New Strategies for Caring for Frail Elderly

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Military medics have been saving lives on the front lines globally in United States military engagements. Medics have performed emergency services meaning the difference between life and death for our soldiers. Their medical skills have been honed under stressful, wartime conditions.

These men and women are among the army of heroes who walk among us every day. However, when they return to the U.S., their certifications and credentials often don’t match civilian workforce requirements. Sadly, our nation’s health care system is not equipped to assist in transforming their skills, experience, and work ethic into appropriate non-military jobs.

Nathan Anspach, CEO of Phoenix-based John C. Lincoln Health Network’s Accountable Care Organization (ACO), saw these heroes as a new force, a Medicare health care corps. With their medical credentials intact, Anspach recognized that former military medics can be instrumental in helping design and implement strategies to help thousands of frail Medicare recipients manage their health care lives.  Anspach’s vision of employing this health care corps to stop the revolving door of hospital readmission for Medicare patients involved a three-pronged strategy:

First, focus on “preventable readmission” of the elderly who are discharged from hospitals. Monitoring vital signs and getting needed medications results in fewer costly readmissions to a hospital or ER.

Second, work with these patients to ensure they get services needed to maximize their independence. This will keep them out of nursing homes.

Finally, serve as personal health care advocates with the health care corps answering questions to help Medicare patients navigate the discharge process and beyond.

Anspach and his colleagues recognized that the future of heath care — Medicare in particular — is based on innovative solutions that treat and manage the care of elderly patients. This starts by helping Medicare patients understand instructions from their medical team, before moving on to manage their medications. Further, a seamless recovery includes daily intervention of a health care worker serving as the patient’s health care transition coach and external lifeline.

Lack of coordinated-care transitions leads to repeat ER or nursing home visits. Many of these fragile patients see multiple physicians, increasing the chance of medical errors, duplicated services, increased costs, and haphazard care.

The Lincoln ACO Plan has had an immediate and remarkable impact at John C. Lincoln.

Since the program was implemented in October 2012, 309 frail Medicare patients have been discharged and only 5 (or 1.62 percent year to date) have been readmitted. For this same time period last year, 64 (or 20.7 percent) people were readmitted.

Center for Medicare and Medicaid Services has published the tables on the three most frequent conditions for re-admit:

ConditionReadmission rates nationallyLincoln Plan
Heart failure24.7%<1%
Heart attack19.7%<1%
Pneumonia18.5%<1%

 

At a time when one in five Medicare beneficiaries discharged from the hospital is readmitted within 30 days costing an estimated $12-17 billion annually, the value proposition of the John C. Lincoln program is an extraordinary beginning.

 

 

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