Program reduces hospital visits for seniors
Tandem365 nurses, social workers give high-need patients specialized care to prevent emergency room trips.
A local home-based health management program created by five senior and medical service companies has significantly reduced hospital visits for its high-need patients.
According to recent statistics, Tandem365 has reduced its more than 1,000 patients’ emergency room visits by 52 percent and their average cost of health care by 35 percent since its inception in 2014. Inpatient visits are down 38 percent, and specialty visits are down 46 percent.
That’s because Tandem365 acts as a “safety net” to its patients, who are all adults ages 55 and older who have complex medical needs and live in their home, according to CEO Teresa Toland.
The program began in 2014 after the partnering organizations — Life EMS Ambulance, Clark Retirement Communities, Holland Home, Porter Hills, and Sunset Retirement Communities and Services — decided to tackle ongoing communication problems and lack of support that forced at-risk seniors to return to the hospital with preventive issues.
The discussion began when St. Mary’s Hospital leadership reached out to the four retirement communities that now are Tandem365 partners. The hospital was on the verge of being fined because of high readmission rates.
Toland said leadership from St. Mary’s and the four retirement communities reluctantly came together to discuss their issues and find a solution. After weeks of meetings, they came to a common conclusion.
“At the end of the day … we realized we all had the same issues,” Toland said. “The communication streams were bad. We were getting incomplete information on patients.”
She said that conclusion was the “very first step in this journey” toward creating Tandem365. And 18 months into the program, Toland said St. Mary’s readmission rates decreased from 22 percent to 4 percent.
The main issue was these at-risk patients had little support and no ongoing plan that kept them out of the hospital, she said. Often, communications about medical issues and history were dropped between paramedics, hospitals, specialists and other medical professionals. Navigating these day-to-day issues can be daunting for many of the patients. As Toland said, Tandem365’s main purpose is to “connect the dots” and keep patients from landing back in the hospital.
“Generally, if you don’t have somebody in your family who knows how to traverse the system, it’s challenging if you have complex needs,” said Laura Kasperski, one of 10 registered nurse navigators who work for Tandem365.
The navigators each have a caseload of the nearly 600 patients. The patients are in continuous contact with their assigned nurse, and they begin the program in communication with a social worker.
The nurses receive patients’ phone calls and coordinate medical needs, but sometimes, nonmedical issues need to be addressed to prevent medical ones. And that’s where social workers come in.
There is more than 200 years of medical experience among Tandem365’s leadership, and they know the importance of addressing all those issues.
“Those kinds of connections that may have nothing to do with traditional health care, but those of us who have been doing this for a long time know are critical to a patient’s success,” said Mark Meijer, president of Life EMS Ambulance.
One of Kasperski’s patients, Grand Rapids resident Ken Sanford, 72, is unable to drive to his kidney dialysis appointments three times per week. So, his social worker coordinated transportation through GO!Bus, an Americans with Disabilities Act paratransit service through The Rapid bus system, a service Sanford didn’t know existed.
“They already have the answers for what your needs are,” Sanford said. “I’m blessed to have them.”
Sanford recently was given a pacemaker, and he said no one had a chance to look at a toe injury that occurred among the busyness of that procedure. When Kasperski saw the injury, he said she immediately arranged a visit for someone to take care of it.
“There’s a lot of times when we know we’ve prevented them from going to the hospital or going to the emergency room because we were able to get to them soon enough or solve their problem before it became a crisis,” she said.
Each patient has an individualized plan of services that can include in-home support and health management, transportation, respite care, home delivered and cooked meals, primary care and specialist physicians, behavioral health, rehabilitation, grocery shopping and socialization. The navigators work with the patients to create the best plan for them.
“We get to know them very well. We get to know their needs and their family life and what their home is like,” Kasperski said. “I find the longer they know me and the more they trust me, the more they’ll reveal and the more in-depth we can work in different areas that they’re struggling in.”
Kasperski and the other nurses also are important in keeping patients out of the emergency room. Rather than being forced to call 911 even when an issue may not be urgent or life-threatening, patients can call Tandem365 any time of the day. The nurses already have their records on file, and they work with the patients to solve the issue, only calling paramedics contracted through Tandem365 if necessary; this way, everyone involved knows the patients’ medical history, and potential lack of communication is avoided. In the end, it saves the patients money and relieves some burden on the health care system.
Each month, the RN navigators review their patients’ cases and ensure they’re being cared for effectively. Every morning, the team reviews calls made the night before and considers whether those patients need more care.
From the beginning, Meijer said the founders’ purpose wasn’t to streamline patients to their own services. The goal is to work with patients to meet their needs. Their current physicians and medical professionals are not replaced, but Tandem365 can assist patients in accessing those services.
“Our default is always in the patient’s best interest,” Meijer said.
The services are covered and available only for Priority Health patients, but there will be an option to register directly with Tandem365 early next year. The service is for adults ages 55 and older who have serious medical needs and live in their homes.
The standard monthly package of $350 includes two complimentary visits, phone calls, physician coordination, six-month reassessment, comprehensive care management, 24-hour emergency service, service coordination and advance care planning. The monthly $450 package includes the standard services, plus up to two monthly medication setups. Another main objective is for each patient to have an advance directive, which documents their medical wishes should they become unable to make decisions on their own.
Toland said some patients require a lot of care and some not as much, but they all want to be safe and comfortable in their homes.
“Some people don’t need a lot, but what they need is someone to call, and they need someone they can count on being there,” she said.
The program is available for those in Kent, Ottawa, Allegan, and Kalamazoo counties.