HealthCare in Retirement Communities: Passive is No Longer an Option.

After reviewing the advertising of my local Retirement Communities, I asked myself:  “What stands out?”

The answer? “Nothing.”  That’s right, nothing.  Absolutely nothing stands out.  Everybody looks the same.

I challenge you:  review the advertising of 10 different Retirement Communities.  Then close your eyes and name 1 single feature that distinguishes any 1 or 2 of the communities from all the others.

Did you have any luck???  If you did, you’re better than I am!  I don’t mean silly things, like “Imagine the excitement of that perfect bridge hand!”  I mean things of substance and real value that seniors will appreciate as a welcome exchange and even motivation when moving to a Retirement Community from the home in which they have lived for so long.

Consider this:  many Retirement Communities spend as much as $5000 – $10,000 per month, EVERY MONTH, on advertising (or even more).  And yet the ONLY thing they accomplish is to make themselves look IDENTICAL to every other Retirement Community.  Same amenities, same verbiage, even many with the same stock photos of the same happy and smiling seniors!

Retirement Communities operate in an incredibly competitive market, and this only promises to intensify with the coming of the Baby Boomers.  So why are Retirement Communities so willing to invest so much money into something that makes them appear so ordinary and average, but are yet so reluctant to invest even 1/10th of that amount in a service (HealthCare) that brings real value and will distinguish them among all their competitors?  The psychology of this observation is hard to understand.

Those who represent Retirement Communities are abundantly aware that HealthCare is one of the TOP CONCERNS of ALL seniors.  This is an opportunity!  So why not take advantage of this opportunity and offer a service that every senior wants and that promises the best chance for not only stabilizing the census but recruiting new residents and growing a community’s census?

In Boise, Idaho, some physicians have stepped up to the challenge and will now provide full primary care in the comfort and convenience of your resident’s rooms.  Yes…it requires a very modest investment to make this happen.  Yes…it requires a community to ACTIVELY participate in the health and wellness of their residents.  But the compelling advantages of this investment FAR outweigh the modest cost.

The Retirement Communities, both Independent and Assisted, who will be thriving in this competitive market 3, 4, or 5 years from now will be those who are prepared to capture the Baby Boomers who bring greater expectations.  The Communities that survive will be those who are proactive NOW and adapt to the changing demands and needs of their residents.  The “passive” approach, when it comes to healthcare, is simply no longer an option.

Physicians MUST partner with Retirement Communities, and here’s why…

Healthcare delivery is changing from a Hospital focus to a community focus.  And with this change, Retirement Communities, operating in a very competitive market, are obliged to be a participant in their residents’ healthcare.

Hospitals, responding to their own set of pressures, are discharging patients earlier and earlier in the course of their patients’ recovery from an illness, transferring the burden and responsibility of coordinating their care during this fragile time to the patients themselves.

  • In 2011 The Centers for Disease Control noted that seniors discharged from hospitals between 1990 and 2010 had a 31-36% shorter length of stay.
  • In 2012 The Agency for Healthcare Research and Quality noted that many discharged patients were home bound and needed either skilled nursing or physical therapy, as there was a 79% increase in patients being discharged to Home Health services during a similar time frame.

This increased demand for community-based healthcare unfortunately has not been accompanied by easier access to primary care physicians.  Although patients were sicker, the only way to see their physician was still to somehow struggle into the physician’s office.  As disagreeable as this was to both patients and physicians, there simply was no alternative to this model.

But now there is an alternative.  House Calls answer is a model that encourages a partnership with physicians, Retirement Communities, and their residents.  Full primary care can now be delivered to residents in the comfort and convenience of their Retirement Community apartment.  Regularly scheduled clinics are put in place where residents may voluntarily see the House Calls physician for either single visits or as their PCP.  And this partnership allows even more benefits:

  • Any new resident to the Retirement Community will automatically be accepted as a patient if requested.
  • Home Health orders will be signed within 24-48 hours of request.
  • Physician directed healthcare coordination, where all who participate in a resident’s healthcare, are now led by a physician and unified as a TEAM rather than acting as separate individual services who don’t communicate with one another.
  • Memory Care residents and their families and staff members are spared the stress and inconvenience of transporting these fragile individuals off-site for routine doctor visits.
  • A Marketing and Promotional advantage that identifies THIS COMMUNITY as a LEADER by offering a service that ALL RESIDENTS WANT, WITHOUT EXCEPTION – easy and convenient access to a physician-led team of healthcare professionals.
  • Stabilization of Community census by reducing health related attrition through pro-active, early, physician-led intervention in a resident’s declining health.
  • Growing of Community census by capturing prospective residents who choose THIS Community because of its unparalleled healthcare support.

EVERYBODY WINS with this partnership.  We intend to meet the challenge of tackling the increasing community healthcare needs by converting our experience into a huge success.  Our communities, not hospitals, will be the focus of healthcare in the future…and we and our partners are ready!

Physician Visibility and Accessibility: Reducing Health Related Attrition in Retirement Communities

The key to reducing health related attrition in a Retirement Community (and therefore stabilizing the census) is early identification and physician intervention in a resident’s declining health.  This is illustrated in the following diagram that we call The Illness Model.  It shows the pathway frequently taken by an elderly person who experiences an illness.

Let’s walk through this illustration, beginning at the green line on the left side, and discuss what can happen when Jane, a resident of a Retirement Community, experiences an illness.

The green baseline that’s shown is meant to indicate a low risk level where Jane functions very independently in the Community.  She has a stable medical status and adequate support with family and friends, and she tolerates the little ups and downs of daily living just fine.

But when an illness begins to set in and her health starts to decline, Jane transitions from low risk (green) to medium risk (yellow).  This very early point of declining health is called the “Inflection Point” and is usually identified by family or fellow residents or especially employees of the Retirement Community (“Jane just doesn’t seem to be doing well and seems more confused,” or “Jane’s been falling a lot recently,” or “Jane seems to be losing her appetite,” or “Jane has missed a few meals.”).  If healthcare is offered proactively to Jane at the Inflection Point with physician attention and possibly additional support services (home health, personal care services, etc.), then there is a high likelihood of stopping the decline and of Jane returning back to baseline and remaining in the Retirement Community.

But without early intervention, Jane’s health may continue to decline and force her to go to the emergency room or even be hospitalized. If this happens, her overall risk level now becomes high (red). And then, if she is too weak or has too many needs to recover from her illness back in the Retirement Community, she may lose her home and need to transition to a higher level of care, and the Community loses a resident.

But if Jane hasn’t been too weakened by her illness and has good physician-directed support at home, she may be discharged from the hospital and continue her recovery in the comfort of her own apartment in the Retirement Community.  In the illustration, she leaves the red, high risk areas and begins climbing the yellow recovery line on the right side of the diagram where her risk level is now about medium. With continued physician-directed support in her home, her goal is to reach the stable baseline health she had before her illness and become low risk again.

This model illustrates the advantage enjoyed by Retirement Communities that partner with House Calls who offers on-site physician services and leadership in the healthcare of any or all of their residents.   Physician visibility and easy on-site healthcare access are essential elements in maintaining the health and independence of community residents and stabilizing the census.

Physicians bringing healthcare to Retirement Communities…EVERYBODY WINS!

House Calls Takes Triple Aim at Retirement Communities!

Part 1 of 4 – Triple Aim for Institutions:  Healthcare Services.

In 2008, Dr. Donald Berwick, the former administrator of CMS (the Centers for Medicare and Medicaid Services) and the CEO of the Institute for Healthcare Improvement, published an article in Health Affairs entitled:  “The Triple Aim:  Care, Health, and Cost.”  In this article, Dr. Berwick and his colleagues describe 3 very broad and linked aims to improve US healthcare:

  • better care of individuals
  • better health of populations
  • lower cost of healthcare.

We view his remarks as being directed primarily at healthcare institutions (healthcare systems including hospitals, insurers, physician offices and clinics, surgery centers, etc.) and the medical services they provide.

Dr. Berwick’s focus represents a “top down” approach – trying to tackle the [healthcare] giant by attacking the biggest and toughest problems all at once – reorienting healthcare institutions to control the cost of healthcare services which has $765 billion in annual waste  [2009 data, Institute of Medicine]:

  • unnecessary services ($210 billion)
  • inefficient services ($130 billion)
  • excessive administrative costs ($190 billion)
  • overly priced services ($105 billion)
  • fraud ($75 billion)
  • missed prevention opportunities ($55 billion)

One can easily get lost and discouraged by the immensity of this giant – the problem is so broad and overwhelming.

But our discouragement can blind us to opportunities where we can make a difference and accomplish real, focused, specific goals…NOW.  We don’t have to wait for the next generation or the government to solve our problems for us.  We can make a difference, a very significant difference, TODAY, THIS WEEK, THIS MONTH.

How do we do this?  How do we attack and conquer this healthcare giant???

Answer:  It’s easier and less intimidating than you might imagine.  We just open our minds.  We don’t think like a giant, we don’t think like a victim.  We simply decide that we are going to win this battle, and then we kill the giant!

How do we kill the giant?

Read Part 2 of this 4 part series.  It’s not as tough as you might believe.

How to Kill a Giant – an allegory

Part 2 of 4 – Open Your Mind.

One day you take a lovely walk down your life’s path.  The sun warms your shoulders, a soft breeze brushes against your face to gently challenge your progress, but overall your journey is very pleasant, and life is good.

In the midst of your lovely journey you don’t even notice yourself wandering off in a direction your parents always cautioned you to avoid.  “Stay out of that prickly Healthcare Field,” you barely remember them warning.  “There are giants in there, they eat people, and once you enter you’ll be lost forever!”

Until now you’ve always had great health and never felt the need to heed your parent’s healthcare advice.  But then you discover you’ve unexpectedly wandered too far and find yourself in the middle of that morass of a Healthcare Field they warned you about, and you’ve acquired some prickly health problems that are making your life very uncomfortable.  And to your terror, you suddenly hear a loud, horrific roar and look up to see the dreaded Healthcare Giant looming over you, the one your parents struggled with and who gave them nightmares!  He is clearly most unsympathetic to your plight, and he realizes your vulnerability.  The hunger in his eyes, his bulging muscles, and his hulking mass overwhelm you.  But just when you’re ready to give up, you realize the presence of a very calm and serene person who has come to stand beside you.  His lack of fear and intimidation by the giant many times his size puzzles you.  And you are even more confused when he smiles reassuringly and instructs you, “Just open your mind.”

What happens next is completely unexpected.  The person calmly approaches the giant to confront him head-on.  Then abruptly he viciously stomps on the giant’s little toe!  The giant howls in pain and begins hopping on one foot.  The person then stomps on the giant’s other little toe, and the giant howls even louder.  The person then stomps on another toe and another toe and another.  Soon the giant can no longer keep his balance and crashes to the ground howling and howling.  Then the person pokes the giant in the eye!  The giant screams.  The person pokes the giant in the other eye, completely blinding him.  The defenseless giant, who now can’t see and can’t walk, screams and howls even louder.  Suddenly there is silence, for the person has grasped the giant by the throat, squeezing hard and shutting off his breathing.  Within a few seconds the giant is dead.

The person now calmly approaches you and says:  “Always remember…just open your mind, and your giants can be conquered, one toe at a time.”

We can learn from this allegory.  To see how it applies to improving our healthcare system, please read on to Part 3.

Making an Impact – NOW!

Part 3 of 4 – Triple Aim for Communities:  Healthcare Delivery.

Hospital-acquired infections cost the American healthcare system $30 – $40 billion annually.  Two million Americans acquire an infection in the hospital every year, and 100,000 people die of them (Tina Rosenberg, The New York Times, April 25, 2011).  Would you like to know the biggest technological advance in treating hospital acquired infections?  Can you imagine the expense and complexity of tackling such a huge problem?

Here’s the answer:  Hand washing!  Something as simple and inexpensive as washing your hands before and after going into a patient’s room dramatically reduces hospital acquired infections and saves thousands of lives annually.

Here’s the lesson:  Simple solutions are easily overlooked but can often have the greatest impact.  Remember what started the downfall of the Healthcare Giant in Part 2 of this series…his little toe!

Here’s how we apply the lesson in communities:  In Part 1, we described Dr. Berwick’s vision of better health, better care, lower cost which is a top down approach directed towards institutions to tackle the Healthcare giant by reorienting the services they provide.  House Calls takes the opposite approach.  We start at the other end of the giant (the “little toe”) to achieve an impact.  We believe that the greatest impact in communities will result by improving healthcare DELIVERY while using existing services.

Our approach is:

  • targeted (seniors)
  • focused (retirement communities)
  • efficient (low overhead, efficient delivery)
  • will develop additional opportunities (the establishment of a Mobile Medical Home and ultimately a Home Hospital – both subjects of future blogs).

We begin small so that we can refine our model and prove and promote our successes, and we’ll then expand to as many retirement communities as possible.

Here is the House Calls Triple Aim model for Communities:

Location:  Retirement Communities.

Visibility:  Daily presence of a House Call representative within the Retirement Community easily reminds seniors of House Calls services, allows frequent and unhurried conversations, builds familiarity and relationships.

Accessibility:  The House Calls physician is easy to access and provides care as a home visit in the comfort and convenience of the residents own apartment.  Seniors no longer need to prolong failing health or avoid physician care due to difficulty in accessing their physician (difficulty scheduling appointments, arranging transportation, etc.).

The Triple Aim for Communities is simple, practical, and builds partnerships in the community that will help achieve its goals.

Now comes Part 4 – the merging of the Triple Aims!  This is exciting, because this is where we put the nail in the coffin of the healthcare giant!!!

Merging of the Triple Aims

Part 4 of 4 – Where our Healthcare Institutions and Retirement Communities unite with a model of improved healthcare services and delivery.

Our healthcare institutions and communities need each other.  But these 2 entities need an easier and more cooperative way of interfacing.  And each needs to do some changing.

Our institutions need to provide services that are more affordable while still rewarding providers.  They also need to develop care models that lead to better health of the community without alienating patients by making access to necessary services and treatment so confusing, cumbersome, complicated, intimidating, and expensive.

Our communities must be more self-reliant by recognizing that the great majority of the healthcare services they require are not provided solely within institutional walls but may also be provided by private businesses located in their neighborhood that are poised and eager to serve and who can deliver their services in the comfort and convenience of the community resident’s home.  Communities must be more open to forming unique partnerships and employ innovative and creative new approaches that bring most of the needed healthcare directly to them where they live.

The unsustainable cost of healthcare in the US is forcing innovation in services and healthcare delivery.  House Calls proposes a creative approach that brings institutions and our communities together by merging the Triple Aims of each and connects them at points of shared function (“Touch Points”).

Our model initially limits our view of “communities” to Retirement Communities.  This addresses the population having the most chronic illnesses and where most of our healthcare dollars are allocated.  It is also where groups of the elderly live together and where healthcare can be delivered most efficiently.

We start with one Retirement Community at a time and develop a working model that can then be exported to all Retirement Communities, thereby relatively quickly affecting a very large population.  In our model, the goal that both Triple Aims share is very broad – “better outcomes.”  The approach must be broad because each Triple Aim achieves and measures this goal differently and according to its own customary practice:  institutions such as hospitals care for higher acuity patients and have access to numerical data (e.g. billing, cost of services, length of stay, rates of readmission, etc.) used for their metrics which is not readily available in the community.  In communities, however, care is delivered in the patients’ homes, and anyone experienced in this area will readily tell you that well-intended recommendations and advice delivered in the hospital or a physician’s office is VERY DIFFERENT than what actually transpires in a patient’s home.  And it is the community physician, the one delivering care on-site in the Retirement Community or the patient’s individual home, who sees what REALLY occurs and adjusts treatments and expectations accordingly.   Numerical metrics are not as available in this setting, but early intervention, reducing risks in the home, and building trusting relationships are measures that affect outcomes.

Although institutional and community approaches differ, they both practice state-of-the-art healthcare and cooperatively share information and resources at the Touch Points in the Figure.  Their focused attention will allow both to achieve the shared goal of improved outcomes, although each must accept that using different metrics for measuring these outcomes (numerical data vs. non-numerical data) does not invalidate the outcome itself.

There is much more to discuss, but we’ve still come a long way in this 4 part series.  From Dr. Berwick, to institutions and communities, to killing giants, and finally to the Merging of the Triple Aims.  We give a vision for improving healthcare to our senior citizens and a specific approach to providing better health, better care, and lower cost by implementing community-based healthcare delivery that emphasizes location of service, visibility of providers, and easy and convenient healthcare accessibility.

The good news is that despite the immensity of the topic, we can make a real and measureable difference in the healthcare of our senior citizens by starting small, “one toe at a time”, one Retirement Community at a time.  This is exciting, and if we keep the vision, work together, and open our minds, we can make a huge and tangible difference…NOW!

We invite your comments and criticism.  Both will only make us better.