Building Bridges To Community Care For Older Adults In Genesee County

At the Health Foundation, we truly enjoy highlighting our grantee partners and the amazing work that they do. Here is a spotlight from our 2021 annual report: Connections.

In rural communities, barriers to high-quality health care for older adults can result from social or environmental obstacles such as a lack of transportation, geographic distance to care providers, and more. There is growing evidence that shows building networks between the community organizations that help address these issues and health care systems can help improve access and care outcomes.

To address these barriers, Lifespan’s Community Care Connections (CCC) program has led an expansion of comprehensive care management and health care coordination services to Medicaid beneficiaries, age 55 and older, and other individuals with Medicare or private insurance living in Genesee County. The Health Foundation supports this work as part of our mid-term goal that communities and health systems are working collaboratively to become age-friendly.

Lifespan’s CCC program works to improve health outcomes for individuals who have medical, behavioral health, and/or social needs by helping them coordinate their care and connect to supportive services. Licensed Practical Nurse (LPN) health care coordinators and social work care managers work in tandem with medical providers to help individuals navigate systems.

They schedule and attend medical appointments with patients, coordinate transportation for those appointments, conduct medication reconciliations at home, and provide health literacy training.

Lifespan’s social workers visit people at home, assess needs, and link individuals and their families to supportive services. The program has been such a success that it was recognized by the Archstone Foundation in 2019 as an Excellence in Program Innovation awardee, an annual honor recognizing programs that effectively link academic theory with applied practice in public health and aging.

“The key to the success of this menu of services is our ability to have a two-way dialogue with doctors and other medical professionals about both health and social support needs at home,” noted Ann Marie Cook, President and CEO of Lifespan. “We’ve proven this model can improve patient outcomes and reduce unnecessary emergency department visits and hospitalizations, and that’s a win for everyone. It also reduces both physician and patient/family caregiver frustrations.”

The COVID-19 pandemic posed some challenges to CCC’s outreach efforts to connect to new primary care physician (PCP) offices in the beginning of the program.

“During that period, PCPs cancelled most routine appointments. Because of the stress on the health care system, it was difficult to make connections with new PCPs,” said Karin Davison, LPN Healthcare Coordinator. “After the initial barriers to the CCC program expansion in Genesee County caused by the pandemic, Lifespan has been successful in outreach efforts. We have established referral pathways with five PCP practices for patients living in Genesee County and, as a result, we exceeded our enrollment goal for 2021.”

The impact on patients has been clear—Karin shared the story of a Genesee County resident who was referred to Lifespan by her primary care physician. The patient’s home was in foreclosure, and her physician noted that she was having issues with medication management. Lifespan’s team connected her with an attorney that prevented her from losing her home, implemented medication management services and mail-order delivery of her medication, and is helping with coordinating medical appointments and transportation to those appointments.

“Her physician has told her that she is doing so much better than she was a year ago, due to the increased support she now has with Lifespan,” said Karin. “At every office visit, she thanks her LPN Healthcare Coordinator for being at the appointment with her and says she looks forward to seeing her again.”

Click here to learn more about Lifespan’s programming.