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The SeniorBridge Approach to Eldercare |
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Among the many things that distinguish SeniorBridge from other in-home care providers is our integrated model of care. This model goes beyond illness to address the entire wellbeing, comfort and functionality of our clients and their families. Clinical evidence has shown that this approach can lead to a reduction in emergency room visits, a greater likelihood of remaining at home, improvements in self-care and increased mobility*. In addition to dramatically improving the overall quality of life for our clients, this approach also results in greater peace of mind for their family members. Clinical Evidence Our model of care is based on a large body of clinical literature dedicated to evaluating patient outcome in chronically ill populations. Many studies demonstrate improved overall health and quality of care for patients with chronic disease through the use of organized care management processes, integrated health teams, and comprehensive services that address multiple aspects of a patient’s condition. A sampling of these studies can be found below. Benefits of Restorative Home Care as opposed to Traditional Home Care In a study of 1,382 elderly patients that compared restorative home care with traditional home care services, restorative home care based on principles from geriatric medicine, nursing rehabilitation, and goal attainment was shown to prevent the functional decline that occurs in elderly patients after they are discharged from a hospital.1 Physician, Nurse and Social Worker Collaboration Improves Patient Outcome A study of 543 elderly patients who received care from their primary care physician working with a registered nurse and a social worker showed less hospitalizations, more socialization, less office visits, more monetary savings, and superior overall emotional and physical health as compared to a control group that received care from their primary physician alone.2 Surveillance, Care Coordination, Counseling & Support Improve Patient Outcomes In a study of 139 elders with cardiac medical and surgical diagnoses, greater nursing time spent and number of contacts per patient, especially involving three interventions, (1) surveillance of symptoms & behaviors; (2) care coordination; and (3) counseling & support, led to improved patient outcome and decreased health care cost.3 Care Management Processes Improve Client Care A study of nine leading physician’s organizations found that incorporating care management processes, such as the use of guidelines, disease management techniques, case management, and patient education to improve self management of chronic disease, led to improved client care. However, the study also found that incorporating organized care management processes into physicians’ practices is difficult, and less common than what would be desirable, due to lack of financial and staff resources, inadequate clinical information systems, and doctors’ heavy workload.4 Another study of one thousand five hundred eight-seven United States PO’s found that while organized care management processes can improve health care quality for patients with chronic disease, physician organizations’ mean use of the recommended care management processes was low: 5.1 out of a possible 16.5 The Chronic Care Model Shows Improved Patient Outcome The Chronic Care Model, a model of care involving multidisciplinary practice teams of six to eight people, including nurses and social workers, each with a “physician champion” has been demonstrated to be effective in improving patient outcome by a number of studies of different chronic illness populations, including diabetes, asthma, depression and other chronic conditions commonly found in the elderly population.6 7 8 9 Third Party Medication Management Improves Compliance and Patient Health Researchers evaluating elderly participants’ self administration of medications versus the management of medications by a third party found that the group of participants who self-administered missed significantly more doses of their medication and had more frequent hospitalizations and physician office visits than the group that was cued by an outside source.10 Exercise Helps Prevent Falls for Elderly Individuals A fall prevention program for elderly individuals was studied in two nursing homes, finding that regular exercise prevents physical deterioration and may reduce falls and improve fall-related outcomes.11 * As published in Journals of the American Medical Association. 1 Tinetti, M., et al. "Evaluation of restorative care vs usual care for older adults receiving an acute episode of home care." JAMA. April 24, 2002 v287 il6 p2098(8) 2 "Physician, Nurse, and Social Worker Collaboration in Primary Care for Chronically Ill Seniors." JAMA. June 26, 2000. 3 Brooten, D. et al. "Patient problems, advanced practice nurse (APN) interventions, time and contacts among five patient groups." HJournal of Nursing Scholarship, Spring 2003 v35 i1 p73(7). 4 Rundall, T. et al. "As good as it gets? Chronic care management in nine leading US physicians organizations." BMJ. Volume 325. 26 October 2002. 5 Casalino, L. et al. "External Incentives, Information Technology, and Organized Processes to Improve Health Care Quality for Patients with Chronic Diseases." JAMA. January 22/29, 2003—Vol 289, No.4. 6 Wagner, et al. Elements of Effective Chronic Care: A Model for Optimizing Outcomes for the Chronically Ill. Epilepsy Behav. 2000 Aug;1(4):S15-S20. 7 Wagner, et al. Improving primary care for patients with chronic illness: the chronic care model, Part 2. JAMA. 2002 Oct 16;288(15):1909-14. 8 Wagner, et al. Improving primary care for patients with chronic illness. JAMA. 2002 Oct 9;288(14):1775-9. 9 http://www.improvingchroniccare.com 10 Outcomes Manag Nurs Pract 2000 Oct-Dec; 4(4):172-6 11 Schoenfelder, DP. "A fall prevention program for elderly individuals. Exercise in long-term care settings." J Grontol Nurs 2000 Mar; 26(3): 43-51. |
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