How We Partner With Our Residents Physicians to Improve Outcomes

About Kim Elliott

Chief Nursing Officer

When it comes to leading clinical programs, Kim is our go-to authority on resident care, while maintaining the highest standards for quality and compliance. As Chief Nursing Officer, her care philosophy is based on the importance of individualized care, personal choice and resident independence. Kim is dedicated to finding more options to help our residents live and age well. That’s why she has taken a population health approach to surrounding our residents with the healthcare services they need to help manage their chronic conditions. Kim’s passion for senior healthcare developed in nursing school during a routine rotation. When she saw a shortage of quality nurses working in senior living, Kim knew she had found her calling and a place where she could make a difference. Kim joined Brookdale in 2014. She serves on the Argentum Clinical Quality Executive Roundtable, is on the Dean’s Advisory Board for the Central Florida University School of Nursing and is a member of the Nightingale Society. She was recently inducted into McKnight’s Women of Distinction Hall of Fame. Kim has a master’s degree in Nursing, with a specialty of executive leadership from Chamberlain College of Nursing.

When Dr. Thomas Lally, Denver-based primary care physician, compared the rates of assisted living to what one of his senior patients was paying for round-the-clock-care at home, he was astounded. Assisted living would save his patient money. Moving into a Brookdale community provided access to 24-hour staff, plus meals, community amenities and social activities. It was a win-win-win for Dr. Lally, his patient and Brookdale.

This is a scenario we see every day as the clinical services in an assisted living setting are evolving. The industry began as a hospitality business, but today, we are caring for many more higher acuity residents living with chronic conditions than ever before.

The healthcare industry is seeing the potential positive impact senior living can have on patients. Here at Brookdale, we want to continue to grow and set the stage for a healthcare-focused assisted living environment. This is why we collaborate with primary care physicians across the country, like Dr. Lally in Denver.

To do that, we need to embrace a population health approach. So what exactly does “population health” mean?

At its core, population health refers to the health outcomes of a group of individuals—like seniors living in an assisted living community. But among practitioners, population health refers to more than just a group of individuals; it’s evolving into a framework for collaboration among healthcare providers, agencies and organizations to work together to improve the health outcomes of the populations they serve. Dr. Lally describes it as the difference between waiting for a patient to come to you and the healthcare community looking at a group of patients and proactively figuring out how to treat them as a whole.

At Brookdale, rather than waiting until a resident or patient is in need, our goal is to provide encouragement for and access to preventive care, help manage chronic conditions and prevent hospitalizations.

So how does the population health model work in a senior living setting?

In a senior living setting, the population health model is a proactive, whole-person view of care, as well as the other non-medical interventions needed to maintain or improve an individual’s health. For example, at Brookdale, our Optimum Life program, based on six dimensions of wellness, is woven into our resident engagement program.

The second way this model comes to life in assisted living is with healthcare methodologies, programs and tracking outcomes that address the overall health of a larger group of people (such as a specific community or city) through actions of its individuals. Brookdale addresses the overall health of our assisted living residents with programs like our falls management program, which focuses on education and reducing risk factors, and our medication management program. We also offer a continuum of care options, including specialized dementia care.

The third opportunity to use the population health model is delivering care that focuses on health and wellness along with education. Coordinating care to address an individual resident's needs has the potential to improve things fora larger group by creating a healthier community of residents.

Collaborating with primary care physicians

And here’s where our partnerships with primary care physicians come in. We want to work collaboratively with our physician partners, like our Denver communities do with Dr. Lally. Together, we can make sure we meet our residents' healthcare needs. To do that, we are working toward including our residents’ healthcare physicians in our collaborative care model, where we meet regularly for care reviews with residents, families and community associates.

We also align with our physician partners to help drive preventive care. For example, we offer immunization clinics to protect our population from the flu, shingles and pneumonia. We will also encourage residents to seek and help coordinate physician visits for annual wellness exams and work to proactively manage chronic conditions to keep our residents healthy.

We want to continue to be a trusted partner for our residents’ primary care physicians, and make sure our residents have the care they need. That’s why we train our staff to meet Brookdale’s high-quality standards.

For example, Brookdale has a medication administration program that includes staff training to increase our staff’s knowledge of intended effects and side effects of certain medications. This training also focuses on raising awareness of medication interactions so we can notify a resident’s physician or healthcare provider if we suspect a potential issue.

Using an assessment process, we develop a customized personal service plan for each assisted living resident. We also apply a uniform approach for various conditions including diabetic management, special dietary requirements, COPD, incontinence and dehydration, so the physicians we partner with know their patients are receiving consistent care from trained staff. We also offer specialized clinical programs in select communities for residents with diabetes, Parkinson's disease, heart failure, COPD, bone and joint conditions and stroke.

Once a resident’s personal service plan is in place, we monitor the quality of care that is delivered. Our Health and Wellness Directors follow a protocol to view quality outcomes in real-time by monitoring fall management, UTIs, timely medication administration and skin conditions. We also have electronic documentation and reporting capabilities to share metrics on quality outcomes with our resident’s healthcare team, including vitals and weight measurements.

As the senior living industry continues to move forward and see more integration between senior housing and healthcare, primary care physicians will play a critical role in the population health model. Our goal is to continue to strengthen our partnerships with physicians by working together to deliver seamless care for our residents.

Dr. Lally notes that there are more options for patients than many physicians are aware of – and assisted living may be the answer they are looking for. Thanks to Brookdale, his patient is thriving at her new community. Together, we can help more seniors find the same level of comfort and comprehensive care.