There’s a program at North Shore Elder Services (NSES) that is proving pivotal to keeping consumers out of hospitals and remaining in their own homes. Developed and managed by NSES Chief Program Officer, Cheryl Krisko, RN, the Improving Health Outcomes (IHO) for L.I.F.E. (Low Income Frail Elders) program is designed for those consumers most at risk for hospitalization or nursing home placement due to difficulty with the management of their health condition, medications, or access to medical appointments. The program has received grant funding from The Clara and Harvey Pillsbury Foundation, Inc., the Andrew W. Preston Charitable Foundation, and The Women’s Fund of Essex County.
The program utilizes a contracted Registered Nurse to provide monthly visits to consumers who are most at risk in the community. The focus of this visit is to provide medication management, disease education, health care planning, risk assessment, and caregiver support. At Your Side medical advocates provide additional support for these consumers: enhancing collaboration with medical providers, supporting care transitions, and offering seamless communication between medical systems. The advocate accompanies the consumer to their medical appointment, ensuring that the consumer has their questions answered, that they understand any changes to their medications or medical regime, and that informal supports are updated if desired. Dr. Mark Messenger, medical advisor for NSES, provides in-home primary care for many of the IHO homebound consumers. Currently, over 100 consumers are enrolled in the program.
“The goal of the IHO program is to improve the quality of life for the consumer which usually means reducing unnecessary hospitalizations or nursing home admissions for consumers who want to remain in the community. The consumer, care manager, and nurse working as a team identify what the consumer’s goals are, analyze where there are weaknesses or gaps in care, and then work to fill those gaps. We also want to encourage consumers to become advocates for their own health care if possible. Consistency and continuity of care is what has made the IHO program so successful.”
For more information, to make a referral to the program or become a medical advocate volunteer, please call 978-750-4540 or submit an application at www.nselder.org.