Improved Outcomes for Those With complex Chronic Conditions

Our approach to care is based on our own unique Integrated Practice Unit. The Integrated Practice Unit (IPU) is a system of organizing and providing care that enables individuals with comorbidities, including Alzheimer’s disease and related dementias, to live at home and get better care. The IPU consists of a dedicated team working together to achieve systematic improvement in the provision of care to clients. Because many individuals’ clinical conditions will be in the moderate to advanced stage, they may be unable to self-manage, walk, maintain their homes, drive safely or take medications appropriately. Other may be depressed or unable to remember recent events. Their conditions may make it impossible to perform the Activities of Daily Living or Instrumental Activities of Daily Living, tasks such as bathing, dressing, eating, shopping, and cooking.

We pioneered the IPU based on many clinical studies of recent years that evaluated the outcomes of care for people with complex chronic conditions. These studies have shown that approaches similar to our IPU model improve outcomes for clients.

Clinical Evidence

Our model of care is based on a large body of clinical literature dedicated to evaluating patient outcomes in chronically ill populations. Many studies demonstrate improved overall health and quality of care for clients with chronic disease through the use of organized care management processes, integrated health teams and comprehensive services that address multiple aspects of a client’s condition.

Widespread Support for Integrated Care Model

Less agitation in Alzheimer’s patients and less stress in caregivers with collaborative care model

In a study of 153 older adults with Alzheimer's disease and their caregivers, two groups were followed for 18 months. One group received collaborative care, spearheaded by an advanced practice nurse. The control group was not exposed to the team approach to health care, but did receive educational materials on the disease. Conclusion: the decreased patient agitation seen in the care group was directly correlated with lower caregiver stress and fewer depressive symptoms, and was achieved without anti-psychotics or sedatives.
-MEDICAL NEWS TODAY, PUBLISHED BY JAMA* (2006)

Care coordination, counseling and support improve patient outcomes

In a study of 139 elderly patients with cardiac medical and surgical diagnosis, it was found that the greater the nursing time spent and number of contacts per patient, the better the patient outcome and the lower the healthcare costs. Three interventions were especially valuable: (1) surveillance of symptoms and behaviors; (2) care coordination; and (3) counseling and support.
-JOURNAL OF NURSING SCHOLARSHIP (2003)

Chronic care model shows improved patient outcomes

The chronic care model, a model of care involving multidisciplinary practice teams of 6 to 8 people, including nurses and social workers, each with a “physician champion,” has proven to be effective in improving patient outcomes. This was found by a number of studies of populations with different chronic conditions, including diabetes, asthma, depression and others commonly found in the elderly population.
-JOURNAL OF THE AMERICAN MEDICAL ASSOCIATION (2002)

Benefits of restorative home care versus traditional home care

A study of 1,382 elderly patients that compared restorative home care with traditional home care services. It found that restorative home care, based on principles from geriatric medicine, nursing rehabilitation and goal attainment, was shown to prevent the functional decline that occurs in elderly patients after they are discharged from a hospital.
-JOURNAL OF THE AMERICAN MEDICAL ASSOCIATION (2002)