A new model of care collaboration for community-dwelling elders: findings and lessons learned from the NORC-health care linkage evaluation

PURPOSE: Providing care for older individuals with chronic illnesses in the community requires a model of service delivery that takes into account both physical health and social health needs. However, packaging care in this way does not fit into existing service or reimbursement structures in the US, and there are few financial incentives that encourage service coordination. Lack of coordinated care can negatively affect access to high quality, appropriate care, putting seniors' physical and mental health and quality of life at risk, as well as their ability to stay in the community. Supportive Social Programs (SSPs), operating in Naturally Occurring Retirement Communities (NORCs), attempt to increase access to care and enhance care quality for aging residents through outreach and service facilitation. Since their inception in 1986, NORC-SSPs have partnered with local health care providers to address both individual and community-wide health issues; however, each sector continues to operate along functional lines, and on a reactive basis. This article presents findings from an evaluation conducted from 2002 to 2006 looking at the feasibility, quality and outcomes of linking health and social services through innovative NORC-SSP and health organization partnerships. METHODS: Four NORC-SSPs participated in the study by finding a health care provider to collaborate on addressing health conditions that could benefit from a biopsychosocial approach. Each site focused on a specific population, a specific condition or problem, and created different linkages to address the target problem. Using a case study approach, incorporating both qualitative and quantitative methods, this evaluation sought to answer the following two primary questions: 1) have the participating sites created viable linkages between the participating organizations that did not exist prior to the study; and, 2) to what extent have the linkages resulted in improvements in clinical and other health and social outcomes? RESULTS: Findings suggest that immediate outcomes were widely achieved across sites: knowledge of other sector providers' capabilities and services increased; communication across providers increased; identification of target population increased; and, awareness of risks, symptoms and healthy behaviors among clients/patients increased. Furthermore, intermediate outcomes were also widely achieved: shared care planning increased across providers; continuity of care was enhanced; disease management improved; and self care among clients improved. Finally, several linkage partnerships were also able to demonstrate improvements in distal outcomes: falls risk decreased; clinical indicators for diabetes management improved; and inappropriate hospitalizations decreased. DISCUSSION: Using simple, familiar and relatively low-tech approaches to sharing critical patient information among collaborating organizations, inter-sector linkages were successfully established at all four sites. Seven critical success factors emerged that increase the likelihood that linkages will be implemented, effective and sustained: 1) careful goal selection; 2) meaningful collaboration; 3) appropriate role for clients; 4) realistic interventions; 5) realistic expectations for implementation environment; 6) continuous focus on outcomes; and, 7) stable leadership. A considerable amount of literature speaks to the importance of organizational partnerships to improve community health; however, findings from this evaluation suggest that less complex, more focused, micro-level collaborations can also make a difference, extending the feasibility that organizations will enter into such endeavors.