July 11, 2024
Fairview and Ebenezer’s Partnership Helps Provide Coordinated and Personalized Care
On July 11, 2024 by Kayla Khang
Fairview and Ebenezer’s affiliation enhances service and resource coordination for seniors.
Ebenezer offers a large range of senior care, including seven subsidized affordable housing units, 37 assisted living facilities, seven long-term care facilities, five adult day programs, short-term rehab programs, and four child day programs embedded within their senior living communities. Fairview Partners, their care management program, focuses on providing services to those living in long-term care (LTC) and assisted living (AL) communities as well as seniors living in their own home in the community.
Fairview has the largest healthcare geographic footprint in the state. Based in Minnesota, Fairview has 10 hospitals, an academic health center, over 80 primary and specialty clinics, more than 30 pharmacies, and over 100 assisted living units.
20% of Fairview patients are over the age of 65. The geriatric team consists of seven physicians and 32 advanced practice nurse providers, delivering comprehensive services in a traditional clinical model. This team serves approximately 2,200 patients residing in nursing or assisted living facilities. Providing care in the communities where the seniors live while coordinating with staff from the senior’s community has resulted in positive outcomes in their care.
Fairview Partners’ Community Model: Coordinated and Personalized Care
The Fairview Partners’ Community Model is a PACE like program designed to support individuals living independently in the broader community. During initial enrollment, an in-home assessment is conducted to develop a personalized care plan for the senior, followed by care coordination and any needed referrals. Regular six-month check-ins and annual home visits ensure support for seniors in the program, addressing preventive care needs and allowing for the care team to revise care plans as necessary. The program currently serves 4,000 individuals, with the capacity to expand as new care managers are added.
This model, primarily aimed at those on government support through dual enrollment programs, emphasizes the critical role of care coordination during transitions. Ebenezer has found that this program is particularly helpful when a senior is transitioning to a different care level.
Adapting to a Changing Healthcare Landscape
Fairview has observed a growing trend of patients with more acute and complex conditions, especially in patients aged 65+. The number of elderly patients admitted for care has increased, now accounting for 38% of discharges—a 3% year-over-year increase. The rising cost of medications and the complexity of care required for elderly patients contribute to these challenges.
Post-acute care settings like nursing homes and assisted living facilities have experienced capacity issues driven by staffing shortages, which have increased post pandemic. The recent increase in patient complexity combined with the need for bariatric, chemical dependency, mental health, and wound care services further complicates patient placement in an appropriate assisted living or nursing home setting that can serve their needs.
Government and administrative processes, such as guardianship, can also cause delays in transition between hospital and nursing home or assisted living settings. In some cases, patients were stuck in a hospital for over 100 days due to county-level delays in establishing guardianship, which was necessary for Medicaid applications and financial management.
Ebenezer recently presented to the Legislative Task Force on Aging to highlight these challenges.
Fairview Health Services and Ebenezer offered the task force several solutions to address these challenges:
- Payment and Care Models: Fairview noted that the Program of All-Inclusive Care for the Elderly (PACE) should be a priority of the legislature in 2025.
- Centers of Excellence: Fairview highlighted the need for centers of excellence for post-acute care.
- Technological Advancements: Fairview showed that new technology in post-acute care settings can assist residents and caregivers. Assistance and support from the legislature addressing the high cost and rapid advancement of technology will be important to ensuring accessibility for seniors and their caregivers.