Senior ASSIST: Bridging a Gap in Care Coordination for High-Risk Elderly

Purpose:
Senior ASSIST provides coordination across the continuum of care and chronic disease management to high-risk multi-morbid elderly persons served by a large tertiary-care hospital. Goals are to improve access to care, clinical quality, satisfaction, and reduce health care expenditures.

Significance:
99% of healthcare dollars are spent for persons with chronic disease ($425 billion/yr). Inadequate management results in hospitalizations and rehospitalizations (10-20% rate). Causes are lack of care coordination and lack of self-care, including medication problems. Care transitions are problematic.

Strategy and Implementation:
Nurse case managers make comprehensive in-home assessments of patients and their environment. They provide in-home safety assessments for fall prevention and strengthen the support system with community resources. They reconcile all medications, teach self-care, and assess response to treatment. They coordinate care and share information about the home situation with the whole health care team, both outpatient and inpatient. Frequency of visits is determined by patient need, not third-party payers. Nurses developed the program in response to a gap in services to the chronically-ill. They collaborated with physicians and inpatient and outpatient nursing personnel to develop processes of care and care-coordination to achieve desired patient outcomes. The program is well-integrated within the hospital through working relationships and the use of the electronic medical record. It extends the hospital's response to Joint Commission National Patient Safety Goals to the end-point setting.

Evaluation:
21,149 visits were made. Positive outcomes were shown in patient/physician satisfaction, clinical indicators (B/P, HgbA1c, nutrition), and 62% reduction in expenditures (hospitalizations). 94% of patients said self-care improved; 90% felt health improved. 95% of physicians said patients benefited.

Implications for Practice:
This integrated model of chronic disease management and care coordination adds value to an organization in a pay-for-performance arena of health reform. It is cost-effective, improves health, prevents hospitalizations, enhances satisfaction, and demonstrates nurses' ability to meet a critical need.