Editor’s note: The John A. Hartford Foundation, the Administration for Community Living (ACL) and The SCAN Foundation fund the Aging and Disability Business Institute, led by the National Association of Area Agencies on Aging (n4a). The mission of the Aging and Disability Business Institute is to build and strengthen partnerships between aging and disability community-based organizations (CBO) and the healthcare system. As partners in the Institute, ASA and n4a are collaborating on a series of articles and case studies in Generations Today that highlight community-based integrated care networks.
JASA, a 53-year-old aging services agency supporting more than 40,000 older adults in the Bronx, Brooklyn, Manhattan, Queens and parts of Long Island is this year’s winner of The John A. Hartford Foundation’s Business Innovation Award. The award recognizes aging and disability community-based organizations for innovative approaches used in reducing healthcare costs and improving the well-being of elders and people with disabilities through partnerships with healthcare entities. This year, the Business Institute was especially interested in recognizing innovations in CBO-healthcare contracting related to addressing health equity or health disparities.
Innovative Program for Complex Patients
Arielle Basch is senior director of Health Services and Business Development at JASA, and has led the development of an innovative Hospital to Home Care Transitions program that has been highly effective in reducing hospital readmissions for older adults.
As part of this program, JASA has contracted with several healthcare entities, including Healthfirst, Maimonides Medical Center, Woodhull Medical Center and Wyckoff Hospital Medical Center. “Healthfirst has conducted a preliminary evaluation of the program. Early results indicate that the cohort of members who agreed to receive JASA’s Care Transitions intervention had 26 percent fewer readmissions in the 30 days following an index admission compared to the cohort of members who did not receive the intervention,” said a spokesperson for Healthfirst.
The program is designed to address challenges faced by older adults who are discharged from the hospital to prevent adverse events when they return home. Geared toward the many older New Yorkers who do not speak English as a first language and/or who have complex medical and social needs, it works like this: Managed Care Organizations and Hospitals refer patients to JASA, and a JASA team member meets the patient in the hospital (during COVID this is done virtually). Patients can opt in or out at that time, but if they opt in, they are assessed to determine health conditions, medications, what they were admitted for, any comorbidities and needs they’ll have at home.
Home Visit within 48 Hours of Hospital Discharge
When discharged all patients are given discharge instructions, the only challenge being they are generally in English or in language that is hard to understand, which makes them difficult to follow for much of JASA’s clientele. JASA staff will make a home visit to translate these discharge instructions for the patients as a first step toward preventing them from returning to the hospital.
One imaginative element that may be unique to JASA and really helps with this tricky transition is that the agency employs International Medical Graduates (IMGs) to work in the Care Transitions program. Not only are most from Spanish-speaking countries, but they are fully trained medically and working at JASA is a stepping stone toward a residency in the United States.
After translating the discharge instructions, the IMGs ensure the patients understand the instructions, have all necessary medications and know their proper uses, and make appointments to follow up with the patient’s physician(s) within a week.
These patients often have multiple complex comorbidities, and the IMGs spend time on intensive patient education. They go over red flags, making sure clients know when they should contact their doctor to prevent an emergency at home, review and update the patient’s medical record, and work with the patient to outline questions for their next doctor’s appointment.
Social Needs Assessment Critical to Prevent Readmissions
During the home visit, IMGs assess client’s social needs; they identify potential depression or other mental health needs, whether the patient needs help with food or nutrition education, transportation, housing, homecare, medication or caregiving support. (For example, in one case a client received help moving to an assisted living facility as their housing situation with a family caregiver was untenable.)
IMGs connect the recently hospitalized person to skilled services, mental health and social support, such as Senior Centers and Friendly Visitor Programs, food, transportation and any other necessary referrals. IMGs also provide COVID-19 education and are helping clients schedule appointments for vaccinations. IMGs generally make one to two home visits per client, with approximately three remote follow-up appointments.
Discharge instructions are generally in English or in language that is hard to understand, which makes them difficult to follow for much of JASA’s clientele.
JASA has one social worker on the Care Transitions team for clients with intense social care challenges an IMG may not be able to solve, but generally the IMGs are trained to deal with most such issues that crop up. The Care Transitions team also taps into the expertise of JASA social workers and other professional staff who have specialized experience in adult protective services, legal services, palliative care, mental health services, homecare and other areas.
Basch says JASA employs 15 IMGs, generally for a year or two as they apply for residency. “IMGs have been a wonderful addition to JASA’s staff,” she says. “I love the team I work with. The IMGs bring diverse cultural perspectives, language skills and strong medical training to JASA. They are incredibly committed to using their skills to address the social determinants of health and help seniors transition home safely. JASA and our clients benefit so much from our work with IMGs and we hope this program helps to prepare them for residency programs.”
Also, as a bonus for the IMGs, they’re learning the complexities of social needs, which isn’t all that common in medical school. And they’re receiving actionable geriatrics training, so perhaps Basch is coaching the next crop of geriatricians as well.
JASA’s client base is one with complicated, entrenched health issues, making it more remarkable that the agency is able to prevent so many hospital readmissions. Many clients are taking more than 10 medications and have some combination of COPD, congestive heart failure, diabetes, low health literacy levels and, more often than not, live in poverty.
“We have to deliver culturally competent care in a language the person speaks, while being considerate of their culture, backgrounds and personal goals,” Basch says. IMGs spend time building trust with patients, and Basch finds patients will call JASA team members even after they have completed JASA’s care transitions program. These clients are more comfortable asking JASA staff questions and for help with medications, home care, food and transportation or other issues beyond hospital discharge.
“Spending time with clients to build trust and understand their personal health goals is key to the success of the program. JASA’s care transitions program is designed to actively engage clients in the healthcare system and to advocate on their behalf,” says Basch.
As one 78-year-old woman client explained when asked about JASA’s program, “I was facing uncertainty, sadness, loneliness and illness. It was made more difficult because of challenges communicating with the hospital [during the COVID surge], and the death of my husband, but the support and understanding provided by JASA's staff gave me a new family in the midst of so much tragedy.”