Helping Older Adults Flourish for a Lifetime

The U of L Institute for Sustainable Health & Optimal Aging brings an innovative approach to coordinated, interdisciplinary care for older adults

LOUISVILLE By 2030, one in five Americans will be considered an older adult; therefore, it is imperative that the healthcare industry innovates to meet the need. The University of Louisville Institute for Sustainable Health & Optimal Aging (ISHOA) is leading the way. According to their website, “The U of L Institute for Sustainable Health & Optimal Aging empowers older adults to flourish by building collaborative community networks of research, education, innovation, and practice. We are dedicated to bringing about a new vision of aging where individuals and society are able to approach aging as an opportunity, not as a disease.”

The Institute leadership team, which is made up of Anna Faul, PhD, Christian Furman, MD, Joe D’Ambrosio, PhD, JD, and Pamela Yankeelov, PhD, is acutely aware of the unique problems facing older adults. “Geriatrics is a specialty. There are things that we do different in geriatrics and gerontology that we don’t do with someone who is twenty or thirty years old,” says D’Ambrosio, who serves as the director of health innovation and sustainability. D’Ambrosio holds his PhD in social work with a specialization in gerontology and also a JD from U of L’s law school. In addition, he is a licensed marriage and family therapist and certified social worker.

Furman, ISHOA’s medical director, elaborates, “In geriatrics, we look at older adults differently. We really focus on patient medications and psychosocial factors. We do a lot of dementia care. We understand that older adults often need palliative care, so we’re focused on advanced care planning. We’re focused on functional status, making sure they can do their daily activities and function at home.” Upon receiving her medical degree from U of L, Furman began practicing geriatric medicine, which she has continued to do for over fifteen years. She is also a professor of geriatric and palliative medicine at U of L.

“We are experiencing a major demographic shift. In 2030, one in every five Americans will be an older adult that comes with a specific amount of complex health issues. We need to have an interdisciplinary-trained geriatric workforce to help with their care coordination, so our older adults can flourish in their communities, homes, and families,” adds director of research Yankeelov. In addition to her role with the Institute, Yankeelov, who possesses a PhD in experimental psychology with an emphasis in social psychology, is a professor and an associate dean of academic affairs at the U of L Kent School of Social Work.

To meet these burgeoning needs, the Institute has developed the Flourish Network, an initiative that seeks to improve the health and well-being of older adults living in rural Kentucky communities. The foundation of the Flourish Network is the Flourish Care Coordination Model. The Flourish Care Coordination Model is based on having individuals from diverse disciplines share patient information and insights to form a comprehensive care plan. “This innovative model integrates behavioral and clinical care plans with community care plans,” says Faul, executive director of ISHOA. Faul holds a PhD in social work, the distinction of Hartford Geriatric Scholar, and has over 20 years of experience in gerontology. She also serves as professor and associate dean at the U of L Kent School of Social work.

“The Flourish Network encompasses five programs that work together in a coordinated, multi-prong approach to provide integrated, interdisciplinary care to older adults,” explains Faul. The other initiatives in the Flourish network address professional education, development of community supports, and dementia awareness and outreach.

Through the Flourish Program, patients receive coordinated care that begins with an in-home visit from a specially-trained healthcare navigator. “What we’re doing differently is meeting with the patients in their homes. And, in meeting with the patients at home, we’re finding a lot of times there are personal issues that have to be addressed,” says D’Ambrosio.

During the meeting, the healthcare navigator performs an in-depth assessment, which often involves speaking with the patient, their caregiver, and family members. During the interview, they not only take the patient’s detailed medical history, but assess their medications, nutrition and exercise, home and personal hygiene, environmental hazards, and psychosocial wellbeing. Traditionally, healthcare navigators were registered nurses, but the Institute has expanded their force to include social workers, behavioral health clinicians, and community workers. In 2018, they are going to begin to train a community workforce that can provide health care navigation.

Upon completing the assessment, the healthcare navigator brings their findings back to the team at a case conceptualization meeting to decide how to best proceed in coordinating the patient’s care. Furman adds, “You have to stand shoulder to shoulder with the primary care doctors and go through the cases and show them how you can really take care of older adults using a health team.” All interdisciplinary providers of care to older adults benefit from this model, adds Faul. The focus is to help all professionals to work within a transdisciplinary team when supporting vulnerable older adults living in the community with their health care needs. These professionals include primary care physicians, nurses, social workers, dentists, community support workers, and physical therapists.

Participating providers receive knowledge and skills focused on the unique challenges of caring for older adults in the community. Primary care practices receive extra benefit as the Flourish team also guides them to maximize their understanding of Medicare billing codes and to work toward coordinated care in a new financial model that can greatly benefit medical practices.

The ultimate goal of this transdisciplinary approach is to ensure that the geriatric patient receives holistic, integrative care. D’Ambrosio states, “What is really exciting about the Flourish Model is that patients are finally able to receive coordinated care that involves not only their body, but also their mind, their heart, and their soul. So, we’re offering a holistic view of health within the Flourish Program.”

“Integrated primary care and community-based models of care have the potential to improve outcomes in frail older adults,” says Faul. Instead of traditional outcome measures focused on a reduction of hospitalizations, ER visits, and improved disease management, the Flourish Care Coordination Model focuses instead on all the determinants of health promoted by the CDC: biological, individual health behaviors, environmental, health services, psychological, and social. “Our data shows that even though these vulnerable older adults did not necessarily improve in terms of actual health outcomes, they improve because they have more support to perform activities of daily living.”

To illustrate, Furman recounts the story of a female patient who was thought to have severe dementia. A healthcare navigator realized that the patient was not suffering from dementia, but rather that the woman was on a multitude of unmonitored medications which caused the symptoms of dementia, had very poor nutrition, and was suffering from social isolation. Using the team approach, the Institute developed an integrative plan that involved modifying her medications, addressing her loneliness, and connecting her with a food delivery service. Furman says, “She turned around and now has no memory problems. Everyone thought she had dementia. She did not have dementia. She was lonely, and she was depressed and on all of these medications she didn’t need.”

Six months after the initial assessment, the healthcare navigator performs a follow-up interview to track patient progress. Over the last 18 months, the Flourish Program has taken 70 referrals, worked with 50 individuals, and gathered pre-and post-data assessment results for 25 patients. Of this data, Yankeelov says, “We are seeing changes—significant, positive changes in all determinates of health.”

This proves that ISHOA is meeting its mission as described by D’Ambrosio, “We are driven by the idea that all patients should be able to flourish in spite of illness. As the body ages, it is more susceptible to disease. But, in spite of disease, all of us should be able to flourish.”

Yankeelov adds, “Flourish is all about helping individuals achieve optimal aging experiences. And, who doesn’t want that?”

“You have to stand shoulder to shoulder with the primary care doctors and go through the cases and show them how you can really take care of older adults using a health team.”– Dr. Christian Furman

“We are driven by the idea that ail patients should be able to flourish in spite of illness. As the body ages, it is more susceptible to disease. But, in spite of disease, all of us should be able to flourish.”– Dr. Joe D’Ambrosio

“Flourish is all about helping individuals achieve optimal aging experiences. And, who doesn’t want that?”– Dr. Pamela Yankeelov