Dr. David Wilner

It’s well-known that by 2050, one-fifth of the total U.S. population will be above age 65, with many of those above age 85 needing assistance. At this rate, the general demand for services will expand vastly across the entire long-term care spectrum.

To adequately provide for this population without overtaxing the current system, the field as a whole is starting to think outside the box. The Program of All-Inclusive Care for the Elderly (PACE) is one innovative model that continues to show success in  helping adults 55 years and older avoid long-term care placement and remain in the community.

The PACE model of care includes a highly integrated approach to treating individuals at risk for nursing home admission, allowing them to stay in their homes. Summit ElderCare, a program of Fallon Health based in Massachusetts is an example of a highly successful PACE program. Operating out of five facilities spread throughout the central and western part of the state, the initiative provides individualized quality care through a comprehensive and diverse team of employed geriatric-focused professionals who work with participants and family caregivers to address a wide range of patient needs. The team coordinates clinical services across a group of 11 professional disciplines, providing medical care and coordination, geriatric case management, social services, functional assistance and rehabilitation, adult day health services, full insurance coverage and in-home support—all in one personalized program.

This comprehensive approach to care has helped Summit ElderCare significantly improve the health of its patient population, realizing better patient outcomes, increased satisfaction and enhanced care coordination. Through interdisciplinary collaboration and truly patient-centered care, supported through technology, Summit ElderCare has been able to successfully manage a significant patient population, showcasing the type of approach needed by others in the industry to achieve population health management goals and move the needle on quality and cost.

Technology’s Role in Facilitating Collaboration

Aside from a strong commitment from the interdisciplinary team to communicate and coordinate services, Summit ElderCare also relies on its NextGen Healthcare electronic health record (EHR) to enable such effective collaboration. Technology facilitates initial care plan development, real-time documentation and smooth information exchange, all contributing to improved patient care and lowered costs.  

For example, once a participant enrolls in the Summit ElderCare PACE program, the team spends 30 days completing a comprehensive assessment across disciplines using custom EHR templates designed for each clinical specialty. The group shares the planning document through the EHR, allowing every team member to get a better sense of the patient’s total health, care goals and next steps.

After the comprehensive plan is in place, the EHR facilitates daily contact, dialog and collaboration between team members, allowing them to provide optimal treatment, therapy and services. For instance, the staff uses the EHR’s mobile capabilities to document any changes in a patient’s condition in different settings, ensuring a timely response to patient needs and access to up-to-date information.

Not only does Summit ElderCare’s technology foster better inter-team communication, but also seamless information exchange with outside providers. For example, when a patient requires hospitalization or transfer to a nursing home, the EHR can easily share complete treatment plans, test results and medical records with the facility. This allows the receiving organization to deliver cost-effective treatment by avoiding duplicative tests or incompatible therapies.

Seeking the Right Technology

Due to its unique, multi-disciplinary treatment approach, Summit ElderCare had to be forward-looking in selecting its EHR platform. Some capabilities the organization sought to include:

  • A fully mobile solution. This allows staff to provide 24/7 care across multiple settings.
  • Multi-specialty documentation. This supports comprehensive, interdisciplinary planning and communication. Many EHRs focus on capturing primary care-oriented information. However, Summit ElderCare needed a tool that looked beyond traditional data to capture information from physical therapists, nutritionists, geriatric physicians, nurses, home health experts, social workers and a variety of other specialists to provide comprehensive care.
  • Efficient documentation. This enables convenient access, retrieval and viewing of information for all team members to enable effective collaboration.
  • Interoperability with other settings. Having this capability allows the organization to easily transfer complete records to skilled nursing facilities, hospitals or other medical settings when patients require a different level of care.

Delivering Success for Stakeholders

Through its interdisciplinary care model connecting different specialties and areas of care through interoperable technology, Summit ElderCare achieves impressive results for its patient population. For example, the organization has a 15.7 percent 30-day hospital readmission rate, as compared to a general Medicare population rate of 18 percent and a skilled nursing facility rate of 23.5 percent. This shows that the care coordination that Summit ElderCare is able to achieve has a direct correlation to reduced readmissions rates—keeping patients healthier and helping to reduce care costs.

It also has unprecedented patient satisfaction with 100 percent of participants indicating they would highly recommend Summit ElderCare to others. This rating stems from the improved care and holistic approach to patients that the organization is taking. Anecdotally, staff satisfaction is also high and care teams are enthusiastic about their work.

New Models to Serve a Growing Population

The increasing demand for long-term health services will require innovative models that serve this rapidly expanding population. Summit ElderCare is demonstrating that an inter-disciplinary, community based strategy is a good option for many patients. The highly collaborative, integrated care approach, facilitated by advanced technology, is helping both patients and family members benefit from a seamless healthcare experience that meets their needs while preserving their independence.

Dr. David Wilner is the medical director and Linda Noll is the EHR application manager at Summit ElderCare and Fallon Health.