Smoothing the Transition From Hospital to Community for Older Adults in Jacksonville, Fla.

    • December 7, 2011

The challenge. In Jacksonville, Fla., older adults were revolving through hospital doors—sent home only to be right back in the hospital again because the community services and supports they needed were either lacking or not well-coordinated. Mark LeMaire led an effort to change that, with support from the Robert Wood Johnson Foundation (RWJF) program, Community Partnerships for Older Adults.

Background. LeMaire grew up in South Florida, which has one of the highest concentrations of older adults in the country. But that is not the main reason he has come to love working on issues related to aging. "I was raised by older parents," he said. "My dad was 45 when I was born, so by the time I was in college, he was close to retirement. I was always surrounded by older people."

Later as a young pastor in churches in Central Florida, LeMaire again found himself drawn to older adults in his congregations. "I enjoyed learning from them," he said, "especially their respect for life. It was not just about how to handle the problem of aging, but how to harness what they have to offer the community."

Hurricanes expose gaps in social services. In 2000, LeMaire went to work for United Way of Central Florida, at a time when aging issues were not high on the organization's agenda. Then in 2004, four major hurricanes roared through Central Florida, disrupting what were already tenuous social service systems. "It really exposed a lot of what elders were dealing with," LeMaire said, "whether it was transportation, medication management or housing. It was hard to ignore."

As vice president of community impact, in charge of assessing community needs and allocating United Way funds for various projects, LeMaire began looking at ways to "do more and better with how we invested our dollars in aging."

Up north in Jacksonville, United Way of Northeast Florida, had already broadened its mission, creating a community partnership, called Life: Act 2, in 2002 to identify and work on issues that threatened the well-being of older adults. The organization asked LeMaire to head up the effort.

"I was not brought into Life: Act 2 because I had an expertise in aging," LeMaire confessed. "But I had a passion for the population. And it was about relationship-building. I was good at that, meeting people for the first time and just being curious."

In its needs assessment, Life: Act 2 had discovered that "care transitions" from the hospital back to the community were a big problem. With the RWJF grant, United Way of Northeast Florida began to create a community strategy to improve those transitions.

The project. Community Partnerships for Older Adults asked its grantees to work from the ground up to improve the well-being of older adults. That meant getting everybody at the table who had a stake in the issues—especially older adults themselves—and working together to set goals and create strategies for reaching those goals.

Because the United Way was not in the "aging business," it was in a good position to provide a "neutral table" where everyone's voice could be heard. The partnership's membership was "quite comprehensive," LeMaire recalled, and stacked with community leaders, including CEOs, heads of foundations and other funders, attorneys, and representatives of social service providers and health care organizations.

"Mostly these were people who did not have a dog in the hunt," LeMaire said. "They just cared about seniors. These were people who were good at leading meetings, good at pushing [for change], good with people. They had solid credibility in the community, and that elevated our partnership."

"What can we do better?" The partnership had zeroed in on the care transition problem not by examining discharge statistics but by listening to what people in the community told them. "We never went and said to the community, 'Here are your problems and we are going to solve them,'" LeMaire said. "We started Life: Act 2 face-to-face in small group settings, asking people what they observed in seniors' lives. 'What could we do better by seniors in the community?'

"When you start with that tone, you invite people in," he said. "People are much more willing to help you solve a problem when they help you identify a problem."

Anticipating what discharged patients need. To address care transitions, Life: Act 2 created a model that called for full-time elder advocates to work closely both with hospital staff to anticipate post-discharge needs and with providers of long-term-care services and supportive services to arrange for what was needed. Two providers in Jacksonville—Baptist Medical Center, the largest hospital system in northeast Florida, and SHANDS Jacksonville Health System, the teaching hospital of the University of Florida—signed on to be pilot sites for the program in 2007.

"The elder advocates focused exclusively on seniors who were at risk of being readmitted," LeMaire said. "They were charged with thinking of the nonmedical needs that could complicate their recovery."

Advocates met with patients in the hospital, talked to family members, and built customized care plans. Sometimes what patients needed to return home was as simple as cleaning spoiled food out of the refrigerator and getting the electricity turned back on. Other times the barriers were more daunting—arranging for the care of a family member with dementia, for example.

The advocates did the research and arranged for services and made referrals to community agencies. They also provided toolkits and made follow-up phone calls after discharge to ensure older patients were making a smooth transition.

Results. By its second year, the care advocates program had helped some 1,400 older adults successfully manage the transition from hospital to home. The service provided most often was meals—more than 5,000 between 2007 and 2010. The program also distributed more than 1,000 informational tool kits during the same time period.

A questionnaire distributed to patients several weeks after discharge, found nearly universal satisfaction with the program. The hospital leaders were pleased too, and decided to incorporate key elements of the program into their ongoing operations.

In May 2009, Baptist Medical Center hired its own elder care advocate, and has since expanded the program so that four of its hospitals now participate. SHANDS Jacksonville launched its own care transition pilot program focused on the needs of elder patients discharged with congestive heart failure.

"Our health systems partners saw the value," LeMaire said, "and they each saw it differently. Baptist saw the customer service value that, with a growing population of elders, fit right into where they were going. SHANDS looked at it from a return-on-investment perspective, which fit within their culture. Both programs have now taken on a life of their own."

Leaving your hats at the door. The effectiveness of the care advocate project owes a great deal to the steadfastness of the Life: Act 2 partnership, LeMaire said. "Keeping together interested, talented, very thoughtful volunteers and leaders over that time frame was important," LeMaire said. "And that is not an easy task. The United Way was able to provide a safe place where people can leave their hats at the door and say, 'What are we going to do now. How are we going to work together?'"

"I think I am most proud that people didn't seem to care about credit," he continued. "At United Way we did not want to be in the limelight. It was gratifying to see our partnership live with those same values. You can see that when you are in the same room. People are contributing. You just didn't see a lot of ego."

The "can-do" spirit continues to hold sway at United Way, LeMaire said. Inspired by the SHANDS pilot program the organization is now creating a community-based education program aimed at helping seniors better manage chronic disease. One initiative underway as of November 2011 is training pharmacists at select Publix supermarkets to help their older customers identify local supports for preventing or managing chronic disease.

"We used the same principals for learning and project development [as we did in the Life: Act 2 Partnership]," LeMaire said. "We didn't start with the hospital readmission data. We started by interviewing seniors and asking, 'What are we missing?'"

The fine art of listening. Working with and on behalf of older adults has challenged common stereotypes about aging, LeMaire said. "We think, 'Oh, you are older, so you have health challenges. You are frail, so you are done for, one step from the nursing home.' Well, I am younger and I have health challenges, too.

"It is easy to get too professional about these topics. We get so drawn into the data, we forget to listen to people. We forget to include older people's opinions and perspectives. That's where some of our best ideas and learning came from—the elders."

In 2011, LeMaire moved up to vice-president of planned giving at United Way, but the lessons learned leading Life: Act 2 continue to inform him: "One conversation should to lead to another," he said. "If I stay curious, I'll stay healthy. If I stay curious, that will be good for me personally and professionally."

RWJF perspective. Community Partnerships for Older Adults was an eight-year, $28 million national initiative of the Robert Wood Johnson Foundation (RWJF) that supported 16 communities to create collaborative partnerships to address the many gaps and inefficiencies in long-term care and supportive systems for vulnerable older adults.

RWJF Director of the Vulnerable Populations Team and Senior Program Officer Jane Isaacs Lowe notes, "One of the goals was to make what is a patchwork of long-term-care services in communities behave more like a coordinated system. We wanted to make sure that along that continuum of care, elders in communities had the breadth of services they needed.

"In general, the partnerships have demonstrated that innovations are possible in communities across the country—that allow people to age in place and that make for better care delivery for people with long-term-care needs."