New integrated model of care for seniors lowers hospitalizations, readmissions, emergency care visits

Nurse with patient
New research shows an integrated care program developed by Juniper Communities reduced admissions, readmissions and emergency department use among elderly, frail patients.

The clinical outcomes of a new integrated model of care for frail seniors that bridges housing and healthcare are so significant that researchers believe the program has the potential for substantial Medicare cost savings.

The model provides residents with onsite, comprehensive therapy, medical care, pharmacy and lab services. Key components to the program include a care navigator who coordinates the residents’ total care and high-tech/high-touch communications that transfer the resident’s information to ancillary and acute care services through an electronic health record.

Although Juniper Communities’ residents were older and more cognitively impaired than the overall Medicare population with similar conditions, independent researchers from Anne Tumlinson Innovations looked at 2012 Medicare Beneficiaries Survey, as well as those living in senior housing that didn’t provide an integrated healthcare program, and found Juniper's Connect4Life program had:

  • 50% lower inpatient hospitalization rates
  • 80% lower readmission rates
  • 15% lower rate of emergency department use
   Lynne Katzmann

“I thought the results might be good but you never know until you get the data. But I didn’t expect the significance of the results,” Lynne Katzmann, Ph.D., founder and president of the Bloomfield, New Jersey-based operator of senior communities in New Jersey, Pennsylvania, Florida and Colorado, told FierceHealthcare this morning in an exclusive interview.

“The results show when you provide supportive housing and services and integrate with clinical care services you can avoid high utilization of the highest cost services,” said Katzmann, noting that it has the potential to address population health among the 5% who use 50% of healthcare resources.

The idea for the model began in 2012, she said, when Juniper began to notice an increase in the acuity of their residents and a lower length of stay among those who suffered from complex, multiple chronic diseases and functional limitations, a population similar to the high-cost, high-need patients who use the most government services.  

The organization decided to take advantage of the fact it had already converted to an electronic health system and used electronics as the basis for all its communications to better connect residents to healthcare services. That ability enabled its staff to make sure residents were able to bring their most important health information and up-to-date records with them to referred providers.

The next piece involved providing residents with onsite access to therapy and fitness classes. But the key to the program was involving primary care, which Katzmann describes as the glue that holds the program together and is the link between acute care and post-acute. Juniper collaborated with Redwood Health Partners, which specializes in patient-centered medical services, to create a model that included regular office hours in the building and became part of the healthcare team and care planning at Juniper.

By 2014 Juniper realized it had developed a program that looked like an integrated health network that promoted patient engagement and preventive care. Katzmann said that the model also includes a care navigator who makes sure ancillary providers do what is asked and serve as a face of the program to residents and their families.

Although the model is new and the research is based on a year’s worth of data, Katzmann said the results are encouraging. “The results are so strong that I think this is a model that can be replicated and have meaningful results for hospitals, health systems, Medicare Advantage plans and individual providers. It’s a win-win,” she said.