Proactive Collaboration Bridges Senior Care Gaps, Reduces ER Visits

Identifying care gaps and bridging them through a care collaboration has helped one nonprofit senior living organization reduce the number of emergency room visits and rehospitalizations among its residents to a nearby hospital.

Hospitals are more conscious than ever of the need to provide quality care and prevent readmissions now that Medicare is docking reimbursements for rehospitalizations above a certain threshold. One route they’re taking to improve quality and reduce readmissions—and costs—is partnering with other care providers along the continuum.

In recent months, Presbyterian Senior living realized many residents from its Harrisburg, Pa. location, Presbyterian Apartments, were using the nearby PinnacleHealth emergency department as their primary care provider.


Accessibility to primary care is a big challenge, says Barbara Terry, vice president for Mission Effectiveness and Chief Diversity Officer at PinnacleHealth, as local public transportation isn’t a viable option for many of the frail elderly, especially those with cognitive issues.

Doctors appointments were turning into 4-6 hour excursions by the time Presbyterian Apartments residents were picked up, had the appointment, and were brought back. “It’s exhausting, it’s difficult, and they would miss meals and medication from being away for so long,” she says.

Residents would also often encounter problems getting follow-up care, or properly following discharge orders from physicians—contributing factors to rehospitalizations.


“The hospital is within walking distance of Presbyterian Apartments, and when you have transportation and care access issues, naturally what’s going to happen is [residents] are going to walk down to the emergency room,” explains Diane Burfeindt, vice president of operations/housing with services at Presbyterian Senior Living. “We were trying to find ways for them to use the ER for true emergencies, not for primary care.”

The senior living organization had already been working with PinnacleHealth for some time in a variety of initiatives involving senior care, including the establishment of a diabetes management program. Through that program, PinnacleHealth worked with Presbyterian Apartments residents to increase their knowledge and understanding about diabetes and its potential risks.

Building on that, the two providers collaborated to develop a new initiative to serve residents, resulting in a community health team consisting of a medical internist, medical assistant, and health navigator from PinnacleHealth, and a service coordinator from Presbyterian Apartments.

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The health navigators function as a primary point-of-contact for medical care. When Presbyterian Apartments residents are admitted to PinnacleHealth’s emergency department, their information is communicated to the navigator who will then schedule a follow-up appointment within 24 hours to make sure their post-discharge needs are being met. The care team works with residents to provide additional support, discuss discharge instructions, and clarify concerns.

If, for example, a resident ends up in the ER for a fall, the care team assesses that resident’s needs to find out the cause of the fall and work to prevent it from happening again. Navigators also work with residents who are diagnosed with some sort of condition, whether short-term or chronic, to make sure they understand their diagnosis and can access necessary information.

The team’s goals were to reduce the number of visits to PinnacleHealth’s emergency department and the number of rehospitalizations within 30 days of discharge; improve access to primary care and any associated follow-up care; and reduce the number of resident falls, says Terry.

So far, the initiative appears to be working.

“We’re definitely seeing a downward trend in emergency room visits and hospitalizations,” says Burfeindt. “We’ve seen greater coordination among all care providers involved.”

Medication management had been identified as the number one issue causing issues with residents being able to maintain good health, she says, because many don’t understand all the combined effects of the multiple medications they may be taking. “Physicians were noticing this was a trend with our residents, who are now being helped to navigate the health system instead of trying to figure it out themselves,” she says. “I think that will prove itself to be significant.”

Results from the collaboration may be similar to the diabetes management program, Terry believes, which saw the number of emergency department visits by those enrolled in the program drop “pretty significantly,” she says. “We’ve been able to reduce the number of people going to the emergency department, because our medical internist and navigator are going each week to visit patients [at Presbyterian Apartments].”

It’s a proactive approach, she says, because the care team can identify potential issues by visiting with residents on a weekly basis and assessing their needs so they don’t end up in the ER.

“Just because they’re older doesn’t mean you can’t apply preventive measures,” Terry says. “Our goal is to keep them healthy and well, and help them age in place safely and in a healthy way.”

Written by Alyssa Gerace

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