BY: LUANN TRUTWIN, MDiv, BCC
Illustration by: Curtis Parker
This is a story about Ben … and many elderly adults who have needs not being met through traditional health care. Ben was in the hospital several times last year. First it was diabetes, then heart problems, then a blood clot in his lung and finally a broken hip. Ben now has to coordinate care with many different providers, he takes lots of pills, and — most importantly — he isn't able to volunteer at the food bank and church. Ben wants his life back.
Enter Providence Elder at Home, the first program of its kind within an integrated delivery system in the Pacific Northwest. Providence Elder at Home is a team-based, multidisciplinary model of care to serve the health and spiritual needs of people like Ben — and to do so in the comfort and familiarity of their homes. For the fragile elderly patient, "home" may be a private residence, an adult care home, assisted living or an intermediate care nursing facility.
The Elder at Home team includes chaplains, who are integral to the patient's spiritual care process. As more health care moves outside the hospital walls, Providence's spiritual care professionals are expanding their services into ambulatory and home settings along with it.
The Elder at Home program began in mid-2015 and is a partnership between Providence Health Plan and Providence clinicians in Oregon. The original goal was to address elderly patients' needs using a team that includes physicians, nurse practitioners, physician assistants, registered nurses, licensed clinical social workers, chaplains, clinical pharmacists, dietitians, licensed practical nurses, medical assistants and rehabilitation specialists. In other words, every team member is a vital caregiver providing services in the home instead of transporting a frail elderly patient from home to a clinic or hospital.
The program is a collaboration between Providence Health Plan, Providence Medical Group and Providence Home and Community Services. Patients receive primary care, annual wellness visits, social support, care management, skilled nursing care, urgent care, palliative services and pastoral care. In its two years, Elder at Home has achieved significant savings — more than $9 million, according to Tim Serban, Oregon's chief mission integration officer, and has served more than 1,100 patients, which resulted in 1,000 emergency department and urgent care visits avoided, a 24 percent decrease in patient admissions and a 26 percent reduction in inpatient days.
Elder at Home exemplifies both the continued effort for Providence in Oregon to become a population health organization and the importance of aligning the health system's core values with its commitment to whole-person care. At its most basic, this is a redesign of traditional care, putting the patient at the center and wrapping Providence's services — and arms — around the needs of each person and his or her family.
The cost savings are an achievement, but it is the improved quality of life for patients and their families that are at the heart of Providence Elder at Home. Through the program, Providence is able to provide spiritual care by meeting the patient in body, mind and spirit. The program provides dignity and respect through personalized care, in keeping with Providence mission and values.
Spiritual care is initiated by referral from a member of the patient's medical team. The Elder at Home board-certified chaplains make home visits and are responsible for getting to know the patient and completing a spiritual assessment to determine spiritual care needs and any resources that might be appropriate.
As patients become increasingly frail, they often lose connection with their faith communities. Elder at Home chaplains work to reestablish such important relationships, if the patient desires, by calling faith communities to update them on the patient's needs. Many churches and spiritual communities are not able to provide in-home services, so the chaplain may function as a home pastor.
After assessing the patient during the first home visit, the chaplain makes a plan of care. On following visits, at approximately 4- to 6-week intervals, the patient and chaplain may address spiritual distress, grief and loss, concerns related to life and death, questions of meaning and purpose, as well as separation from a previous community of faith.
As integral members of the care delivery team, chaplains also serve as leaders in an organizational culture of holistic, appropriate self-care, which helps staff sustain the work of Providence Elder at Home for the long term. Spiritual care serves a dual role by providing care to patients and by supporting staff as they face the challenges inherent in care of frail, elderly patients. To that end, the chaplains engage in purposeful rounding with staff, one-on-one as well as during team meetings. These activities provide opportunities for caregivers to talk about their experiences.
Providence's innovative Elder at Home program is both transforming care and following in the footsteps of foundress Blessed Emilie Gamelin, SP, who sought out medically fragile and destitute elderly women — some of the city's most vulnerable people — in the streets of 19th-century Montreal. As medical director for geriatric medicine at Providence, Marian Hodges, MD, puts it, "There is a parallel between Blessed Gamelin and Elder at Home — we are continuing her commitment to our vulnerable elders and improving the quality of care and patient experience."
"Responding to the signs of the times" and "serving our dear neighbor" — like Ben — are core commitments of Providence Health & Services. The integration of spiritual care services in this new and emerging world of population health provides many exciting opportunities to continue to reveal the love of God, witnessed through the ministry of Jesus.
LUANN TRUTWIN is director of mission integration and spiritual care home and community services, Providence St. Joseph Health, Portland, Oregon.