Diane Burfeindt

Diane Burfeindt is the vice president of population health for Presbyterian Senior Living in Dillsburg, Pennsylvania.

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	For a time, it seemed that home visits from doctors were a tradition of the past. However, with a growing population of seniors in need of access to affordable care, senior housing communities are experimenting with ways to link to the healthcare system through the Affordable Housing Plus Services Model.

BurfeindtRooted in population health management, this model represents a mutually beneficial partnership between healthcare providers and affordable senior housing organizations to maintain and improve the health of seniors over time.

	Presbyterian Senior Living first implemented the Affordable Housing Plus Services model in June 2011 at Presbyterian Apartments, an affordable senior housing community in Harrisburg, Pennsylvania.  Partnered with Pinnacle Health, and funded by Enterprise Community Partners, Presbyterian Apartments linked on-site clinicians from the local hospital with the apartments’ on-site supportive services coordinator to provide weekly medical support to apartment residents.

	Six years later, an expanded and evolved program is now funded by Enterprise Community Partners in five additional sites as Presbyterian Senior Living continues to identify and implement initiatives that support sustainable independent housing and improve health and service outcomes for residents.

	Seniors living in affordable housing communities often lack access to transportation, regular health monitoring and knowledge of proper self-care. Combined with difficulty coordinating and understanding care options, medical issues often are unaddressed and eventually escalate to avoidable complications, readmissions to the hospital, or unnecessary visits to the ER (as hospital and ER visits become seniors’ primary outlet for medical care).

	This translates to high costs on all sides, and the likelihood of additional exacerbation of medical issues due to a system that is unable to address the underlying causes.

	The idea behind the Affordable Housing Plus Services Model is to impact patient engagement by having trusted resources available on-site to match residents with healthcare providers to facilitate proactive healthcare. By intervening where seniors live, these programs reduce hospital visits and prevent premature transitions to higher levels of care.  

	Presbyterian Senior Living, one of the largest senior living providers in the mid-Atlantic, has been a leader in the effort to implement this model. Several years ago, it noticed that Presbyterian Apartments, an affordable senior apartment building in Harrisburg, Pennsylvania, had seen an increase in the number of resident hospital and ER visits.

	Staff members conducted research to identify the root of the problem, finding that the majority of incidents could have ultimately been:

	(a) Prevented by a more comprehensive awareness of health conditions, or

	(b) Redirected to a primary care provider.

	Residents had been making regular trips to Pinnacle Health, a leading healthcare provider and hospital. Armed with information, staff connected with Pinnacle Health staff to discuss the growing issue and determine a solution that would support shared population health management goals.

	Both organizations also collaborated with Enterprise Community Partners, a group that serves as an advocate for low-income individuals, to develop a strategy to better serve low-income residents and patients, particularly those with chronic health conditions in need of more consistent care.

Promising results and further initiatives

	Doctors and social workers from Pinnacle Health were assigned to conduct house calls, routinely checking in with residents, developing an understanding of their medical histories and establishing rapport with each individual.

	Since implementing the program in June 2011, Presbyterian Apartments has witnessed a reduction in ER visits by more than 50% and hospital admissions are down by more than 70%.

	This initial work propelled staff to examine how they could link services together that made the healthcare system more efficient. This led us to its most recent project with five housing locations in York County, Pennsylvania.

	In these settings, an on-site nurse has been added to the existing supportive services program to collaborate on a consistent approach to identifying resident healthcare needs and health related issues. 

	By meeting with residents in the privacy of their homes to discuss recent hospital stays, fall risk indicators, medication lists, care coordination issues and difficulty understanding medical tests, the nursing team helps facilitate communication between the resident and healthcare providers.

	Bringing the medical and social aspects of health together in one setting ensures needs are being met in a timely manner.

	This program has quickly influenced patient engagement and metrics that many managed care organizations, health systems and alternative payment providers have difficulty impacting. 

	There are significant opportunities for senior living communities and the healthcare community to engage in a dialogue about how to proactively establish effective, evidence-based population health initiatives. Partnerships can close the gap in care among underserved low-income seniors, decrease hospital visits and reduce the cost of care. By understanding and targeting the social determinates of health, housing and healthcare can work together to keep our seniors healthier.

Diane Burfeindt is the vice president of population health for Presbyterian Senior Living in Dillsburg, Pennsylvania. 

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