by Rona S. Bartelstone, LCSW, MSW, CMC, Senior Vice President of Care Management

As a leader in the care management industry, SeniorBridge is demonstrating the positive outcomes of its high-tech, high-touch approach to caring for elders and others with chronic health concerns. The company’s in-depth database system allows for tracking the health outcomes of clients for comparison with the outcomes of the general Medicare population. With this information, SeniorBridge can demonstrate to families and health systems the significant savings resulting from reduced re-hospitalizations and falls and improved medication management.

The SeniorBridge model is built around the concept that “hands-on” Care Managers work in tandem with other healthcare providers to ensure the care of patients across multiple settings. This means that highly trained and experienced social workers and nurses work with primary care physicians, hospital discharge planners, rehab facility staff and Medicare homecare companies to coordinate the care of patients as they move to different levels of treatment. This “hands-on” approach is unique because the CareManager is at the bedside giving information about the patient to each provider, smoothing transitions and assuring that care is individualized to each patient’s unique set of circumstances.

The Care Manager also works with the family, support system and in-home caregivers to customize care to meet the needs of each patient. This includes an understanding of the safety needs within the home environment, dietary preferences and restrictions, and emotional coping skills and needs. This individualized approach has been shown to increase the chances for improved health outcomes.

It is widely known that older adults and persons with multiple chronic illnesses are difficult to treat and the cost of their care is high. A 2007 study showed that 50% of the elderly do not recall anyone talking with them about how to care for themselves after a hospitalization. And, within the same client group of Medicare beneficiaries, 20% are re-hospitalized within 30 days of discharge. Of those re-hospitalized, 50% have not seen a physician from the time of discharge to the time of re-admission.

SeniorBridge clients, who have similar characteristics to, and are most often themselves, Medicare beneficiaries, have 46% fewer re-hospitalizations than the general Medicare population. SeniorBridge attributes this to the company’s ability to follow the patient across multiple settings, provide concrete support and diseaserelated education, and the proactive efforts of its staff in the areas of follow-up care, in-home monitoring of vital signs and medication management.

According to a 2004 Robert Wood Johnson and Johns Hopkins University study, Medicare beneficiaries with five or more chronic health conditions fill about 53 prescriptions each year. This can lead to confusion about appropriate medication schedules, which are often complex. Improper administration of medications can lead to significant exacerbations of health conditions or cause interactions that create additional disability. The SeniorBridge approach to utilizing an integrated team of healthcare staff helps to prevent mismanagement that often leads to additional health issues, including falls and hospitalizations. According to the SeniorBridge database, our clients have 96%fewer falls than nursing home patients and 55% fewer falls than homecare patients. These statistics suggest that the ability to provide individualized care plans and specially trained caregivers who are supported by regular Care Manager visits have better health outcomes in general and safer environments and care.

Because most daily healthcare is already provided in the community, it makes sense to concentrate the efforts of healthcare providers in the home environment. This approach is consistent with the desire of most people to be able to remain in their own homes when they need care, while reducing the cost in both acute care and long-term care settings.

When an individual has multiple health concerns and limitations in their daily activity level, they need an advocate to help manage the complexity of care that ensues. SeniorBridge has demonstrated that, with the proper support, these individuals can remain healthier longer, have fewer hospilizations and a better quality of life, and present fewer challenges to family caregivers and the healthcare system.

While not everyone can afford to hire SeniorBridge, it is our hope that the SeniorBridge care model will inform the healthcare debate and help to create greater access to “hands-on” care management nationally.