The care needed and provided for seniors today is vast. Known as long-term care, it encompasses services like assisted living, home care, post-acute care, skilled nursing and memory care. According to the National Institute of Aging, “[t]he need for long-term care can arise suddenly, such as after a heart attack or stroke. Most often, however, it develops gradually, as people get older and frailer or as an illness or disability gets worse.”
When a family member is new to the caregiving role for a parent or loved one, it’s often overwhelming to ensure that they receive all of the care they need. For both the caregiver and the senior, this switch in roles and reality can be confusing and scary. With a slow progression, the caregiver has the time to learn about all of the options offered in caring for their loved one. Whether they need to start with home care or assisted living, they are able to work with their doctor to make educated decisions. However, when it happens quickly, the decision becomes more challenging.
Frequently advancement from one level of care to another for people with chronic conditions and complex health care needs happens over time. For other families, it can be a sudden traumatic event. Often this means that a family is transitioning from one health care facility to another which can cause transfer trauma for the patient. Thankfully, the health care industry continues to grow in its offerings to ensure the wellbeing for seniors. A focus on a continuum of care, including population health has become essential after a hospital admission or a change in condition.
But what does continuum of care mean and what is population health? continuum of care means the right care at the right time in the right place. It is an important concept when it comes to the increasing intensity of health care services that a person may need as they age. For Spring Hills, the continuum of care means they can provide the same quality of care and services at every stage of the health care journey. From home care and post-acute care to assisted living and memory care, Spring Hills is able to ensure that, regardless of where a patient is located, they are receiving proactive clinical care and personalized support.
Population health, according to the CDC, is defined as “interdisciplinary, customizable approach that allows health departments to connect practice to policy for change to happen locally. This approach utilizes non-traditional partnerships among different sectors of the community – public health, industry, academia, health care, local government entities, etc. – to achieve positive health outcomes”. It refers to the health status and health outcomes within a group of people rather than considering the health of one person at a time by leveraging machine learning algorithms that allow personalized engagement and targeted interventions along the continuum of care.
We believe that caring with a commitment to quality should be at the core of every health care decision,
whether that be in home care services, post-acute care, assisted living or memory care/
– Alexander Markowits, Spring Hills
An increasingly influential approach, it addresses all the factors that affect an individual’s health. “Comprehensive population health management fills critical gaps in the patient journey,” said Dr. Pierantonio Russo, Spring Hills’ newly appointed chief medical officer and chief clinical transformation officer who is leading the Spring Hills population health program. He continues, “It also provides connective tissue for our fractured health care system. Advanced information technologies and artificial intelligence allow us to anticipate the likely course of a patient’s health condition and create a care plan to bypass known risks and meet – or even pre-empt – their needs.” The program will be integrated into all of Spring Hills’ clinical programs, post-acute care communities and home care services to offer patients and residents uniquely comprehensive health services and support.
“We know from 20 years of experience how personal and individual this stage in life is for everyone,” said Alexander Markowits, founder, president and CEO of Spring Hills. “We’ve seen each person’s needs change and have grown our ability to care for someone by offering all of our services, regardless of where the patient calls home.”
To understand the need for a comprehensive program, that spans the continuum of care, it is important to understand all the various levels of need.
Post-acute care. Caring for a patient who has just left the hospital following an illness, injury or surgery is complicated. Most people are accustomed to caring for a loved one at home for their recovery, but there are times when too much is required. Spending a few days to a few months in a post-acute care facility manages the range of medical services needed to fully support recovery.
Home care. In-home care can be defined as a non-medical caregiving and assistance in your provided home. This does not include medical care and therapies. Families and seniors might choose home care as a way for the senior to stay in their own home as they receive the assistance the need. One might need home care if they struggle with mobility, memory impairment, assistance for meal prep, bathing, transportation and more.
Assisted living and memory care. Assisted living can be defined as a form of senior housing in which residents receive regular help with activities of daily living. Assisted living facilities don’t primarily handle medical situations but do require nurses for minor medical tasks such as first-aid or minor wounds. These facilities usually provide the feeling of living at home. They are designed to have residents feel comfortable and supported with compassionate staff, balanced meals, and regular opportunities to socialize with other residents. Socialization can occur through one-on-one visits or through activities such as bingo, fitness programs, arts and crafts, gardening, and more. Memory care offers care as assisted living but with the added support for residents with Alzheimer’s Disease and dementia. The environment offers engagement, health care and security to address each resident’s specific needs, even as those needs change over time.
Population health management. Population Health Management was created to improve health outcomes using information technology and artificial intelligence and give real-time insights to both clinicians and administrators and help them to identify and address care gaps within the patient population. Data is collected by monitoring a group of individuals within a pre-determined group. These data are then analyzed to form a comprehensive patient record and improves the clinical health outcome of the patient or group of individuals through improved care coordination and patient engagement supported by appropriate financial and care models.
“It’s this continuum of care that makes Spring Hills so effective,” Markowits said. “We believe that caring with a commitment to quality should be at the core of every health care decision, whether that be in home care services, post-acute care, assisted living or memory care. Our multidisciplinary team of professionals ensures that every critical transition, such as the move from hospital to home or the move from home to a long-term care residence, is safe and seamless.”
Referring to the continued growth of care services Spring Hills is creating, Markowits said: “As Spring Hills adds clinical programs, it is essential that we position both our patients and the programs for success. Comprehensive population health management directly supports clinical treatment plans by filling the costly gaps in care that can derail a patient’s journey from hospital to home and better health. It is a key part our plan to improve health outcomes and provide measurable benefit for our patients, providers, and payer partners.”
While population health is its own study and practice, Spring Hills believes that these programs should be intertwined. The relationships that the Spring Hills team builds with the patient and family while in the hospital, for example, ensures a smooth transition to Spring Hills and provides support during their stay at a post-acute care facility and for 90 days post-discharge. Services include coordination of care with the patient, family and physicians, intense engagement with the patient and caregiver through personalized communication channels, home visits, remote monitoring, and addressing and removing social and financial barriers to access to care. By offering a full continuum of care including population health management, Spring Hills keeps its average rate of hospital readmission after 90 days under 10% — far lower than the national rate of 23-27%. Further, they ensure that the patient and family have the education and support they need to adhere to the plan of care.
As Markowits discusses in his blogpost Purpose and Principle Drive Success from Sept. 20, 2020: “Delivering the highest level of medical care and quality-of-life experience for seniors is at the heart of all that Spring Hills does. If our health care professionals’ commitment to providing the best possible care is truly personal, fueled by a dedication to always do what is right and a focus on quality over profit, we can have a real impact on the lives of the people for whom we care.”
Christina O’Leary Everett is vice president of branding and media at Spring Hills.