Editor’s note: The John A. Hartford Foundation, Administration for Community Living (ACL), The SCAN Foundation, Gary and Mary West Foundation, Marin Community Foundation and Colorado Health Foundation have united to fund a three-year grant to develop and establish the Aging and Disability Business Institute (goo.gl/45uLBu), housed within the National Association of Area Agencies on Aging (n4a). Under the grant, ASA and n4a are collaborating on a series of articles and case studies in Aging Today that will help prepare, educate and support community-based organizations (CBO) and healthcare payers to provide quality care and services.
John Zabawa, who recently retired as president and CEO of Seniors’ Resource Center (SRC) in Denver, Colo., and Grant Wicklund, president and CEO of Lutheran Medical Center (Lutheran), in the Denver suburb of Wheat Ridge, Colo., speak to one another like respectful longtime friends. This may be a particular and happy outcome that can occur when two organizations form a successful, lasting partnership—one that benefits older adults as they return to the community.
SRC sought a pilot partnership with Lutheran to help older adults with chronic heart failure make a safe and successful transition to home, and to avoid hospital readmissions. The pilot yielded “A Perfect Homecoming,” a program that came about in 2015 through SRC’s participation in the Colorado Linkage Lab, and formally launched in 2017. A Perfect Homecoming’s three goals are to improve overall quality of life; reduce the risk of hospital readmissions; and provide cost-savings to the community.
The SRC, which has functioned as a home- and community-based service provider since 1978, was envisioned originally as a one-stop shop, offering a wide variety of programs and services to a 10-county area throughout the Denver metro region and surrounding rural communities. In 2016, SRC served 21,800 older adults and employed 280 full- and part-time staff.
Lutheran has been “entrenched” in the greater Denver area for 100 years, Wicklund says, and older adults have long been its focus. The hospital housed the first emergency room dedicated to older adults west of the Mississippi in 2011. Lutheran signed onto A Perfect Homecoming because “John came up with this simple, innovative idea that can have an effect on people’s lives in an optimal environment to heal—their home. It gives seniors a sense of safety and independence, which they wouldn’t have in a nursing home,” says Wicklund.
“Lutheran is truly mission driven,” says Zabawa. “Decisions are not based solely on the bottom line, but on recognizing what’s the right thing to do. Grant has stated that this is the right thing to do—to support an older adult once they leave the hospital and transition home, and to provide the support necessary to allow them to stabilize and heal in the community.”
The Genesis of a Trusted Partnership
The SRC-Lutheran partnership goes back 30 years, during which SRC has helped manage volunteers for Lutheran, provided transportation services to and from the medical center and expedited referrals to adult day services housed on the SRC campus.
Although the exact origin of their partnership is “lost in time,” as Wicklund says, “John and I see each other regularly, our care management people and those at SRC talk often and we always have someone from Lutheran on John’s board. [SRC’s] expertise and level of energy is second to none,” Wicklund says, “there really aren’t any like organizations—it’s a community jewel.”
Lutheran and SRC are geographically located within Colorado’s largest geriatric population, and many in this cohort have been diagnosed with chronic heart failure. When it started, A Perfect Homecoming made several attempts at meeting various populations’ needs. Initially, the partners tried working with Medicare beneficiaries recovering from elective compound joint surgery, but ran into program restrictions from the Centers for Medicare & Medicaid Services.
Then SRC and Lutheran shifted gears, zeroing in on serving older adults with chronic heart failure and putting together their current comprehensive service package. The partnership has since delivered steady positive outcomes, reducing readmissions.
A “Perfect” Structure
The SRC staff begins the program with an in-hospital care management assessment, working with onsite Lutheran case managers. They provide transportation home, follow-up trips to the pharmacy and to medical appointments, and deliver three day’s worth of frozen meals. Once home, SRC care managers formulate a game plan, which includes offering in-home care to support recovery, light housekeeping and laundry services, changing bed linens
The program has two plans: Silver, which provides comprehensive services for 30 days, and Gold, which extends those services to 90 days. The original objective, beyond ensuring successful transitions into the community with a high quality of life, was to prevent 30-day readmissions to the hospital. To date, Zabawa reports that of the nearly 30 transitions that have been managed thus far in the pilot, all but one was successful, with that exception being for a person with multiple, unrelated health complications.
Lutheran also is open to using A Perfect Homecoming in other situations.
“[Lutheran’s] care management people have the option of doing this for anyone, and they have taken care of people who don’t have congestive heart failure or chronic heart failure … we believe that when possible, recuperation from a hospital stay is best done at home,” says Wicklund.
“That may mean clinical homecare and, if so, we have a homecare company that provides that. And if [patients] have been in a skilled nursing facility but could [use] SRC and be at home, we’ll try to do that every time,” Wicklund adds.
A Perfect Homecoming is paid for by the medical center, at no cost to the older adult, through the Lutheran Medical Center Foundation funding. SRC also has received funding from the Colorado Health Foundation and the Community First Foundation to build the program’s infrastructure, to collect data and to institute a system model that is replicable in other settings.
Challenges of Care Management
The program has experienced some snags, which generally have to do with a breakdown in communication at the time of transition. “One gentleman refused to allow the care manager into his home,” says Zabawa. “So she met him outside, began to converse with him and over time built that trust—it’s all about relationship-building, feeling safe, trusting the individual and not passing judgment.”
After allowing the care manager into his home, he accepted support to talk through his reticence and let other SRC staff perform in-home services. He also embraced the proposed treatment plan, even lowering his tobacco use.
Others have been homeless, some living in their cars, which presents another difficult situation for care managers, who then must make the best of the limited tools at their disposal to meet the needs of the older adult and engage with and support them in the best possible ways.
Wicklund reiterates that this unique partnership is simply the right thing to do. “Our 30-day return rate was already low,” he says, “so while the program helps with that, the program exists because it’s the right thing to do. We know the people who live around us—personally. This is a low-cost program that raises our quality of care because it extends caring past the hospital walls.”
Continuous Communication Is Key
Perhaps mirroring the way conversation flows between the partners, Wicklund says the key to the collaborative process has been continuous communication.
Zabawa had the germ of the idea, ran it by his people, then by Wicklund, asking if he’d commit to financing the program. Wicklund agreed and arranged a funding mechanism through the Lutheran Medical Center Foundation.
“After that, it was constant communication, collaboration, a presumption of positive intent and the sharing of a trust relationship. We both know the other [organization] is in existence to serve, and … even if we have partial failures, we can still sit in a room and instead of throwing rocks at each other, we fix it,” says Wicklund.
Zabawa echoes the idea that Lutheran is an optimal partner because it is focused on its mission and doing the right thing for the right reasons. “We are committed to positive outcomes, an increase in overall satisfaction and being successful in keeping the older adult home,” he says.
He also stresses the importance of flexibility throughout the collaboration process. “Unfortunately, lots of hospitals may not have the same values and perspective [as Lutheran],” says Zabawa. “At the end of the day, it’s really about relationships and trust.”
Editor’s Note: This article appears in the November/December, 2017, issue of Aging Today, ASA’s bi-monthly newspaper covering issues in aging research, practice and policy nationwide. ASA members receive Aging Today as a member benefit; non-members may purchase subscriptions at our online store.