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Chapter Quick Links: IV. The Ultimate in User-Friendliness for the Aging PopulationIt is apparent from the preceding sections that seniors have a number of diverse needs and that there is a critical escalation in the number and severity of needs as an older person reaches his or her final years. There is a myriad of organizations in most communities that attempt to satisfy one or more of an older person's needs. Accessing one organization can be relatively easy but, for an older person, accessing several organizations and coordinating their services can be daunting. The problem is equally complex for an absentee family member who is attempting to manage an elder's care from afar. A trip to the elder's locale may satisfy immediate needs, only to find that the needs have changed a few weeks or months later. Moreover, the family care manager in this situation may know nothing about the services that are available or how to access them without considerable research…which translates into time and money. Of all the community organizations, the local health system is in the best position to significantly improve the quality of life for seniors and their caregivers. Not only do the hospitals have the clinical, technological and financial capability to do it, they are at the top of the order with respect to credibility when compared by seniors and caregivers to other organizations. Unfortunately, only a minority of healthcare systems in the nation are truly user-friendly to the aging population. A MYRIAD OF ORGANIZATIONSHelp for the aging individual in almost all communities with populations exceeding 75,000 to 100,000 will be available from most of the following sources:
Each of these organizations is usually quite effective and is relatively easily accessed. The problem occurs when multiple services are required; unfortunately, multiple needs are quite common. Many communities have centralized information sources that can guide elders and their caregivers to particular service providers. The challenge to the patient/caregiver, though, is to access more than one service agency and to coordinate their services. The information sources are generally operated by commissions on aging or similar organizations. The information is typically available in hard copy booklets, only rarely by telephone, and even more rarely on web sites. One progressive community in Florida does have a single source number that not only provides information to elders and their caregivers but follows up in a case management model. Very few communities in the nation have centralized information sources that seek to move an elder within the services as the elder's needs change. As an example, the home food service organization in the vast majority of communities will not alert the day care agency to the socialization needs of the particular senior even if they happen to note the need [Survey Results, Fry Consultants Incorporated, 1999]. More importantly, no community provides a service similar to that of a real estate agent who takes into account a client's needs and makes recommendations accordingly. Absentee children find it almost impossible to find and coordinate care for aging parents from afar. There are a few geriatric care management organizations (private pay and charity based) that can fulfill the local "hands on" tasks but their professionalism varies greatly and there is no commonly accepted and promoted code of ethics or performance. TURF PROTECTION HINDERS COLLABORATIONWork in a number of communities has highlighted the absence of a core group or center with both the motivation and the funding to assume leadership of establishing a continuum of care for the elderly [Client Assignments to Develop Community-Based Care Collaborations: Fry Consultants Incorporated]. Two major reasons exist that negate the creation of the continuum of care. In most communities, the need just is not recognized by the volunteer organizations. In those communities where it is recognized, the problem has become one of turf protection. Paid staff members in the various agencies are fearful of losing their positions and recognition if collaboration is pursued. Interestingly, even volunteer, unpaid board members in the organizations seek to preserve that which exists. This protectionism is even more acute when the potential collaboration involves crossing political boundaries. Collaboration is the key and technology is the method to establish a continuum of care and they must be pursued aggressively. Community efforts must concentrate on putting the needs of seniors first and, as been shown throughout this document, access to a continuum of care is absolutely mandatory for seniors and their caregivers. Community agency leaders must be helped to understand that their goals will be enlarged and their effectiveness enhanced through collaboration. One of the most effective processes for overcoming turf protection is to facilitate the leaders of the community agencies in agreeing upon a common set of goals--goals oriented to the benefit of the seniors…not to the benefit of the agencies. An example of one community's goals is to keep the seniors in their homes (not institutionalized), keep them in the community, keep them active (mobile), make the providers effective, position the seniors properly in the continuum of care (including access and movement), and encourage effective collaborative grant solicitation. Of all the involved organizations, the health system is usually in the best position to augment the continuum of care process since the process will become heavily technology driven as time progresses. Achieving this kind of collaboration usually requires an outside third party who is seen as impartial by all parties concerned. The third party needs to have a thorough understanding of the motives and personal goals of all the leaders who are involved in the goal setting process. An important element is the understanding by the participants that the final goal is bettering the quality of life for the seniors and their caregivers. CONTINUUM OF CARE COMPONENTSThe continuum of care components need not all be under one organizational umbrella, but one model seems to work better than others do. The model is built on the collaborative efforts of a commission on aging type of organization. The commission on aging provides a one-source community inquiry line and a referral to the necessary agencies. This type of a model results in a community/health system continuum that is geriatric friendly.
(Click image to enlarge) The difference between what should exist and what exists now is that the typical commission on aging agency alerts each of the referral agencies to the inquiry and those agencies are responsible for contact of the senior. At the very least, the inquiry line operators should call the senior or the caregiver back at an appropriate time to ensure that the contact has been made. Healthcare related inquiries are relayed to the local hospital which, ideally, has established a geriatric or senior center type of service line concentration. The ideal program components through the hospital will include:
An example of user-friendliness within these components would be that inpatient acute care be oriented to the special needs of seniors with respect to facility environment, clinical requirements and social needs. Not all the components need to be internal to the hospital. They can be integrated through collaboration, affiliation, contract, and so on. It is logical that the hospital be the center for the healthcare considerations of seniors but its executive leadership will have to work carefully with the community agencies so as not to be considered the "the big elephant that will trample us." The hospital's geriatric center leaders will also have to work carefully with local physicians to ensure that the physicians do not view the senior service line as a competitive threat, i.e., "stealing my patients!" Here, again, a third-party facilitator can be extremely helpful in facilitating a mutual understanding of how the implementation of user-friendly geriatric services can benefit all the involved parties. THE GERIATRICS SERVICES CENTER IN A HEALTH SYSTEMIntroduction of a geriatric services center in a hospital or health system requires varying degrees of good public relations, especially with the local community and the medical staff. Care must be taken to ensure that the community agencies see the center as an enhancement to their efforts with the elderly. The medical staff must be helped to understand that the center will help them and their patients. Medical staff typical response in the initial stages is to regard the center as an attempt by the hospital to "steal" their patients. The center needs to be within the health system facility or very close to it on the campus. Typically, the center should have dedicated space that is easily found, easily accessed and well marked. The space needs to accommodate a reception area, resource area that can double as a conference room, two exam rooms, chart storage, administrative office space, two conference rooms, equipment and supply storage, lavatory and the physician's (director's) office, which also can double as a conference room. The geriatric or aging population services at a hospital need to be focused on four major, required fundamentals. These are (1) an interdisciplinary geriatric assessment capability, (2) a continuum of care/wellness emphasis, (3) education and awareness and (4) a resource information service. INTERDISCIPLINARY GERIATRIC ASSESSMENT CAPABILITYInterdisciplinary geriatric assessments optimally require a board-certified geriatrician, who also acts as the clinical director of geriatrics within the institution, an administrative director, a geriatric nurse practitioner, pharmacist, social worker, nutritionist, gero-psychiatrist, secretary-receptionist, and the hospital's regular support and clinical units. The assessments are performed by the team during two visits. The assessments occur by the senior or the caregiver making a request to the primary care physician. Concomitantly, a primary care physician may recommend the assessment to his or her patient and/or their family. The primary care physician then refers the patient to the center, thereby ensuring that the physician is in control of the referral as well as making the assessment meet the requirements of Medicare for reimbursement. The first visit is typically one to two hours long as each member of the team obtains relevant information. Between the first and second visits, the team meets to develop a care plan. The care plan is the core of the second visit, which usually lasts an hour or so with the patient and any caregivers (usually family members). A copy of the care plan then is sent to the referring physician along with any other relevant information and insights. The referring physician is responsible for overseeing the implementation of the plan. The patient does not see the center personnel again until referred by his or her physician. Such assessments make sense every two to three years over the age of 65 and should be performed annually from about 75 years of age on, depending on the health of the senior. The following illustrations list the numerous advantages of interdisciplinary geriatric assessments to patients/caregivers, physicians and hospitals.
(Click image to enlarge) (Click image to enlarge)
(Click image to enlarge) A CONTINUUM OF CARE/WELLNESS EMPHASIS Using a case management approach, the geriatric center draws on all related services available to it within and outside of the organization to ensure an effective continuum of care. Basic elements include inpatient and outpatient care, rehab, respite care, adult day care, congregate living, skilled nursing and home health. Hospice and fitness are other components that are often added. If the hospital has a home health unit, the case management function may frequently be a separate section in the home help service. Case management is best tracked on a high-risk patient basis through electronic technology. A hospital need not own or even manage all the components of the continuum. In fact, in some cases, it is better that a component be independent. There are all types of ways to work with continuum components, including collaboration, affiliation, contracts, management, cooperation, etc. As an example, the health system may not provide adult day care and, where there is none in the market area, may work with a leading local religious institution to set up such a program. Nursing home ownership by a health system is usually not a good use of capital and management resources if there are other well-managed skilled nursing facilities available in the area. Fitness can be provided by contracts, or purely cooperative arrangements with local fitness centers. The administrative manager of the center operates organizationally much like a product or brand manager in that he or she has little authority over the services involved but has the responsibility to bring them all together as a service line. EDUCATION AND AWARENESSThe geriatric services center has the responsibility for overseeing and conducting frequent educational and awareness programs, seminars and meetings that need to occur with physicians, nursing staff, hospital employees, patients, family and caregivers. Additionally, local health fairs, radio and TV programs, newspaper and magazine articles, and web sites may be used to encourage recognition of seniors' needs as well as their opportunities for improving their care and related quality of life. Subjects include the broad spectrum of health and related subjects of special interest to seniors, including osteoporosis, Alzheimer's, nutrition, dementia, cancers, cardiology, depression, incontinence and medication management. Beyond health topics, seniors have great interest in related topics such as finance, computer use, Medicare billing, insurance coverage, reverse mortgages, living wills and various trusts. Another key element in an education and awareness program is a membership or affinity program sponsored by the hospital's senior center. The membership program highlights opportunities for the seniors and offers special discounts on services such as travel, pharmaceuticals, eyeglasses, hearing aids, etc. Too many institutions view the membership program as a senior service center in itself. In fact, the membership program is fundamentally an educational and marketing tool to promote the senior services of the institution. To have a membership program without interdisciplinary assessments and a continuum of care is akin to having a marketing program without a product. It is within the membership program that special aging population-oriented electronic capability can be used for program members. The site can be independent of the health system's website or be part of it. Of course, if independent, it should be linked to the system's site. The site can be used for education and awareness, schedules of events, prevention and wellness reminders, clinical trial invitations, support group chat rooms and numerous other applications. The site should also be hyperlinked to other reviewed and approved sites that would be of interest of seniors, thereby making it the preferred home site for many of the area's seniors. Whether electronic or face to face, support groups are a major part of education and awareness. Typical support groups include grief, suicide, caregivers, alcoholism and drug dependency. RESOURCE INFORMATION SERVICESThe senior services center needs to become the leading source of information and data within the community for seniors, their caregivers, physicians, the media and other persons seeking information related to the aging population. It is possible to collaborate with the local library in the provision of this information but, to the extent that this occurs, the hospital loses the credit for being "the center." Being an information source includes access to computerized information as well as hard copy materials. A valid question can be raised with respect to, if the senior services center is going to be the information center, why should the commission on aging or similar organization operate the single referral infoline for the community. In some situations the health system does operate the line but, most of the time, community operation of the line will assuage community relations concerns, reduce health system operational costs, and minimize politically motivated grievances. A CASE ON POINTTo illustrate the values of a senior service line concentration it is useful to draw on a case study of one of Fry Consultants' clients. Mark Health System (identification disguised) is located in a large town in the Midwest and competes with another local hospital of similar size, both have about 300 beds. The competitor had no specialized services for the elderly but its management believed in aggressive advertising and promotion. Mark Health System had extensive specialized services for the elderly but its management did not advertise or promote on a comparable basis. More importantly, the services for the elderly were fragmented within the organization. They reported to at least three different vice presidents at the administrative level and they seldom met together. In fact, in some cases they competed with one another for patients. The services included an exceptionally wide array: inpatient acute care, outpatient care, sub-acute care, inpatient rehab, inpatient adult psych unit, dialysis, cardiology rehab, fitness center, assisted living units on the campus, an owned nursing home off campus, an in-home hospice, home health and several off-campus adult day care centers. Spread throughout these service units were more than 40 case managers, each vying for patients. In addition to this wide breadth of services, there was an off-campus senior health center managed by a geriatric nurse practitioner and directed by a local primary care physician whose practice included a preponderance of Medicare patients. This center conducted geriatric assessment (not interdisciplinary), prescribed medications, sought to keep patients, marketed its services, and conducted educational and support group activities. As one can imagine, relationships between the center and the medical staff were far less than cordial. There were a number of community-based senior services, some more effective than others, but none doing anything remotely akin to promoting collaboration. There was a weak commission on aging-type organization that was almost out of business. Since there were so many senior services already available in the health system, the stage was set for major improvement with little or no investment or additional expense. The first step after an exhaustive inventory and evaluation of the health system's and the community's services was to arrange for all the health system senior-related components to report to one administrator. Clinical units were left as they were at the time. The senior center was moved to the main hospital campus and a geriatrician was recruited on a part time basis to direct its operations, including the conduct of interdisciplinary geriatric assessments. The center began accepting patients only on referral from local physicians; patients were returned after the assessment with a care plan for implementation. One of the most significant actions was the creation of a case manager organization into which all the case mangers were reassigned. They were left physically housed with their original units but organizationally they reported to the director of case management. Almost immediately this eliminated the competition for patients, thereby improving effectiveness, physician relationships and the quality of care for patients as well as smoothing patient movement through a continuum. The improved effectiveness of the case managers enabled the health system to reduce the overall number of case managers as well as place some of the unneeded case managers in the offices of some of the larger multi-specialty groups. The education department of the health system now had, for the first time, a cohesive group from which unified direction made possible new educational programs for the elderly. Similarly, the marketing department had a clearly delineated service/product line that could be promoted in the marketplace. The development of a membership program linked with e-capability completed the internal changes. With the internal units working together, efforts then turned to the community and the development of senior-related community services. All of which better served the community and public relations interests of the health system and helped establish it as a leader in senior care for the aging population.
(Click image to enlarge) In summary, there are several concluding observations relevant to any health system contemplating establishing itself as a center for services to the aging population.
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