Newport News, Va. – Taking care of yourself isn't easy when you're aging, living alone and juggling multiple health problems.

That's when senior care navigators can step in.

Navigators, which Riverside Health System has been using for years to help guide patients through a cancer diagnosis, are now being used by the health system to aid seniors.

The service is free.

Riverside introduced senior care navigators in January 2011 in an effort to help seniors have a smooth, seamless transition from care to the community. The pilot program aims to not just help the 80-year-old fall patient, but to help her from falling again.

Senior care navigators offer help for free

In January 2011, Riverside Regional Medical Center's emergency department and health system's Lifelong Health division started working on a pilot program to improve seniors' experiences during and after emergency room visits, said Kim Harper, director of emergency services. Seniors make up about 20 percent of the patients who visit the emergency department, and they may have different needs than the rest of the population.

Patients who are at high risk for readmission – who are older than 65, have five or more medications and go home alone – are assigned a senior care navigator. A free service, the navigator checks on patients by phone to review discharge instructions, help arrange follow-up appointments with the patients' primary care physician or help patients find a physician if they don't have one, said Kim Weitzenhofer, director of community ventures for Riverside's Lifelong Health and Aging-Related Services division.

Navigators point patients to a rich variety of services Riverside offers seniors, such as PACE (Program of All-Inclusive Care for the Elderly), a memory clinic, in-home care, personal response systems, medication dispensing devices and long-term care facilities, as well as community resources, such as Meals on Wheels, Alzheimer's support groups and the Peninsula Agency on Aging.

"There's so much out there that people don't know about," Weitzenhofer said.

Riverside has two senior care navigators -- one a registered nurse (RN), the other a seasoned licensed practical nurse (LPN). Both are certified senior advisors, a designation provided by the Denver-based Society of Certified Senior Advisors.

Studies have shown that community-based care management is successful in reducing readmissions, Weizenhofer said. Keeping people healthier is expected to keep medical costs down for everyone.

As a result of the pilot program, navigators have assisted about 300 seniors, and emergency department patient satisfaction rates have improved.

Success stories

A 72-year-old man came to the emergency department for pleurisy, or inflammation to the lining of his lungs. In a follow-up phone call, the senior care navigator learned he planned to get a prescription filled that he no longer needed. She intervened and prevented him from needlessly taking the prescription.

In another case, an 87-year-old woman visited the emergency department for weakness, Parkinson's disease and high blood pressure. She was told to follow up with her primary care provider and to see a neurologist. The patient told the navigator she had no plans to follow up because she didn't have transportation to the appointments. The navigator arranged for a volunteer-based organization to provide her a ride.

Better care for the elderly

The emergency department itself underwent changes to better assist elderly patients.

The department, the Peninsula's only Level II trauma center, expanded the criteria on what would trigger the trauma team for older patients. That means better care for people who are over 65.

A healthy young adult could fall from a standing position and not suffer trauma.

"If an 80-year-old falls from a standing position, they're going to break something," Harper said.

In response to feedback about cold rooms, the department bought Bair Paws, which hooks patient gowns to a heater to keep patients warm.

Emergency department staff was educated on caring for seniors. Nurses began taking more time going over discharge instructions. The department is working on examining the medications patients are on to help prevent patients from experiencing side effects such as dizziness, which could lead to frequent falls.

"A lot of it was just training our staff to look not just what they're here for, say, a hip fracture, but to look beyond that. To look for more that could be going on with the patient than just the emergency they came in for," Harper said.

"It's doing the right thing for our community members," Weitzenhofer said.

Riverside Senior Care Navigation is a free service offered by the health system. For assistance, call (757) 856-7030 or toll free 1-877-287-6061.


Published: June 11, 2012