Help at Home - A Proper Assessment is the key to an effective Care Plan

y name is Jenny Lind and, I’ve been working in the home care industry for 14 years. We’ve recently implemented the Senior Helpers Life Profile assessment tool in partnership with Performance Based Healthcare Solutions (PBHS) out of Galveston, Texas. I’m excited to share our new approach to home care and how it can reduce the risk of hospitalization.

We can now categorize and quantify the 13 key areas in which a person must have their needs met in order to successfully age in place. Using our Autonomy Profile Score, we can help reduce the risk of a senior going to the hospital in the next six months from 80% to less than 10%.

We have found that over 3.5 million potentially preventable adult hospitalizations occur each year in the United States.

This study was verified by AHRQthe Agency for Healthcare Research and Quality (AHRQ.gov). In this statistic, hospitalizations are three-night stays where the person is admitted, and does not include short trips to the ER, which is significantly more often.

Let’s take for example, a senior who has a fall in the shower. This senior has arthritis and has difficulty standing for long periods of time. The fall could have been easily prevented with the addition of a tub bench. EMS takes the senior to the hospital where they are diagnosed with a hip fracture. The hospital does a hip replacement and discharges this senior to skilled nursing where they receive therapy. The skilled nursing then discharges them home with home health where they complete therapy and then are discharged from therapy. No one ever identifies the root cause of the fall, missing a tub bench. We now have a senior who is weaker after going through the healthcare continuum and the root cause of their fall was never addressed, or maybe it was - after the incident occurred!

communities, hospices, and physicians, and with over 75,000 participants.

Results of the study showed:

1. Improved outcomes - reduced hospitalizations and increased ability to age in place

2. Improved care modelsbetter support across the healthcare continuum

Life Profile gives us the ability to “scan” a senior’s living situation and determine their risk of hospitalization in the next six months.

We assess 144 safety risks around the home including medication management and with a focus and priority on quality of life, including leisure interests and social interactions in terms of weekly and monthly activity plans.

These are the 13 key areas that a senior must have their needs met, in order to be able to age in place successfully. The first 10 include:

1. Hydration/nutrition

2. Bills paid

3. Getting groceries/supplies

4. Getting help

5. Laundry

6. Garbage removed why seniors fail and go to the hospital. Because of this, Medical Condition Management is triple weighted on the scoring system.

After the assessment and scoring is completed, we immediately work on ways to reduce the score, which will result in a lower likelihood of hospitalization.

Once the Life Profile assessment is complete, we can suggest improvements for their living situation; and a care plan can be put together. A care plan that will lead to better outcomes.

We want to work toward having the senior person safe, confident, supported, and enjoying a fulfilled life with the maximum independence possible.

My agency, Senior Helpers, provides licensed non-medical home care and is proud to be working out of Brentwood, Oakley, Antioch and Discovery Bay for 15 years. If you are interested in finding out more, please call me at my office at 925-240-0001.

These occurrences are most often related to medical condition management. How often are these hospitalizations related to someone not properly managing their hypertension or diabetes and they get dizzy and have a fall because their medical condition was not being managed?

In the healthcare continuum, rarely is there someone assigned the responsibility to look for the root cause of what led a senior to the hospital.

Life Profile gives Senior Helpers the ability to identify these risk factors and reduce the risk factors for going to the hospital.

Life Profile

Life Profile is built from a national research collaborative, which has assembled over 20 years of research, 300 organizations across the healthcare continuum including: private duty, hospitals, skilled nursing, senior living

7. Cleaning and managing their house

8. Transportation and using the phone.

9. Mobility (walking, transferring)

10. Activities of daily living (dressing, hygiene, etc.) present a higher risk of going to the hospital and are double weighted.

Not having their medical condition managed is the number one reason