Providence Elder at Home

Shannon Jackson, M.D., associate medical director, Providence Elder at Home
Ruth Johanson, executive, Providence Geriatrics Program

As Providence medical providers, we have all seen patients whose conditions or symptoms are not well served by the typical medical care model. Patients with chronic illness and frailty often seek care repeatedly in the emergency room or hospital setting due to difficulty accessing after-hours or immediate help during the day.

That is why Elder at Home, a new collaboration between Providence Health Plan and Providence Geriatrics Program, has been created. EAH will serve a select number of PHP Oregon Medicare Advantage members who meet specific clinical, age and risk criteria and who reside in Clackamas, Multnomah, Washington and parts of Yamhill counties.

EAH is a team-based model of care. It is designed to meet the needs of the most medically fragile PHP Medicare Advantage members by providing multidisciplinary support in the patient's home. They may define home as a private home, an adult care home, an assisted living facility, or an intermediate-care nursing facility.

All EAH team members are experienced in caring for the elderly. The core team comprises physicians, nurse practitioners, physician assistants, registered nurses and licensed clinical social workers. Depending on the needs of the patient, EAH will add other specialists to the team, including chaplains, clinical pharmacists, dietitians, licensed practical nurses, medical assistants and rehabilitation therapists. The EAH team will work with the patient's primary care provider to monitor the patient's health, design a treatment plan, manage medications, address safety concerns and identify needed support services solutions.

EAH providers will handle routine and chronic care management visits as well as urgent visits for acute symptom assessment. Patients participating in EAH will have access to 24/7 nursing triage support. And, if needed, they will receive in-home assessment by RN and medical providers, even during nights and weekends.

The patient's primary care physician will still be very much involved with the patient and engaged in decisions about referrals to specialists, transition to hospice, and more. When EAH patients do come to the ED or hospital, an EAH nurse or provider will engage in the discharge planning, including creative management of illness in the home setting.

The EAH patient is charged the regular co-pay when seen by a medical provider. There is no cost to join the program and no cost when seen by a social worker or nurse. There is also no financial risk to the primary care provider in having a patient co-managed by the EAH team.

Shannon Jackson, M.D., is EAH's associate medical director. She is a former PPMC internal medicine resident, ElderPlace physician and PPMC hospitalist. Dr. Jackson, with five provider-led core teams, started seeing referred patients on Aug. 8.

The EAH program is rolling out to select PMG clinics and Portland IPA clinics in the coming months, starting with PMG-Gateway, PMG-Sunset, PMG-Gresham, PMG-Scholls and Westside Internal Medicine.

Questions regarding EAH may be directed to Tanya McGee, director of operations, or Shannon Jackson, M.D., by calling 503-215-0750. To learn more about the Providence Geriatrics Program, please contact Marian Hodges, M.D., medical director, or Ruth Johanson, executive director.