By JULIE MINDA

ORLANDO, Fla. — A program from Chicago's Presence Health enables homebound elderly to remain in their homes even as their health is declining. Two staff members and a corps of volunteers visit the elders regularly to address a wide variety of needs.

"It's a blessing" to elderly Chicagoans who do not want to move out of their homes but whose health and circumstances make it difficult to stay there, said Rosann Prosser, director of clinical operations for Presence Home Health of Des Plaines, Ill., and head of the Presence Health Homebound Elderly initiative. She presented an Innovation Forum session last month at the Catholic Health Assembly titled "At the Margins of Society: Helping Homebound Elderly Age in Place."

Photo credit: Jerry Naunheim Jr. / © CHA
Rosann Prosser

She explained to attendees that the program began four decades ago when five Chicagoland hospitals — some of them now part of Presence Health — collaborated to address the problem of frail, low-income seniors using the emergency department for acute but not emergency-level conditions. "They were coming in sicker and sicker," many were repeatedly coming to the hospital for unmet health needs and many were being discharged to skilled nursing facilities because they didn't have the right support at home to address medical and nonmedical issues, Prosser said.

The group of hospitals developed the model of engaging hospital staff and volunteers in homebound seniors' care. The program has evolved and now, as the Presence Health Homebound Elderly program, it uses a nurse, medical social worker and trained volunteers to visit dozens of frail elders annually to help coordinate their care, monitor their medications, educate them on their conditions, address their spiritual needs, or perform light household duties.

Funded by a foundation and by grants, the homebound elderly program dispatches staff and volunteers to the elders' homes weekly. "This way, there are eyes on (the patients). They can detect when there are issues and communicate with the patients' physician," said Prosser.

The team uses technology to monitor patients in between live visits. This can include a heart monitor, scale and pulse oximeter. According to information from Presence's home care division, a member of the home care staff installs a telemonitoring device that transmits the patients' bio data back to Presence home care. A nurse monitors the data and can act when warranted. The nurse may contact the patient or the patient's clinicians, or the nurse may send homebound elderly program staff to the patient's home.

Team members also assist with disease management, ensuring the patients are properly heeding care instructions from providers. Especially the poorest patients can struggle to comply with such instructions. Some cannot afford out-of-pocket expenses associated with drugs. The team helps them address such concerns by checking on other potential payers like secondary insurance. Foundation dollars can bridge the gap.

At a cost of just $4,000 per patient per year, the initiative has improved the patients' health, reduced their hospital admissions and reduced the length of stays of those who did have to be hospitalized.

However, said Prosser, the intangible outcomes are important as well. "Our staff and volunteers become the friends and family to our homebound seniors. The success and happiness we can bring to our seniors is everything to us."

Copyright © 2016 by the Catholic Health Association of the United States
For reprint permission, contact Betty Crosby or call (314) 253-3477.