administration of assessment tools. In particular, the
collection of information related to activities of daily living, fall prevention, medication
management, home safety checks, blood pressure screening, depression screening, and
Alternative Care/Elderly Waiver eligibility screening could all be improved. Also,
hospital readmission data (instead of hospital admissions data) would allow for a more
meaningful measure of the project’s impact on the quality of the hospital-to-home
transition.

Considerations for the SPICE-Bridge partnership

Referral line

The difficulty of contacting SCCP, or the discomfort with leaving a message or sending a
fax, led most partners, hospital staff, and clinic staff to comment on the need to improve
the referral line. Specifically, respondents suggested that the referral line be answered
24-hours a day a by a person.

SCCP set up a dedicated voice message line to accept referrals from health care providers
early in the project. Unfortunately, the dedicated referral line did not work as well as
expected, because health care providers found that they were not comfortable leaving a
message and not knowing how quickly their issue or need would be addressed. They also
found that they needed a short (1 hour) turn around time that was not possible with the
voice/fax line.

In response to the suggestions for improvement, SCCP has now implemented a referral
line with Wilder Home Health, the provider of nursing services to several Living at
Home/Block Nurse Programs. As part of the next phase of this project, known as SPICE-
Bridge, this line is answered by an intake person who notifies the appropriate program
within one hour. Preliminary comments from hospital social workers have been positive.

Clinic physician participation

As evident from the slow response to the follow-up survey, clinic physicians were not
well-integrated into the project. Possibly as a result of the lack of presence at the clinic,
the SCCP tools may not have been fully integrated into the routine of the clinic’s
physicians. Based on the experience of SCCP, the partners in the next phase of the
project, called SPICE-Bridge, may need to be more creative and more assertive in their
approach to establishing a presence with the clinic physicians and staff.



       Senior Care Community Partnership      35         Wilder Research Center, February 2005
        Progress toward service integration
Administration of standard assessments

The Living at Home/Block Nurse Program service coordinators may want to consider
routinely administering the medication management review, the fall prevention
assessment, home safety check, blood pressure screening, depression screening, and the
Alternative Care/Elderly Waiver eligibility screening. Not only would consistent record
keeping improve evaluation efforts, but routine screening would likely yield improved
quality of service. For example, as noted in the participant outcomes discussion, a
statistically significant correlation between medication problems noted and hospital
admissions was found, which suggests the value of universally conducting the medication
management review. Furthermore, routine screening of Alternative Care/Elderly Waiver
eligibility may lead to a higher number of participants for whom the Living at
Home/Block Nurse Programs may receive direct reimbursement.

Lastly, data maintained by the hospitals should include readmission data as well as
hospital admissions data. Readmission data will facilitate measurement of the
effectiveness of the hospital-to-home transition.




       Senior Care Community Partnership      36      Wilder Research Center, February 2005
        Progress toward service integration
Appendix
Clinic staff survey responses
Participant survey responses
Services and contacts summary




     Senior Care Community Partnership      37   Wilder Research Center, February 2005
      Progress toward service integration
Senior Care Community Partnership      38   Wilder Research Center, February 2005
 Progress toward service integration
Clinic staff survey responses

A1. Clinic staff members’ ratings of the uses and helpfulness of various aspects
    of Home Evaluations (n=8)

                                                                                 (Of those who said
                                                                                      the Home
                                                                                  Evaluation helped
                                                              Number who         them) number who
                                                             said the Home         said the Home
                                                              Evaluations         Evaluations were
Has the Home Evaluation…                                      helped them           “very helpful”
Helped you get to know patients better                              6                      3
Made it easier to complete a diagnosis                              3                      0
Made it easier to develop a treatment plan                          5                      2
Provided a good snapshot of the patient’s home
situation                                                           6                      3
Helped you to identify potential services or help that the
client may have at home in the community                            5                      1
Increased your comfort about the patient’s ability to live
in their current housing                                            6                      3
Increased your confidence that the patient’s needs will
be attended to when they return home                                5                      3



A2. Clinic staff members’ (n=11) awareness of programs provided through the
    Living at Home/Block Nurse Programs and their requests for the program to
    provide the services for their patients

                                                                                Number who asked
                                                             Number who           the program to
                                                             are aware of       provide the service
Service                                                       the service        to their patients
Arrange for transportation                                          7                      0
Arrange for Meals on Wheels                                         8                      3
Help with long-term care planning                                   8                      1
Help with advance directives or living wills                        8                      2
Set up LifeLine or other emergency contact system                   9                      2
Provide relief from loneliness or isolation                        10                      4
Help to prevent unnecessary clinic visits                           8                      2
Help with medical follow-up when a patient is
discharged from the hospital                                        8                      3
Help with non-medical follow-up when a patient is
discharged from the hospital                                        9                      3
Help in monitoring health problems                                 11                      5


        Senior Care Community Partnership         39         Wilder Research Center, February 2005
         Progress toward service integration
            Participant survey responses

            A3. Participants reported ease of setting up services

                                  It was easy for me to            The services
                                    find out about the        scheduling process met            It was easy to set up
                                    services that were        (my/my care recipient’s)         the services (I/my care
                                         available                    needs                       recipient) needed
            Strongly agree            25            44%             19              39%             21            44%
            Agree                     29            52%             27              55%             25            52%
            Disagree                   0             0%              1              2%              0             0%
            Strongly
            disagree                   2             4%              2              4%              2             4%
            Total                     56           100%             49              100%            48           100%




A4. Specific types of relief reported by caregivers (n=7)

 As a result of using services, our             Strongly                              Strongly      Don’t        Not
 family has…                                     agree       Agree       Disagree     disagree      know      applicable   Total
 Received relief from caregiving
 responsibilities                                    4         2            1              0            0          0        7
 Felt less stressed                                  4         2            1              0            0          0        7
 Felt less isolated                                  1         2            3              0            1          0        7
 Spent time with friends and engaged
 in social activities                                2         2            2              0            1          0        7
 Spent time with the rest of the family              1         2            2              0            1          1        7
 Had time to pursue personal interests               3         2            2              0            0          0        7
 Been able to go to work                             3         2            2              0            0          0        7
 Been satisfied with the services
 overall                                             4         3            0              0            0          0        7




                      Senior Care Community Partnership            40           Wilder Research Center, February 2005
                       Progress toward service integration
A5. Specific types of services received by participants

                                                                       Yes                    No                      Total
Did you…                                                          N           P          N           P           N            P
Have a visitor from (PROGRAM) come to (your/your care
recipient’s) home?                                                58         95%         3          5%           61       100%
Get help connecting to other services you needed in the
community?                                                        24         40%         36         60%          60       100%
Get help setting up medications or have someone call
with a reminder to take medications?                              15         24%         47         76%          62       100%
Get help with rides to doctor’s appointments or other
places?                                                           23         37%         39         63%          62       100%
Get help with paperwork or forms needed for services?             19         31%         43         69%          62       100%
Get help with figuring out medical bills or understanding
health benefits?                                                  6          10%         54         90%          60       100%
Get help understanding advanced directives for health
care such as a living will or other instruction for health
care staff?                                                       25         42%         35         58%          60       100%
Get help writing an advanced directive for health care?           10         17%         49         83%          59       100%
Have someone call the clinic for you?                             12         20%         48         80%          59       100%
Have someone go to the clinic with you and help you talk
with the nurse or doctor?                                         10         16%         52         84%          60       100%




                   Senior Care Community Partnership         41              Wilder Research Center, February 2005
                   Progress towards service integration
A6. Helpfulness of services as reported by participants*

                                                                Extremely       Somewhat         Not too      Not helpful
Was …                                                            helpful         helpful         helpful        at all      Unsure
Having a visitor from (PROGRAM) come to (your/your
care recipient’s) home? (n=58)                                      61%             37%             0%             2%        0%
Getting help connecting to other services you needed
in the community? (n=24)                                            71%             25%             4%             0%        0%
Getting help setting up medications or have someone
call with a reminder to take medications? (n=15)                    73%             27%             0%             0%        0%
Getting help with rides to doctor’s appointments or
other places? (n=23)                                                87%              9%             0%             4%        0%
Getting help with paperwork or forms needed for
services? (n=19)                                                    74%             26%             0%             0%        0%
Getting help with figuring out medical bills or
understanding health benefits? (n=6)                               100%              0%             0%             0%        0%
Getting help understanding advanced directives for
health care such as a living will or other instruction for
health care staff? (n=25)                                           60%             32%             4%             4%
Getting help writing an advanced directive for health
care? (n=10)                                                        90%             10%             0%             0%        0%
Having someone call the clinic for you? (n=12)                     100%              0%             0%             0%        0%
Having someone go to the clinic with you and help
you talk with the nurse or doctor? (n=10)                          100%              0%             0%             0%        0%

*Note.       Only those participants who said they had received the service were asked if it was helpful.




                   Senior Care Community Partnership               42             Wilder Research Center, February 2005
                   Progress towards service integration
Services and contacts summary

A7. Living at Home/Block Nurse Program activities and the number of
    participants with completed Services and Contacts forms (n=95)

                                                                               Percent of
                                                             Number of            total
                                                              persons           persons
Program activity                                               served            served
Activities of daily living assessed                               77               81%
Fall prevention assessed                                          71               75%
Medication management reviewed                                    64               67%
Blood pressure screening                                          50               53%
Home safety check                                                 49               52%
Clinic advocacy contacts                                          46               48%
Other advocacy contacts                                           45               47%
Completed Health Care Directives                                  41               43%
Health advocacy contacts                                          40               42%
Nurse visits                                                      38               40%
Volunteer services                                                38               40%
Vulnerable or suspected abuse assessed                            37               39%
Transport to clinic                                               36               38%
Chore/homemaking                                                  35               37%
Screen for AC/EW eligibility                                      29               31%
Depression screening                                              28               29%
Home health aide visits                                           25               26%
Meals on Wheels                                                   25               26%
Falls noted                                                       24               25%
LifeLine                                                          21               22%
Occupational or physical therapy                                  14               15%
Medication problems noted                                         13               14%




        Senior Care Community Partnership      43   Wilder Research Center, February 2005
        Progress towards service integration

				
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