Insights

The healthcare system as a whole is fractured, fragmented, and difficult to maneuver. Healthcare providers and recipients are being penalized for a system that has been unable to fix itself. There are creative organizations all across the nation participating in innovative pilot programs in an effort to accomplish Better Care, Better Health, Lower Costs (the triple aim of the Center for Medicare/Medicaid Services (CMS).

Healthcare collaborations have become a necessity in order to create systems that address the many gaps in available healthcare resources. Collaborations with the right organizations provide necessary resources, expertise, and capacity to manage a larger population of individuals with a variety of needs than could possibly be managed by one organization alone. Through the collaborating efforts of multiple organizations we will be able to touch the lives of many in an efficient and coordinated way. Porter Hills, Clark Retirement, Holland Home, Life EMS and Sunset Retirement have collaborated to form a new organization by the name of Tandem365.

The intent of the program is to address the many gaps that occur when a patient transfers between healthcare environments. Our focus is patient transition from acute care to skilled nursing or home health needs. Through our research it is clear that preventing re-hospitalizations and unnecessary emergency room visits is key, and to reduce these occurrences would require a more strategic approach.

Many older adults are frail, socially isolated and otherwise without a reliable support system in place which lends to frequent emergency room visits and deteriorating health conditions that go unmonitored or remain undetected. Identifying these individuals who are at risk and initiating a health plan as well as an individual who “manages or coordinates” the adherence to a plan and access to appropriate resources could greatly reduce healthcare costs related to frequent trips to the hospital.

Program design provides comprehensive supports and services that promote choice and alternatives for care in the least restrictive environment as possible. The model is designed to closely resemble a PACE (Program for All inclusive Care for the Elderly) structure with many of the same components that have brought success to these type of programs. Program elements include resources that not only provide physical care and interventions as needed, but also include resources that are focused on preventative care and wellness.

PROGRAM ELEMENTS INCLUDE:

• IDT – Interdisciplinary Team
• Community Resources – Paramedicine Program and Volunteer Program
• Telephonic Visits
• Health Improvement Plan
• PERS (Personal Respone System)
• Telehealth
• Day Center
• Transportation
• Communication Across All Levels of Service

For more information on Tandem365 visit www.tandem365.com.