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Elder Care Advocate Program in Jacksonville Product of Partnering

As Dorothy recited in Oz, "There's no place like home." Certainly in the case of a hospital stay the best part is going home, but sometimes that transition is anything but smooth. For some older adult patients, a hospital stay may be extended only because arrangements for long-term care aren't in place or because services to ensure the senior's well-being at home haven't been arranged. Worse yet, some vulnerable elderly patients, discharged without a thorough follow-up plan, find themselves returning to the hospital rapidly because those unmet needs have caused a crisis. Poor pre-discharge assessment, lack of communication and thinly stretched services all contribute to this malfunctioning system.

In the Jacksonville, Florida area, however, where the population of older adults is burgeoning, that system is now much smoother, thanks to BECN (Bridging Elder Care Networks), a community partnership that grew out of Life: Act 2, which is a United Way of North East Florida aging initiative. Comprised of 35 member organizations, BECN became a Community Partnerships For Older Adults grantee in 2006. BECN is committed to improving at-risk elders' access to health, information and support systems and to better educating everyone—health care providers, community-based service providers, and the public—about the unique needs of this population. Last year BECN achieved one of its major goals, creation of an Advocacy and Transitional Care Management (ATCM) Program that places full-time elder advocates on staff in hospitals. Already implemented in two major hospitals, two more hope to add the program.

The Jacksonville ATCM Program is itself a partnership, in which at-risk, older adult patients—together with their caregivers and elder care advocates (staff and volunteers)—communicate with hospital personnel, community-based service providers and longterm care facilities in advance of discharge. Post-discharge needs are anticipated more effectively, and connections with necessary services are arranged efficiently, thus reducing unnecessarily long hospital stays and rapid readmissions. The program has the distinction of being the first of its kind in this country, and it is helping to shift the perception of hospitals as reactive, acute-care facilities where people are treated and then “cut loose,” to health care settings that are serving patient needs for the long term.

Problems with the hospital-to-home process aren't new, and they certainly aren't unique to Jacksonville. A 2002 review of 94 nursing reports on transitional care, published in the Annual Review of Nursing Research, noted, “ A high proportion of elders and their caregivers report substantial unmet transitional care needs, with the need for information and increased access to services consistently among the top priorities.” And a 2005 study by the School of Public Health at University of California, Berkeley found that in the San Francisco Bay area “At least one-third of patients and caregivers have substantial unmet needs and high levels of dissatisfaction with the transition process; hospital staff do not adequately support and prepare families technically and emotionally for home care.”

To tackle a problem of this magnitude, accurate information and a broad range of input are critical.  In Jacksonville, BECN, say those involved, brought everyone and everything to the table from the start and invested the necessary time. Over an 18-month period hundreds of stakeholders—older adults, hospital leaders, long-term care providers, community-based service providers and community leaders—met in various forums to target needs, assess resources, and discover solutions, utilizing their own information as well as that from a major demographic study of at-risk, older adults in the five-county region. A consensus regarding critical needs emerged, including improving access to community resources; reducing unnecessarily long hospital stays; and reducing post-discharge difficulties and rapid hospital readmissions. Simultaneously, these forums were at work on solutions.

An effective partnership creates an environment where individual members can safely assess their operating systems. In the Jacksonville partnership, participating hospitals were willing to conduct self-assessments about how elder friendly their facilities and services to at-risk older adults were. But BECN had been coalescing for many months, and solutions, including the Elder Care Advocate Program, were already in the planning stages. Consequently, major systemic changes—shifts in thinking and in ways of doing business— were able to proceed in a thoughtful fashion and from within (including hospitals deciding to set up their own task forces on elderly care), not as measures imposed by state or federal bodies.

Becky Gay, a vice-president with Blue Cross and Blue Shield and chairperson of BECN, stresses the importance of early partnering with key stakeholders. Says Gay, “Because of the relationships established, we have been able to 'learn' with our health systems about ways that we could better assist seniors.” She continues, “Because we approached our health system friends and asked for their expertise, experience and advice early on in the Development Grant phase, we were better positioned to design a pilot project. They [participating health systems] essentially identified a problem we could work on together.”

BECN's overall mission is to advance everyone's understanding of the needs of at-risk, older adults and the services available to them, and the journey to that goal is well underway. Nearly 50,000 “Quick Reference Cards for Seniors” have been distributed over a five-county area to local businesses, grocery stores, libraries, senior centers, and physicians' practices, and print ads, TV and radio spots around the five-county region are increasing the public's awareness of the many available services.

Additionally, efforts to better educate those who work directly with at-risk older patients in health care settings are underway. Twenty BECN members, including health clinics and hospitals, have met and expressed interest in sharing one another's training opportunities. Noted Mark LeMaire, Director of Life: Act 2 and BECN, “We had a productive, informative discussion and gathered valuable information about the current landscape of geriatric education within the medical community….and have taken an important step to identify gaps and potential collaboration opportunities.”

All parties benefit in a successful partnership. In its first year, Jacksonville's Advocacy and Transitional Care Management Program has assisted over 400 older at-risk adults. Ninety three per cent of those patients said they were connected to services they would not have received without the Elder Advocate. The hospitals involved in the partnership are reaping benefits in so many ways: Fewer patients stays are being extended and although readmission rates have fluctuated from month to month due to chronic illnesses of this at-risk population, preliminary monthly data has shown approximately 85% of patients assisted by the Elder Care Advocate did not return to the hospital within 30 days, enough so that the hospitals are already seeing the community benefit, as well as possible savings and are planning to pick up the cost of the elder advocate program themselves. Hospital staff are becoming more knowledgeable about the unique needs of their at-risk older adult patients. Community-based service providers benefit, too. Early contact from the Elder Care Advocates often gives an agency an opportunity to more effectively plan and direct valuable resources. Giving an example, LeMaire explains, “Sometimes the community organizations are not even aware of a hospitalization, so we are able to see to it that meals, for example, are not delivered needlessly, thus saving on resources until the elder returns home.”

It is through the stories of the most vulnerable seniors themselves that the value of community partnering becomes truly tangible. LeMaire described one situation in Jacksonville, where an older hospital patient about to be discharged was facing seemingly insurmountable challenges: a limited income, more exhausting chemotherapy treatments and parenting responsibilities for a grandchild. But through the hospital's new strategy—the Elder Care Advocate and a team of volunteers— the patient was efficiently connected to state and community services that would provide food stamps, home-delivered meals, personal care and even babysitting assistance. Additionally, the patient and grandchild were referred to the 'Be A Santa To A Senior' program and adopted' by a local church that provided food and gifts for the holidays. “This,” concluded LeMaire, “is definitely community collaboration between health and community services.”