Sustaining Health in the Home
Community-academic partnership involves churches, nurses, physicians, friends and family in effort to prevent common causes of hospitalization for older adults
If a senior neighbor, parent or grandparent were to suffer a serious trauma, like a heart attack or stroke, there is no better place for them than the hospital. The acute care expertise that begins with the emergency responder can drastically change the outcome of a health crisis.
While hospitals provide vital acute care to older adults who are admitted, research also indicates that the hospital environment can contribute to accelerated functional decline in elderly patients. Seniors are being admitted in droves, as persons aged 65 and over accounted for nearly 39 percent of hospitalizations in the United States in 2010 while comprising only 13 percent of the overall population, according to the Centers for Disease Control and Prevention. And African-American seniors aged 65 and over are hospitalized at above-average rates.
“The hospital is not always a conducive place for these older adults,” Julie Ellis, PhD, RN, GCNS, Columbia College of Nursing, said. “There are syndromes that can occur, such as falls, sleep disorders, and delirium, which is new-onset confusion. Delirium by itself carries a significant mortality rate.”
“Hospitals are not bad places, they are absolutely crucial for many things,” Jeffrey Morzinski, PhD, MSW, Medical College of Wisconsin Department of Family and Community Medicine, said. “But it is important to avoid those hospitalizations that can be prevented and keep older adults safely in their homes and communities whenever possible.”
The Advancing a Healthier Wisconsin endowment funded the One Hundred Healthy, At-Risk Families project in 2013. The pilot project is implementing an intervention to sustain the health of 100 African-American seniors in Milwaukee who are considered “at-risk” for decline because of their history of chronic disease along with recent hospital, emergency room or urgent care use. The endowment supported the work through its Healthier Wisconsin Partnership Program, which invests in partnerships between Medical College of Wisconsin faculty members and community organizations that aim to improve community health.
“We’re an initiative that is implementing a grassroots strategy with a segment of this population,” Dr. Ellis said, “which happens to be church community members, to attempt to link, connect, empower and educate through churches and through pastors.” Ten cross-denominational churches joined the partnerships because their pastors wished to do more to sustain the health of their congregations.
“Pastoral leadership is crucial to the success of this type of project,” stated Dr. Morzinski.
The project partners use a number of strategies to reduce risks and avoid preventable hospitalization. Nurses working with the project meet monthly with groups of enrolled seniors and their designated support persons. During the meeting, the nurse provides an evidence-based curriculum on relevant topics, such as preventing falls, and facilitates a discussion between the participants as they share experiences and realistic solutions.
“Participants love the sessions,” Dr. Ellis said, “and they are eager for more engagement around health-related topics.”
In addition to the education and support sessions, the project partners work with enrolled seniors to create an “activated support team,” which includes their primary care doctor, a nurse involved in the project, a church volunteer and the elder’s designated key support person. These support teams help the seniors pinpoint personal “red flags” that could lead to hospitalization.
“The nurses and the support teams help our participants understand what red flags to be vigilant about and how to effectively respond,” Dr. Ellis said. She explained that red flags are signs or symptoms of pending illness specific to the health of each individual.
To keep everyone associated with the seniors’ care well-informed, the project partners facilitate communication between the participants, the support teams and the seniors’ health clinics regarding the status of red flags.
“One participant,” Dr. Ellis said, “recently told me about the change in their doctor visits, saying, ‘I used to just go and kind of sit there and see what they had to tell me. Now I have questions to ask.’”
The project partners recently shared their work at a “Summit on Safe Homes and Senior Health” held at St. Martin de Porres Catholic Church, one of the partner churches involved in the project. The ministers and community members in attendance were excited about the work that has been done to-date and its future potential to be incorporated in more churches throughout Milwaukee.
“We are focusing now on learning from the partnership,” Dr. Morzinski said, “so that we can continue our efforts to better maintain the health of at-risk seniors and strengthen our communities.”