Bridging a Gap in Services for the Community Dwelling Elderly


Background & Goal

Frail, elderly individuals are at risk for adverse health outcomes, hospitalizations and premature nursing home placement. Those still living at home but not qualifying for home health care via Medicare need higher care levels than typically provided through outpatient physician visits. Senior ASSIST’s goal is to help the frail elderly deal with multiple medical problems, cognitive impairment and the lack of support systems so that they can avoid hospitalizations and continue to live safely in their own homes.

Program Description

Senior ASSIST (Assisting Seniors to Stay Independent through Services and Teaching) is a program under which a geriatric-trained registered nurse care manager makes home visits for comprehensive assessments and follow-up care. It provides individualized, ongoing instruction in self-care, including how to take medications, home safety, nutrition and more. Nurses collaborate with physicians, report changes in condition, assess response to treatment and refer clients to other community resources to strengthen the support system.

Evidence of Success

  • Client satisfaction (1998-2010):
    • 97% would recommend the service to others
    • 91% were highly satisfied with their health care
    • 95% reported the nurse helped get services essential to staying in their homes
    • 93% said health care services were coordinated
    • 94% reported they were taught about medications and diet
    • 91% believed their health was improved through Senior ASSIST
  • Physician satisfaction(1998-2010):
    • 96% saw program as beneficial to their patients
    • 93% said the program helped patients appropriately enter and use the health care system
    • 80% found patients were better able to self-manage their care
  • Cost Effectiveness (2000):
    • 63% decrease in hospitalizations
    • 46% decrease in ER visits
    • 62% dollar savings to the health care system
  • Significant improvements in patient clinical health indicators: B/P, nutrition, weight, HgbA1c, overall risk level (2000)

For More Information Contact:

Diane McGee, RN, MSN

The Nebraska Medical Center
987454 Nebraska Medical Center
Omaha, NE 68198-7454