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Dramatic results show how collaboration helps older adults

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Lyn Lais
Lyn Lais

In recent years, healthcare providers have sought to prevent rehospitalizations for older adults, so they don't wind up riding a roller coaster of health crises. The statistics have not been encouraging.

According to the New England Journal of Medicine, one in five people were rehospitalized within 30 days after discharge. One in three returned after 90 days. Today the Medicare national average for readmissions within 30 days has dropped to 15.2% but that still means close to one in seven people are returning to hospitals within a month of being discharged. That's far too many people experiencing the roller coaster of healthcare crises.

Statistics like these sparked Minneapolis-based eldercare provider Augustana Care to team up with home care provider Lifesprk to help older adults succeed when they leave hospitals or rehabilitation centers. Augustana Care's Chief Operating Officer Tim Middendorf feels the issue of readmissions could not be solved solely by any one agency. Instead, a strategic partnership with Lifesprk was needed to keep older adults thriving at home once they are discharged from care communities.

The Thrive On @ Home program partnership between Augustana Care and Lifesprk is coordinated by me, as a life-care navigator and registered nurse. I have been in the healthcare field more than 25 years and have seen firsthand how gaps in care occur. Figures from the Center for Health and Learning show 90% of health outcomes are shaped by factors other than healthcare, yet those are rarely addressed.

Once people are home, those non-health issues can exacerbate and trigger a spiral of crises, ultimately causing a return to the hospital. That's because at home, there's no professional using a whole-person approach to help guide people through this next life phase and give them the confidence and tools they need to successfully transition and stay home.

The goal of the Thrive On @ Home program is to bridge the care received at Augustana Care's Chapel View community with care at home to achieve the Triple Aim—improve individual experience, improve health of our population, and reduce the cost of healthcare. Since October 2015, I have enrolled 140 people into the Thrive On @ Home program, with 110 identified as being at high or moderate risk for readmission.

Based on the Medicare national average for readmissions within 30 days, 17 were likely to be readmitted. Due to the Thrive On @ Home program and its interventions, we've found, through client self-reporting, that of the 110 at-risk, only 6 were readmitted—a 65% drop in the expected readmissions from the national average.

Those who did need to go back to the hospital were able to return without paying a visit to the emergency room or using an ambulance transfer, saving both time and cost. Lifesprk CEO and Registered Nurse Joel Theisen believes Thrive On @ Home provides an integrated solution that stops the roller coaster of crises.

I believe the program has been successful for several reasons but a major one is because isolation is fatal. Partners must work together as systems of excellence for a continuum approach - as opposed to silos - using a whole-person focus to help people be successful once home and eliminate any gaps that may occur. These continuums will play a vital role in building an effective framework for community-based population health.

With all the changes and fragmentation in healthcare, Augustana Care senior leadership believed a new, creative way to serve their customers was needed. Lifesprk's affinity-building whole person model fits well with the continuity and support Augustana Care wants to provide. The main goal of Thrive On @ Home is to help clients enjoy longer, fuller and healthier lifestyles following a discharge.

The partnership has afforded many learning opportunities that have strengthened our ability to work together to achieve common goals. In fact, Lifesprk was recently honored at Augustana Care's Annual Leadership Conference as the recipient of the honorable Tim Tucker Spirit of Collaboration Award for its vision and proactive guidance approach to keep people out of the hospital through the Thrive On @ Home program.

We know we have more work to do, of course. Ultimately, we want to see zero rehospitalizations within the first 30 days for as many people as possible. The partnership is an important step that is bringing us closer to this goal.

Lyn Lais, RN, is a Thrive On @ Home Life Care navigator.


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Guest Columns

Guest columns are written by long-term care industry experts, ranging from academics and thought leaders to administrators and CEOs.