Community Partnership Program Helps Maryland Seniors Age in Place

According to a study from the Pew Research Center, roughly 10,000 baby boomers turn age 65 every day. This rapid aging of the U.S. population means that by 2030, the number of seniors will nearly have doubled compared to 2010, leading to serious challenges for older adults, their families and the health care system. By some estimates, it is expected that the number of Medicare beneficiaries could reach 81 million by 2030.

Many seniors have serious chronic health issues, so coordination of their care with providers is critical. This situation is compounded when beneficiaries are also low-income or don’t have family members who can check in on them to ensure they are seeing their doctors and taking their medications.

The Centers for Medicare & Medicaid Services’ Quality Improvement Organization (QIO) Program has prioritized improving care coordination services for beneficiaries. In 2014, the Quality Innovation Network-QIO (QIN-QIO) for Maryland and Virginia, VHQC, began engaging the H.E.A.L.T.H. Partners (Hospitals Effectively Assisting Lasting Transition to Home) coalition in Montgomery County, MD, to help keep seniors at home and in their communities as long as possible.

H.E.A.L.T.H. Partners includes several key stakeholders in the county, such as local hospitals and care providers, as well as strong representation from community volunteers, including Medicare beneficiaries. The local coalition’s care coordination work started in an independent living, high-rise building that houses predominantly low-income seniors who are dually-eligible for Medicare and Medicaid.

“This is a population at risk,” said Carla Thomas, Director of Care Transitions at VHQC. “Many residents are dealing with multiple chronic illnesses, low health literacy and limited access to health care services.”

With those challenges in mind, the H.E.A.L.T.H. Partners coalition got to work. They launched a pilot program and started holding group information sessions with building residents. After receiving consent from residents to share if they had recently been hospitalized, the coalition developed an open line of communication among hospital staff, EMS personnel and the high-rise building management.

When a resident of the building received medical services, the building manager was notified. This gave management the ability to prioritize resident check-ins to ensure that seniors at risk for readmission had the support they needed. Building management also coordinated with a local pharmacist who visited the building to provide medication education and reconciliation services, helping to ensure that residents had the medications they needed and were taking them correctly.

“Typically, care coordination has focused on more traditional settings such as hospitals, home health and nursing homes,” Thomas said. “This program stands out because of its efforts to engage new partners and settings. EMS, pharmacists and building managers are important stakeholders, and the successes we’ve seen in Montgomery County show how effective these partnerships can be for helping seniors in independent settings.”

Since starting the program, Montgomery County EMS has reported a 43% reduction in emergency calls for residents at the pilot building. These early successes led H.E.A.L.T.H. Partners to look for ways to expand the program.

Leveraging program data and analysis from VHQC, H.E.A.L.T.H. Partners members worked with the Primary Care Coalition of Montgomery County, The Coordinating Center, pharmacies and all six county hospitals on a proposal for additional state funding. It was recently announced that their regional partnership is one of nine that will receive grant funding from the Maryland Health Services Cost Review Commission (HSCRC) for System Transformation. 

“We’re looking forward to supporting this community’s new and expanded program. Our small pilot project in an independent senior housing community was the inspiration for a much greater collaborative that will now enable the program to reach up to 30 additional independent senior living settings in the county,” Thomas said.