Successful Aging in Place

According to the Robert Wood Johnson Foundation, one in five elderly patients nationally are readmitted to the hospital within 30 days of discharge. Now, a new Northland collaborative program, Aging in Place, will help ensure proper supports are in place for elderly people who return to the community, thus reducing the rate of rehospitalization.
Community partners include:

  • North Kansas City Hospital 
  • LifeWise Renovations
  • Cerner Corporation 
  • Shepard Center of the Northland 
  • Clay County Senior Services 
  • Platte County Senior Services 
  • K2 Consulting Solutions

Aging in Place Approach

The comprehensive program is a holistic approach with a multidisciplinary focus on clinical care, health behaviors, and social and physical environments. On January 1, North Kansas City Hospital began screening all discharging Clay and Platte County inpatients 65 and older for program eligibility. Primary care physicians will be notified when their patients qualify.

Aging in Place has three components: care coordination, service-enriched housing and community engagement.

Care Coordination

An NKCH RN will serve as the program case manager and coordinate care management. The case manager’s responsibilities include: 

  • Recruiting patients
  • Coordinating care, such as doctor appointments with primary care physicians and other health services
  • Assisting with the patient’s transition of care from hospital to home
  • Following up with post-discharge home visits and phone calls
  • Educating patients about disease management and medications

Service-enriched Housing

An occupational therapist from Lifewise Renovations is responsible for:

  • Conducting a full home safety assessment
  • Creating a prioritized list of suggested modifications
  • Working with participants to make low-cost and simple modifications
  • Scheduling and overseeing home modifications

Community Engagement

A social worker from Northland Shepard’s Center will coordinate community support services such as workshops, wellness classes and transportation. The social worker will also:

  • Conduct a community-based needs assessment upon patient discharge
  • Assess available community resources
  • Connect participants to services
  • Identify barriers to patient engagement

The Aging in Place program will track process measures and outcomes including:

  • Rate of hospital readmission
  • Rate of falls
  • Functional independence
  • Quality of life

James Stewart, MD

James L StewartDr. Stewart, NKCH case management medical director says, “Program partners believe there is no place like home for recovering patients and that this innovative program will positively contribute to the patient experience and help people recover at home successfully and avoid readmissions.”