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

NORC-SSP site	NORC community	Staffing	NORC health care partner (existing)	Linkage focal point (new)
Mid-Manhattan	A coalition of a public housing complex and a moderate-income cooperative on Manhattan’s Upper West Side where more than 800 of the approximately 3200 residents are seniors. Senior residents are primarily Black and Hispanic (76% combined). NORC-SSP established in 2000	Two and a half full-time social workers, one full-time nurse	Local hospital	Emergency Department of local hospital partner, and local pharmacies
Lower Manhattan	A public housing project on Manhattan’s Lower East Side with 27 buildings, 3000 residents, 860 of whom are seniors. The senior population is diverse: 59% Hispanic; 22% Asian; 14% White; 5% Black. NORC-SSP established in 1993	Four full-time social workers, one part-time nurse (3 day/week)	Certified home care agency	Local primary care clinic
Queens	A moderate income garden apartment cooperative in northeast Queens, home to more than 4000 residents, 1000 of whom are seniors. Senior residents are overwhelmingly White. NORC-SSP established in 2000	Two full-time social workers, and a 75% time nurse (4 days/week)	Local hospital	Community physicians affiliated with local hospital partner
Brooklyn	A large, primarily low-income rental housing complex in an isolated part of southern Brooklyn, with 46 buildings, 14,000 residents, 2700 of whom are seniors. The senior population is diverse: 44% Black; 41% White; 15% Hispanic and a growing Russian population. NORC-SSP established in 2000	Three full-time social workers, one full-time nurse	Local hospital	Community physicians

Table 2.

Primary linkage interventions: systematic sharing of information

NORC-SSP site	Target condition	Description of systematic sharing of information
Mid-Manhattan	Transition from ED to community	• Daily email list of ED discharges within the NORC-SSP catchment area • Electronic medication record housed by and updates by local pharmacies
Lower Manhattan	Diabetes	• Shared Electronic Patient Database with diagnostic, treatment and appointment information
Queens	Falls	• Consultation letter from NORC-SSP to PCPs with results from the Hartford Falls Risk Assessment Protocol and recommendations for treatment and/or referral
Brooklyn	Depression	• Shared Client Passport with results from the Hamilton Depression Screening Protocol and notes on all medical and social work visits

Table 3.

Increased awareness of partner services

Site	Evidence
Mid-Manhattan	• Seventy-one percent of ED staff correctly identified the NORC program, its services and client eligibility • One hundred percent of ED staff correctly reported the MyMeds program purpose • Eighty-six percent of ED staff correctly identified MyMeds partners • Ninety-three percent ED docs were able to correctly report how to identify a MyMeds member
Lower Manhattan	Seventy-four percent of primary care physicians working in diabetes at the primary care center were aware of the Lower Manhattan NORC, and 63% of the joint diabetes Linkage project
Queens	• Twelve formal presentations were made by the NORC-SSP for community physicians (3–4 per quarter) • On average, 24 community physicians attended each presentation
Brooklyn	Anecdotal evidence (i.e. increases in documented communication between NORC-SSP and physicians during the Linkage project) suggests increased awareness

Table 4.

Increased communication among partners

Site	Evidence
Mid-Manhattan	• On average 117 contacts per quarter, 28% related to medications • On average 8% of all contacts with the NORC program were initiated by a pharmacy per quarter
Lower Manhattan	• Eighty-four patient-related contacts documented for the 39 test patients; of those, 15 were referrals from the primary care center to the NORC program, 12 were new referrals for home care services, and 15 involved self-management plan interventions
Queens	• Approximately 30 contacts (telephone, fax, in person) between the NORC-SSP and community physicians per quarter; increasing percentage initiated by the community physicians (20% on average, per quarter), • NORC-SSP communicated with 39 different community physicians during the project
Brooklyn	• Over 50 patient-related contacts per quarter (over 200 by the end of the implementation year for 45 enrolled patients) with 34 participating community physicians • Increasing number initiated by community physicians (11% by the end of the implementation year)

Table 5.

Increased identification of residents in need

Site	Evidence
Mid-Manhattan	• One hundred percent of ED visits by participating residents enrolled in the MyMeds program were reported to the NORC-SSP • Approximately 30% of the (100) enrollees were new to the NORC-SSP
Lower Manhattan	• All enrollees received at least one intervention (e.g. home care referrals, NORC nurse visit, phone reminders, etc.) through the integrated diabetes assessment program, with many receiving multiple interventions
Queens	• Approximately 100 client assessments or reassessments were conducted by NORC-SSP staff (approx. 25 per quarter) using the Hartford Falls Risk Assessment protocol • Approximately 70% of those clients assessed for falls risk were determined to be at risk and in need of intervention
Brooklyn	• Approximately one-quarter of all participating residents reported that their physician or physician office staff asked if they were a client of the Brooklyn-based NORC at the time of an office visit

Table 6.

Increased shared care planning

Site	Evidence
Mid-Manhattan	• Providers reached out to the NORC-SSP to get information on shared patients or to find out how to enroll other patients into the Linkage project
Lower Manhattan	• Fifty-two collaborative assessments of diabetes status conducted for the target patients over the course of the year • Quarterly group visits at the primary care center drew approximately 5 NORC program clients each time • Fifty-six percent of residents report seeing the NORC-SSP and the primary care center staff work together to assist them in their diabetes treatment
Queens	• Providers responded to assessment findings and care plan recommendations that were sent by the NORC-SSP nurse or presented by the resident • Residents reported that physicians began asking them about mobility issues and falls
Brooklyn	• Twenty-four percent residents reported that their physicians either looked or wrote in the client passport

Table 7.

Increased continuity of care

Site	Evidence
Mid-Manhattan	• Shared medication information led to sharing of other health information across providers • By the end of the implementation year, 14 pharmacies had joined the MyMeds network
Lower Manhattan	• All diabetes linkage program enrollees visited a doctor during the implementation year • Forty-eight percent missed appointments in 2005, only 27% missed appointments in 2006, a 45% reduction
Queens	• By the end of the implementation year, the majority of residents surveyed were able to identify falls risks • Increased number of residents report telling their physician about a fall (38% in the 1st quarter, 50% in the 4th) • Increased number of residents made a change to prevent a fall (53% in the 1st quarter; 67% in the 4th) • Fewer participants reported a fear of falling (35% in 1st quarter, 20% in 4th) • Fewer participants reported discomfort speaking with providers about falls
Brooklyn	• Increased comfort talking to physicians about emotional health issues (from 12% in 1st quarter to 43% in 4th) • Increased comfort talking to NORC-SSP staff about emotional health issues (from 27% in 1st quarter; 47% in 4th) • Increased numbers of clients reported showing their passports or NORC-SSP chart stickers to physicians over time (10% in 1st quarter; 30% in 4th)

Table 8.

Improved care outcomes

Site	Evidence
Mid-Manhattan	• Number of ED revisits at 30 days decreased from the beginning of the implementation year to the end, from 21% of all ED visits to 5%
Lower Manhattan	• By the end of the implementation year, enrollees were showing improved levels of A1c (14% increase in number of enrollees with A1c <7), blood pressure (19% increase in number of enrollees with blood pressure <130/80) and LDL (12% increase in enrollees with an LDL <100), and were getting a greater number of annual eye (10% increase) and foot exams (38% increase)⁸
Queens	• Hartford assessment scores improved over the four quarters (approx. 60% decreased risk; approx. 30% stabilized risk; approx. 10% increased risk)
Brooklyn	• Improved emotional health status doubled (from 41% in 1st quarter to 88% in 4th)