Chapter 15

Summa Health System and Area Agency on Aging Geriatric Evaluation Project

Kyle R. Allen, Joseph L. Ruby, Susan Hazelett, Carolyn Holder, Sandee Ferguson, and Phyllis Yoders

Introduction

Historically, the clinical course for older patients with chronic illnesses was a steady decline in health punctuated by frequent symptom exacerbations requiring acute hospitalizations, with each hospitalization accelerating the rate of decline. More recently there has been a growing trend for hospitalized patients to be cared for by a Hospitalist, as well as any number of specialists, leading to fragmentation of care. Communication among medical providers is not routine and the patient’s primary care physician (PCP) is rarely aware of the discharge plan or, often, that the patient was admitted to the hospital at all.

The medical model has dominated patient care and little, if any, consideration is given either to the prevention of functional decline during or after an acute hospitalization or to the psychosocial issues that might impede the medical plan of care. Traditionally, little effort was put forth for discharge planning, which typically involved a written set of instructions given to the patient as he/she walked out the door. Patients were discharged to home or to another care setting with no post-discharge follow-up. Patients returned to their homes often to find that they did not understand the plan of care or medication changes, they faced new functional deficits, and they had no knowledge of the resources available to help them overcome the psychosocial barriers that impeded optimal health. PCPs faced a health care system, financed mainly through Medicare and private pay, which encouraged disease treatment over prevention, limited time for office visits, little formal training in geriatrics, and little knowledge of the community resources available to their patients. Even further siloed were community-based long term care providers who had no way to communicate with hospital discharge planners, outpatient geriatrics staff, health plan or health maintenance organization case managers and the PCP, so no single provider had a complete picture of the patient’s overall status, and no one was responsible for making sure all aspects of the discharge plan of care were implemented. As a result, these complex patients frequently suffered potentially avoidable illness exacerbations which brought them back to the hospital, more debilitated each time, to undergo the same chain of events.

In the early 1970s a number of demonstration projects were undertaken to try to establish effective ways to deliver chronic illness care in the community setting. In the early 1980s the Omnibus Budget Reconciliation Act was passed which allowed states to deliver home and community-based services to Medicaid recipients. In the 1990s the Social Health Maintenance Organization (S/HMO) demonstrations and the Program for All Inclusive Care for the Elderly (PACE) were initiated (Harrington & Newcomer 1985; Branch et al. 1995) which provided better links between acute and long-term care services. With today’s focus on health care costs and accountable care organizations, models of care that effectively integrate acute and long-term care are needed.

This chapter describes the development of a unique collaboration between a health care system and a community-based long-term care provider whose goal was to mend known gaps in care by integrating the social and biomedical models of care and coordinating funding streams.

The beginning: a new model of acute care for chronically ill older adults

In the mid 1990s, the Division of Geriatric Medicine at Summa Health System (SHS) in Akron, Ohio, was participating in a randomized trial testing the effectiveness of a model of care known as the Acute Care for Elders (ACE; Palmer et al. 1994). SHS is an integrated, not-for-profit health care delivery system that provides a coordinated continuum of services to its patients. It includes its own health insurance plan, skilled home care, hospice, a foundation, an independent and employed medical staff, and several joint ventures. It is the major teaching hospital for Northeastern Ohio Universities Colleges of Medicine and Pharmacy. In 1995, Summa was just two hospitals, Akron City and St. Thomas, with 963 beds; now Summa is composed of six community teaching hospitals with more than 2,000 beds. SummaCare Health Plan currently has over 150,000 covered lives, including a Medicare Advantage plan of 23,000.

The ACE concept tested at Summa was a model of hospital care delivery aimed at improving the functional status and clinical outcomes for hospitalized older adults. Many of the concepts used in the ACE Model are adaptations of the principles of Wagner’s model for chronic illness care (Wagner et al. 1996a). This model makes heavy use of interdisciplinary teams and has been shown to be effective in ensuring comprehensive care of patients with chronic diseases in numerous studies (Stuck et al. 1993; Stewart et al. 1999; Wagner et al. 1996b; Hansen et al. 1995). The results of the ACE trial showed improved care processes, as well as patient and provider satisfaction, without increasing costs. ACE patients also showed fewer declines in functional status and fewer nursing home admissions at discharge and at one year post-discharge.

The success of the ACE model in the acute care setting prompted the investigators to extend it to other inpatient units, outpatient clinics, and long-term care entities. Summa’s geriatric care delivery model was one of “consult and support” to collaboratively manage and assist PCPs in caring for their chronically ill elderly patients.

Expansion of the ACE model of care

Despite the comprehensive nature of these programs within the health care setting, the impact they were having on post acute outcomes was not optimal. What was missing was a patient connection in the outpatient setting, which is emphasized by Wagner’s model.

As an integrated delivery system, Summa needed to expand its reach to elderly patients across the continuum of care, so Summa created the Center for Senior Health (CSH) at around the same time the ACE research trial was taking place. The CSH is an outpatient consultative service that supports the PCP through interdisciplinary comprehensive geriatric assessment, high risk assessment, a geriatrics resource center, a clinical teaching center, in-patient geriatric consultation, and post-inpatient consultation follow-up. CSH blends the medical and social models, attempting to treat the whole patient by addressing acute and chronic medical needs, psychosocial needs, and holding family conferences.

A major limitation of the CSH was that it did not have access to patients in their homes nor could it provide long-term case management. CSH began to rely heavily on community-based, long-term care agencies to access in-home assessment information, as the home is the setting where most chronic illness care occurs. Thus, it made sense to formally integrate with the local Area Agency on Aging (AAA) since they already provided the case management for Ohio’s Medicaid waiver community-based long-term care program called PASSPORT.

Summa’s community-based care partner: the area agency on aging

Ohio’s AAA 10B Inc., is an independent, private, nonprofit corporation that serves more than 20,000 elderly consumers in northeast Ohio. The AAA is designated by the Ohio Department of Aging to develop a network of services to assist older adults and their families. Its mission is to provide older adults and their caregivers with long-term care choices, consumer protection, and education, so they can achieve the highest quality of life. In addition to its community care coordination programs and its elder rights division, the AAA administers the state’s Medicaid waiver program, PASSPORT, which is a social model of care delivery that addresses the functional, social, psychological, and behavioral needs of low-income, chronically ill older adults whose functional status qualifies them for nursing home placement. A primary goal of PASSPORT is to delay or prevent nursing home placement.

Around 1995 the AAA found itself managing a growing number of consumers with functional decline, geriatric syndromes, and multiple chronic illnesses. As much as 10% of their total client population fell into this high-risk category. The AAA leadership recognized that there was a great need to be integrated with the acute medical sector because of the limitations they were seeing on their ability to reduce permanent nursing home admissions, manage polypharmacy, geriatric syndromes and chronic diseases, interface with PCPs, and the limitations of only “brokeraging” social services versus a more comprehensive approach to improving overall outcomes for their consumers.

At the time the AAA leadership was planning a paradigm shift from service provision to care management. Nevertheless, the AAA still operated under a social model. When a consumer became acutely ill and required hospitalization there was no formal communication process among PASSPORT care managers and health care providers. Without access to input from medical professionals to manage chronic illnesses in the home, too many consumers were prematurely institutionalized. Indeed, every year almost 50% of PASSPORT consumers were transferred to a nursing facility and another third died.

Rationale for integration

Current health care reform posits that a solution to improving quality of care and financial outcomes, particularly for patients with chronic diseases, is a redesign in payment and quality monitoring which will drive integration of services and providers, and thus enhance clinical and financial outcomes. However, clinical, financial, and inter-institutional integration rarely exists, and, without strong incentives, is fairly elusive in the U.S. health care sector.

The AAA and Summa’s Senior/Post-Acute Care service-line identified a lack of continuity of care related to communication problems and fragmentation of care for the complex population that each was serving. The silos of Medicare and Medicaid funding enabled this fragmentation, creating two infrastructures (Medicare for medical issues and Medicaid for social issues) and no incentive for these to become integrated. Each was faced with having to provide more services to a growing population with increasingly complex needs and limited resources. It was recognized that in the medical model, acute medical needs were of paramount importance, and psychosocial and functional issues were least likely to be addressed, and in the social model the opposite was true. What was needed was a model that “spanned the boundaries” between the two (that is, a bio-psycho-social model).

While recognizing and wanting to build off of the strengths of the programs they had established, geriatric medicine leaders from Summa and the AAA also recognized the challenges and deficits they faced in providing continuity of care, and began meeting to discuss how they could build a new model of care. This new model needed to integrate multidisciplinary geriatric services in an acute hospital and community-based care to eliminate duplication or gaps in services, and improve outcomes of care for their mutual consumers/patients. They also realized that everyone involved shared a common goal for their consumers, and that these goals could be better met through streamlined communication across the continuum from the medical to the community setting.

The SAGE project

Thus, Summa and the AAA 10B, Inc., embarked upon the SAGE project (Summa Health System/Area Agency on Aging, 10B/Geriatric Evaluation Project). SAGE provided the organizational structure to develop the resources and processes to effectively integrate geriatric medical services and community-based long-term care services. There were no development or planning grants, integrated funding mechanisms or contractual relationships to work from – just a collaborative effort and strong leadership on behalf of both organizations to meet common goals and coordinate funding streams. The goal of SAGE was to provide a coordinated care delivery model to improve linkage to community resources and reduce fragmentation of care to improve the health, functional status, and prevent institutionalization of older adults at risk for nursing home placement. The SAGE project furthered the goals of both organizations and provided a “value added” benefit.

The CSH/AAA task force

The first step in the SAGE project was to form what was called the CSH/AAA Task Force. This was begun in 1995. It provided a forum to promote communication, provide feedback, and create initiatives to bridge the acute and community aging network. Task force members included: a Summa geriatrician, an ACE and CSH social worker, an ACE Clinical Nurse Specialist, the AAA Screening and Assessment Director and Care Management Supervisor, and a PASSPORT care manager and social worker. This task force eventually expanded to include representatives from Summa’s Home Care, a non-Summa owned and skilled nursing facility with a short-stay geriatrics rehabilitation unit, Summa’s Internal Medicine and Family Practice Centers, and SummaCare’s Medicare Managed Care program.

The task force met monthly for two years, then changed to quarterly meetings. Its objectives were to:

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