By Dr. Kyle Allen and Susan Hazelett
The Summa Health System/Area Agency on Aging, 10B/Geriatric Evaluation Project(SAGE) is a collaboration between an integrated health system and the local Area Agency on Aging which was begun in 1995. SAGE provided the organizational structure to develop the resources and processes needed to effectively integrate geriatric medical services and community-based long-term care services. Such integration is essential to bridging gaps between acute medical care and community-based care, enabling medical and social services providers to reach frail older adults living in the community with multiple chronic conditions, and to improve their quality of life. The SAGE project, which operates in the Akron, Ohio, metropolitan area, has managed to do just that. Results of the 17-year collaborative indicate that consumers, health care systems, health care providers, and payers have all benefited from the focus on integrating service delivery.
In the early 1990s, Summa Health System (SHS), an integrated not-for-profit health delivery system, had launched several projects aimed at improving care for frail elders. Summa comprises six community teaching hospitals with more than 2000 beds, as well as its own health plan, skilled home care, hospice, and a foundation. Summa’s insurance plan has 150,000 covered lives, including a Medicare Advantage Plan of 23,000.One of the projects being tested at Summa was the ACE (Acute Care for Elders) model, a model of hospital care delivery aimed at improving the functional status and clinical outcomes for hospitalized older adults. Recognizing that this model did not have the necessary patient connection in the outpatient setting, Summa realized it would need to expand its reach to elderly patients across the continuum of care. To this end, it created the Center for Senior Health (CSH), an outpatient consultative service that supports primary care providers by offering an interdisciplinary, comprehensive geriatric assessment; high-risk assessment; a geriatrics resource center; a clinical teaching center; inpatient geriatric consultation and outpatient consultation followup. The CSH attempts to treat and reach the whole patient by addressing acute and chronic medical needs, psychosocial needs, and family concerns. Despite the range of services provided, the CSH continued to be limited in its scope because it did not have access to patients in their homes, nor could it provide long-term case management. As a result, it began to rely increasingly on community-based long-term care agencies for this kind of information and management.
At about the same time, the Area Agency on Aging 10B, Inc. (AAA) found itself managing a growing number of consumers with functional decline, geriatric syndromes, and multiple chronic illnesses. The AAA, which serves more than 20,000 elders in Northeast Ohio, recognized that it needed to be better integrated with the acute medical sector if it were to achieve its goal of delaying and preventing nursing home admissions.
Leaders from Summa Health and the AAA recognized the challenges and deficits each one faced in providing continuity of care to patients/consumers, and began meeting to discuss how they could build a new, integrated model of care. They realized that they shared a common goal and vision to improve care for frail elders, and launched SAGE, which provided the organizational structure needed to effectively integrate their services. SAGE had no grants or funding, just a spirit of collaboration and cooperation, and a common desire to do more than just business as usual.
A SAGE task force was created comprised of staff from both organizations, including physicians, nurses, and social workers, as well as senior leaders, to promote communication, provide feedback, and create initiatives that linked the two. The group met monthly for two years, and now meets quarterly. Among its early objectives were the development of protocols to screen and identify at-risk older adults, to establish mechanisms for information sharing and resources, to identify gaps and duplication in service delivery, to locate a AAA case manager at the CSH, to educate staff from both organizations, to collect data and information, and to identify and address barriers to implementation.
Eventually SAGE created an RN care manager assessor program, in which placed an AAA assessor in the acute care hospital. The assessor works closely with the ACE team to identify hospitalized patients who can benefit from community-based programs, as well as patients who are eligible for PASSPORT, the state’s Medicaid waiver program. This was a new initiative for the AAA, which had traditionally conducted these assessments post-discharge, in the patient’s home. That assessment now occurs before the patient is even discharged from the hospital, thus helping to determine needs for community based services and facilitating the process for eligibility and approval for Medicaid long term care benefits. This is beneficial because patients will typically receive Medicare covered services for skilled needs but long term care needs are not addressed as well and the Medicare skilled benefits are provided for only a limited time usually < 30 days. Without the other supports this vulnerable population is at risk for poor health care access, emergency department visits and hospital readmission. The AAA then assumes case management for the consumer, and offers periodic geriatric follow-up.
This program has facilitated improved capacity management for complex patients in the acute care hospital. It improved AAA communication with primary care and hospital staff, reducing repeat hospitalizations, ED visits, and nursing home placements. It improved outcomes for complex patients, and decreased discharges from PASSPORT to nursing homes. During the pilot period, referrals to and enrollments in the PASSPORT program doubled. The AAA was also successful in replicating this model at other hospital systems in the Northeastern Ohio AAA service area. A more recent positive outcome related to this collaboration work was the awarding for AAA 10b Inc. one of the first seven Community Based Care Transitions projects from CMS/CMMI as part of the The Community-based Care Transitions Program (CCTP), created by Section 3026 of the Patient Protection and Affordable Care Act
In developing SAGE, several barriers had to be overcome, primarily those affecting leadership of the program, development of an effective multidisciplinary workgroup, and resources (in terms of staff time). The program can be adapted by other communities around the country, offering their acute medical system and community-based programs a way to align their services and collaborate in ways that better address the needs of frail older adults.
Key words: community collaboration, SAGE Project, ACE Units, CCTP, 3026, pilot programs