By Steve Syre
LTSS Center researchers tracked the impact of Hebrew SeniorLife’s R3 program.
A demonstration program providing enhanced services in affordable senior housing to about 400 older adults in greater Boston had a positive impact on key health care utilization measures, according to a new study conducted by researchers at the LeadingAge LTSS Center @UMass Boston.
Researchers studied the impact of Hebrew SeniorLife’s Right Care, Right Place, Right Time initiative—known as R3—on older adults living in multiple senior communities over an 18-month period, and compared results with the experience of older adults in similar buildings who did not receive the R3 intervention.
“There were statistically significant changes in health care utilization over that period that we believe can be attributed to the program, the so-called R3 effect,” said Marc Cohen, co-director of the LTSS Center.
HOW THE R3 PROGRAM WORKS
The goal of the R3 program is to create a replicable, scalable, and sustainable model of housing with supportive services to enable older adults to live independently with a high quality of life for as long as possible.
A key aim of the intervention was also to lower health care spending by reducing unnecessary hospital, emergency department, and nursing home utilization.
The main components of the demonstration program were 2 on-site wellness teams, spread across the 7 buildings, consisting of a wellness coordinator and a nurse. The teams either added services where few were in place or enriched an existing package of supportive housing services.
Based on promising early results, the program was extended for a second phase that began early in 2019.
HOW THE R3 STUDY ANALYZED RESULTS
Cohen and a team of researchers compared the health care utilization of residents living in the R3 intervention sites with the same group’s health care activity during the previous 18 months. They also compared the R3 group’s health care utilization with the experience of more than 9,000 residents in 3 control groups not receiving the intervention.
Data collection limitations required researchers to measure health care utilization of all residents at the buildings where intervention group members lived. However, about two-thirds of those residents did not participate in the intervention.
Cohen said the study’s design—measuring all 1,200 residents living in the buildings rather than only those who engaged or participated—led the analysis to be quite conservative.
“While we were able to avoid the selection bias that arises by analyzing only members who agreed to participate, the design makes it more difficult to find statistically significant differences in results, when they exist,” he said.
HOW R3 IMPACTED HEALTH CARE UTILIZATION
The age-controlled analysis suggested rates of hospital admission, emergency department admissions, and hospital readmission were positively affected by the program and tended to grow more slowly compared with control groups.
Though actual utilization rates for many services increased over the time period, researchers said the key findings were based on how differences in rates between the intervention and control groups changed over periods before and after the implementation of R3.
The analysis found particular improvement when measuring overall hospital admission rates and emergency department utilization. However, it also found a growing difference in outpatient overnight hospital observations, reflecting an increase among R3 residents compared with control group members.
“That suggests R3 participants are less likely to utilize the emergency departments for care but instead go through a standard hospital admission for observation purposes,” said Cohen. “This is not unexpected, given the objectives of the program.”
Being in the intervention group was associated with a 19.3% smaller difference compared to control groups when hospital admissions were measured for the 18-month period.
Emergency department utilization among residents of intervention group buildings declined modestly, while rates increased among each of the 3 control groups during the period.
The difference between intervention and control groups in overnight hospital observations increased by 10.2% during the period.
REDUCING AMBULANCE USAGE
An analysis of ambulance transfers to emergency departments from buildings where the intervention groups lived showed an 18.2% decline in the monthly rate during the measured period. Declines in the control groups over the same period were not statistically meaningful.
“We also found that declines were greater in buildings that had lower service levels prior to R3 implementation, compared to buildings that had more robust service offerings,” said LTSS Center Fellow Pamela Nadash, an associate professor of gerontology at UMass Boston who worked on the project.
THE RESIDENT PERSPECTIVE
The LTSS Center research team also conducted focus group interviews with intervention participants to gauge their overall satisfaction and solicit ideas for improving the R3 program.
Most focus group participants said the R3 program was a good source of information, helping them identify and arrange available services and supports. Beyond day-to-day health advice, monitoring, and assistance, participants also said they appreciated more subtle supports, such as having someone to talk to and feeling cared about.
The interviews highlighted the need for clarity regarding the purpose of such programs, their components, and staffing. Residents also stressed the importance of building relationships between program staff and residents, as well as addressing concerns about privacy and confidentiality.
“Understanding the resident experience is a critical step to creating a sustainable and replicable model of affordable resident-centered housing with supportive services programs,” said LTSS Center Fellow Edward Miller, a gerontology professor at UMass Boston and a researcher on the project.