Healthy Seniors Project
By Lisa Legge
Allan Swanson, 89, is glad to be back at his home in south Minneapolis, with its beautiful view of Lake Nokomis. He had lived there for years, running errands for the older folks and contributing to his neighborhood. But in 1995, surgery to remove a tumor in his lower back nearly devastated his health.
"I lost everything," he said. "I couldn't walk. I was like a baby."
Swanson went to a nursing home, then eventually returned home with the help of a live-in aid. But he still needed physical therapy, and getting to the clinic was not easy. "It was a hassle because I had to take a [bus] at noon and I'd get picked up at 6. And I had only a half hour of therapy."
But shortly before he entered the hospital, he met Mary Kay Stillson, RN, MPH. Stillson is a primary nurse with The Healthy Seniors Project, a community nursing organization with a mission to serve seniors in their neighborhoods, keeping them healthy, happy and independent. She is seeing him through his recovery. She works with him, his family and neighbers and visits once a week to change his dressings and discuss issues he may have. Stillson has marshaled community and health-system resources that mean he can stay home.
"I said if I could only get home and sit at the window and watch them golf or cross-country ski," Swanson said. "But I did 100 percent more with the help of the nurses."
Stillson and her colleagues at The Healthy Seniors Project have made health care more accessible for many people in Swanson's neighborhood. For some, the Healthy Seniors Program enabled them to stay in their homes when moving to a nursing home seemed inevitable.
And while happiness and independence are two of the project's main objectives, another is Medicare savings. The Healthy Senior Project — located in Owatonna, Cambridge and two Minneapolis neighborhoods, as well as three other sites nationally — is designed to show the federal government how community nursing organizations can trim Medicare costs and improve the health of neighboring seniors.
Primary nurses like Stillson provide blood-pressure checks and other care at the program's "Nurse is In" clinic, a storefront shop in south Minneapolis' Nokomis neighborhood.
Stillson and her colleagues staff the walk-in clinic, providing blood-pressure checks and health advice. They also each manage the health of about 175 Medicare enrollees through assessments, home visits.
Their work is part of The Healthy Seniors Project, one of four sites in the United States exploring nurse-managed health-care systems for Medicare. The project could shape the future of Medicare and, consequently, care and wellness for seniors across the country. It tests cost capitation (allotting a fixed dollar amount of care per client) and whether up-front, personal nursing care and prevention, in partnership with clients, keeps them healthier, therefore cutting costs.
The non-profit Living at Home/Block Nurse Program teamed with HealthSpan on the project, which agreed to provide care for 5 percent less that Medicare does. UPDATE: So far, the project has provided care for even less than its budget — demonstrating that it can lower the costs for senior wellness and health care. Emergency-room visits, 911 calls and other medical needs are down.
In all, 11 primary nurses authorize and/or deliver the myriad services of The Healthy Seniors Project, with the aid of volunteer nurses. "They really mobilize the resources," said Linda Robertson, RN, MSW, MPH, the project director. They get to know their clients well, and clients learn they can depend on their primary nurses and call them any time. With primary nurses coordinating health care and community services, there is less fragmentation. And nurses' proximity and ready availability spur clients to take more responsibility for their care, supporters say.
The project could have a huge effect on the nursing profession, because nurses act as brokers of health-care services. The staff also uses the Omaha assessment system, which measures nursing interventions — not just medical actions. "We look at members' problems from a nursing perspective, how the nurse can affect the member's knowledge base, their behavior related to that problem and then their symptoms and health status," said Sue Shepperd, RN, BS, the project's nurse manager. "The nurses have certain actions they apply, and then they reassess them along a Likerts' Scale to determine how (members) progressed. So we'll be able to measure the impact of nursing care on the population."
More than 1,600 seniors — all of whom depend on Medicare and not an HMO for health insurance — receive active care. Members of the "action group" (as opposed to the control group of the research project, who receive routine Medicare attention) get a primary nurse and assessments every six months. The assessments measure members' health and quality of life as well as level of happiness, isolation or socialization and activity.
NOW PROJECT DEVELOPERS HOPE TO ADD ANOTHER RESEARCH DIMENSION. THEY ARE HIRING A NURSE RESEARCHER TO
Besides nurse availability, members can volunteer or receive volunteer services, and take part in health promotion and other program activities. The Cambridge site MENS BREAKFAST
As Mr. Starr's visit shows, members drop in at the Nurse Is In clinics, open part-time, with their medications and questions about recent doctor visits, diet, exercise and other health issues.
One member, Richard Starr, began coming to the clinic after the needle stuck on his blood-pressure cuff. What may seem insignificant was insurmountable to the 83-year-old Minneapolis man. After he could no longer check his own pressure, he had to make his way to local drug stores or take two buses to a hospital to check his rate. "This worked out just in time," said Starr, who lives one block from the office of "his" nurse's clinic.
Members' average age is 76. Most — 70 percent — are generally healthy, while about 30 percent have well managed chronic illnesses. Of those, only about 10 percent need home-care services. The program provides the case management, home care, rehabilitation, social work evaluations, respite care for caregivers, health counseling and other services that bolster members' health, with no co-pays or deductibles.
A Day in the Life
Reassessments, usually done in members' homes, are a big part of the work the primary nurses perform. Stillson, for example, does as many as seven in one day. (Occasionally, the project accepts new members, so nurses still do initial assessments, which take up to 2 1/2 hours.) They also make or field many phone calls each day, to members, their health-care providers, family members, community programs, volunteers and others.
As home-care professionals know, nurses learn about members' health from being in their homes, or just small-talking about family, friends or hobbies. "You can tell from those conversations how people are generally looking at life. You can pick up if someone is depressed or feeling blue," Stillson said.
Stillson, a former pediatric nurse practitioner, tells of one member for whom the initial and second assessments were quick and business-like. "I thought the next reassessment was really going to be quick again and maybe I should do it over the phone," she said. Instead, the member was excited about the visit and had doughnuts and coffee ready. "That's when he really started to talk about his health problems," she said. For most, after two or three visits or phone calls, the barriers drop and members really begin to share their health information. Many become quite loyal.
"One gentleman who is 95 said, 'Boy, no one has ever cared about me this much,' " Stillson said. That member eventually called the project and shared his feelings of depression. Another Nokomis member, whose primary nurse is Gayle Godfrey, RN, had been suffering from the same affliction for an astounding 50 years. Faced with leaving his home for a care facility, all he needed was the right specialist referral. "Just one call started the process. Then I turned it over to him," said Godfrey, who earlier was an intermittent-home-care nurse for HealthSpan.
Each week, the staff huddle to discuss members' needs. For example, Stillson, Godfrey and Jan Hatling, all primary nurses, meet with Terri Ann Flynn, who has a social work background. Nurses, who are the primary contact with members, share other needs members have, such as rides for groceries or doctor's appointments, lawn mowing and snow shoveling or friendly visitors. Together, the interdisciplinary team marshals the right community resources to try to keep seniors living in their homes, healthy and independent. Staff also stages health-promotion programs, on topics suggested by members who attend them in surprising numbers.
At the Owatonna site, for example, has standing-room-only crowds
Robertson and Shepperd credit Godfrey with devising a popular assessment tool: "pedicures." Members soak one foot while Godfrey clips toenails, files calluses and massages and lotions the other foot. All the while, she assesses members' circulation and looks for other problem signs. "You can tell a lot about a person's health by looking at their feet — what shape they're in, how they take care of themselves, their mobility," Stillson said. Healthy feet mean active, social members.
Mr. Starr, one of the members, said he entered the project because it was free. "But of course I jumped at the chance for a pedicure," he said. Men and women book a month in advance for pedicures during the two days Godfrey offers them.
Cost, Utilization, Advocacy
The most compelling nursing issues, of course, are the decisions nurses make each day about their clients' care. As case managers, they closely scrutinize utilization and cost while acting as advocates who are well-versed in their clients' health issues.
"That's a real important piece: Giving the nurses the responsibility for making the assessment and matching the care in the most cost-effective manner," Robertson, the project director, said.
"The nurses have the relationships with the members — they know them well enough so they can make decisions with the members a lot more easily than someone who's not familiar with them, who might place them in costly programs that aren't as beneficial," Shepperd said.
So far, the project seems to be staving off some problems and has kept people living independently at home. Robertson told of one member whose spouse had a fever and bad cough. The member called The Healthy Seniors Project, where a nurse advised them to go to their ER. It turned out to be pneumonia. Another member moved to a care facility after she fractured her hip. Her primary nurse remained involved, and eventually the member returned home, with home-care services. Members' satisfaction with the nursing care is a key element in The Healthy Seniors Project.
"It was a surprise to us the value they place on the relationship with their nurses," Shepperd said. "They value having someone they can call with questions."
The satisfaction is there for the nurses, too. They are happy knowing they are "going beyond the health care" — as Godfrey says — and using community resources to help keep seniors active, healthy and happy in their homes. Godfrey also gets satisfaction in learning about what it takes to keep someone healthy. "There's more accountability, but you get the big picture," she said.
The number of nurse-volunteers also attests to that. Lori Quinlan, RN, is a mother and works part-time at Abbott Northwestern Hospital's cardiovascular unit. But she volunteers once or twice a week, providing foot care and helping staff the Nurse Is In clinic — for her own neighbors in Nokomis. "It's nice to see how people are getting along outside the hospital," she said. "I think it's going to be a really rich experience."
He is grateful enough to the Healthy Seniors Project to have written a letter to his congressman, Martin Sabo, and to U.S. senators Wellstone and Grams to urge continued funding for the program.
"I hope this organization keeps on, especially as long as I live," he said.
CUTLINE: Richard Starr, 80, sits with his primary nurse, Mary Kay Stillson, RN, MPH, at the Minneapolis Nokomis office of The Healthy Seniors Project.