ElderCare health recovery project model for consideration

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Primary and Ambulatory Care

Dr. Angela M. Kelly-Shelby
ElderCare Health Recovery Project
Escambia County Medical Society Foundation

Dr. Donna Jacobi
Florida State University

The ElderCare Health Recovery Project is a transitional, client-centered system of community-based care. It was developed following two and a half years of information gathering through the collaborative efforts of the Escambia County Medical Society Foundation (ECMS Foundation) and a stakeholder group comprised of 35 health and social service agencies in Escambia County, Fla. The goal was to offset re-hospitalizations of patients 60 years old and older.

The re-hospitalization rate for acute and repeated sentinel events in just 60 days post- hospitalization is 22 percent. This does not include visits to the emergency department, use of emergency medical services (EMS), or admissions to higher levels of care such as nursing homes. The project volunteers will provide assessment of cognition, activities of daily living, nutrition, substance abuse, safety, and referral to appropriate community resources. These same volunteers will enlist cost-shared services as appropriate: personal care, home-delivered meals, homemaker services, case-management for complex cases, and home visits by nurse practitioners at the request of the primary care physician. The ECMS Foundation and stakeholders believe that the ElderCare Health Recovery Project will provide an easy to use and replicable system of care that will reduce re-hospitalizations, emergency department visits, ambulance transports, and nursing home admissions. They expect this to reduce overall health care costs by providing the elderly with increased knowledge on the services available to help them maintain their independence.