Journal of Geriatric Care Management Spotlights the Effectiveness of SeniorBridge’s Integrated Approach in Improving Health Outcomes and Reducing Overall Cost of Care
SeniorBridge's unique model of care management involving teams of licensed nurses, licensed social workers, certified caregivers and professionals including nutritionists, occupational therapists, geriatric exercise specialists and massage therapists, was spotlighted in an in-depth article in the peer-reviewed Journal of Geriatric Care Management. The article, penned by SeniorBridge's Rona Bartelstone, LCSW, points to the positive impact of keeping frail seniors out of this hospitals on families, health organizations and society at large.
Below is an excerpt from the article. To read the whole article, click here.
Transitioning Care to the Home: Reducing Rehospitalizations Among Frail Elders
Rona S. Bartelstone, LCSW, BCD, CMC, C-ASWCM
As healthcare companies innovate to create sustainable solutions to this growing challenge, SeniorBridge has created a model that facilitates good social policy without investment of public funds and is therefore poised to inform social policy and create models for replication and continuity. As the largest care management company in the country, SeniorBridge provides a role model for how other care management practices can also begin to impact positive health outcomes for Medicare beneficiaries throughout the country.
SeniorBridge’s integrated approach addresses the reality that disease management is only part of the problem -- and that until we address patients’ functional needs, we cannot provide these patients the care they deserve. The company’s interdisciplinary approach utilizes an integrated care management team of nurses and social workers to address functional, environmental, behavioral, and medical needs. This person-centered approach facilitates the creation of partnerships that build on the strengths of care recipients in a manner tailored to their needs and preferences.
SeniorBridge’s proprietary web-based electronic health record allows for documentation of health information from multiple physicians and care manager assessments including information about the living environment, the social support system, the behavioral health issues, and legal and financial status in addition to the traditional medical diagnoses, medications, treatments, and hospitalizations. The breadth of this health record enables our care managers to monitor and address the full array of issues as they relate to the medical concerns that impact chronic care needs. Furthermore, the electronic health record facilitates real-time communication between care managers and health care providers to assure that the services in the home are consistent with the physician-driven plan of care. In this manner, the care manager becomes the physician extender into the home setting, while assuring maximum use of primary care to forestall preventable use of emergency room visits and hospitalizations.
To read the whole article, click here.