By Geralyn Magan
Service coordinators at National Church Residences sip tea and chat on front porches while connecting rural elders with home-based services.
When a service coordinator from National Church Residences arrived recently at a private home in rural Ohio, she was greeted on the front porch by an older man bearing 2 cups of tea.
The gentleman, who had just come home from one of his many hospitalizations for chronic obstructive pulmonary disease (COPD), did not invite the service coordinator into his house. Instead, the two sat on his front porch, sipping the tea and getting to know one another. After an hour, the gentleman asked the service coordinator to return the next day.
The service coordinator, who works in National Church Residences’ Home for Life program, and the older man, who is a patient of Adena Health System in Chillicothe, OH, followed the same routine for several days. The service coordinator returned, tea was offered, and an informal conversation took place.
During the third visit, however, the man finally invited the service coordinator inside. There, she discovered that, in addition to managing his own chronic condition, the gentleman was serving as primary caregiver for his wife, who lives with dementia.
“During those afternoons on the porch, they had formed enough of a trusting relationship that he felt comfortable letting her inside,” says Terry Allton Spitznagel, senior vice president of home and community services at National Church Residences, a LeadingAge member based in Columbus, OH. “He didn’t want anybody in that house because he was worried that they would take his wife away.”
The service coordinator didn’t skip a beat before assuring her new friend that she could arrange in-home services to help both him and his wife maintain their health and independence. Those services included a homemaker to keep their house in order, a home care agency to meet their personal care needs, home-delivered oxygen to help prevent an expensive COPD-related emergency room (ER) visit, Meals on Wheels for enhanced nutrition, and other services as needed.
“He didn’t know how to access any of these services,” says Spitznagel, who received the 2018 Robert Wood Johnson Foundation (RWJF) Award for Health Equity, presented by LeadingAge. The award acknowledged the role Spitznagel plays, as leader of the Home for Life initiative, in advancing RWJF’s primary goal to ensure that all Americans can lead healthy lives and achieve overall well-being, regardless of their location or socioeconomic background.
“When you think about health equity, it is about access to services that so many folks don’t even know exist,” says Spitznagel. “We recognized that these seniors in southern Ohio were using the ER and the hospital for their primary care because they literally felt they had no other choice. They just didn’t know. The solution is not about giving people more health care providers. The solution is about sending someone out to address why it is so hard for seniors to manage and navigate their health care. That is all we do.”
HOME FOR LIFE: A LIFELINE FOR RURAL ELDERS
National Church Residences understands the powerful role that service coordinators can play in helping older adults manage chronic conditions so they can remain healthy and independent while saving health care dollars. The organization has employed service coordinators—now numbering 400—in its affordable senior housing communities for almost 2 decades.
Twelve additional service coordinators now work through the Home for Life program to provide non-clinical care coordination to older adults, many of whom are homeowners living in the state’s poorest and most isolated areas.
Home for Life provides service coordination in partnership with a variety of local organizations, including 3 fire departments that refer their most frequent 911 callers to the program, and an insurance company that uses the program to improve health outcomes for beneficiaries who are dually eligible for Medicare and Medicaid.
The most impressive intervention to date involves the partnership with Adena Health System, an Accountable Care Organization (ACO) located about 50 miles south of Columbus. Home for Life service coordinators, like the one who sipped tea on the front porch, work with the ACO’s highest risk, highest cost patients: 100 individuals living with COPD.
During the first year of the intervention, the service coordination program saved the health system $874,000, and lowered rehospitalization rates among its COPD patients from 33% to 14%. In addition, customer satisfaction soared because, says Spitznagel, “the patients said, ‘Finally you cared enough about me. When I got home from the hospital, it wasn’t a phone call just checking in, it was literally somebody coming to my home.’”
4 PROGRAM COMPONENTS
Spitznagel says the success of the Home for Life program is rooted in its 4 core components:
- An enhanced service coordinator: Service coordinators receive training in motivational interviewing and exceptional caring that enhances their ability to connect with individuals, says Spitznagel. “Face-to-face is where the relationship happens,” she says. “Without that face-to-face relationship, it’s hard for seniors to comply with their care plans.”
- A management tool for assessing and meeting needs: Home for Life service coordinators use a Care Guide tool to assess individuals and identify and address the social determinants that may be preventing them from complying with a physician’s care plans. “Once those assessments are done, a score comes up, and the Care Guide recommends interventions,” says Spitznagel. “That helps the service coordinator decide what steps to take, how often to monitor the person, how to intervene, what kind of services to connect them to.”
- A partnership with a preferred provider: The Home for Life program always works with a local “preferred provider,” which is usually a home care company or a physician’s office group. The provider agrees to assist the service coordinator when necessary. “Service coordinators may get to a place where they are uncomfortable with what they are witnessing and they are not sure what to do,” says Spitznagel. “That’s when the preferred provider sends over a nurse at no charge to provide guidance on how to proceed.”
- A focus on the social determinants of health: Service coordinators spend a good deal of time trying to identify how social determinants—including income, housing, and access to food, transportation, health care, and social supports—may impact the health of older adults. Socialization programs organized by National Church Residences also help to improve health and well-being, says Spitznagel, “because social isolation is one of the key barriers to improving health.”
ALL YOU NEED IS LOVE
Maintaining these 4 components across settings, and supporting service coordinators through every step, has helped the Home for Life program make inroads in communities throughout Ohio. Spitznagel acknowledges that finding a sustainable funding mechanism would help ensure the program’s long-term success. She’s currently working with payers in the state to lay the foundation for that funding, with help from the outcomes data the program has been able to collect through the Care Guide tool.
But, in the meantime, Spitznagel points to the story of the service coordinator on the rural front porch to illustrate the key ingredient of the Home for Life program.
“If you really are interested in helping older adults comply with care plans and promote good health outcomes, you need engagement and relationship-building, and a whole lot of love,” she says. “That might sound mushy, but I don’t care. If we had walked into that home and just flipped open a laptop and starting punching in data, rather than sipping tea for a couple of days on the front porch, we would not have been successful.”