On Site for Seniors, a Coeur d'Alene-based mobile primary medical-care provider, recently started a test pilot program to evaluate an integrated-care approach for its elderly clients who are recovering from a medical procedure.

Lynne Martin, On Site for Senior's office manager, says the pilot test's intent is to ensure that elderly patients who undergo a procedure receive continuity of care from the time they are discharged to when they're fully healed.

"We have found in various studies that one in five Medicare patients is re-hospitalized within 30 days of being discharged," she says. "What happens is that many times, the re-hospitalization can be because patients don't understand how to care for themselves when they get out, and they didn't embrace that (discharge) information."

On Site for Seniors is based at 7950 N. Meadowlark Way and employs a total of 16 people, eight of whom are either medical doctors or nurse practitioners, Martin says. The nonprofit organization has more than 600 active patients, and it provides on-site medical care to those patients in their homes or in an assisted-living facility. Martin says the nonprofit provides care to adults of any age, but that most of its patients are well into their 60s or older.

On Site for Seniors' service territory includes all of Coeur d'Alene and extends to State Line to the west; Lancaster Road, in Hayden, to the north; the Spokane River to the south; and the Canfield Mountain area to the east.

The ongoing test pilot to improve a patient's transition from a hospital seeks to create a standard form that is used by all of the Coeur d'Alene area's medical-care providers, including hospital staff and assisted living and acute-care facilities, Martin says.

She says because all of those care environments use different forms to record a patient's basic health information and care regimen, instructions could become lost, overlooked, or skewed each time that information is transferred to a new form. That, in turn, could affect a patient's ability to heal or recover from a medical procedure, she says.

"If we all speak the same language and get on the same form, the better the chance that nothing will go unnoticed because we all are looking at the same form, so it becomes a collaborative effort," Martin says.

She says the program also intends to make sure that patients' care providers all are on the same page in terms of making sure the person is taking the correct medications at the correct times and is following the recovery instructions provided to them upon being discharged.

"When they get home, they have sheets with orders and what they are supposed to do, but someone might be too tired or confused, and doesn't grasp the instructions," Martin says.

Martin says the participants so far in On Site for Seniors' patient transition pilot program include Ivy Court, a skilled-nursing facility in Coeur d'Alene, and Kootenai Medical Center. Ivy Court also provides short-term rehabilitation services to patients who are transitioning from a hospital after undergoing a procedure there, but aren't yet ready to go home.

"The next step would be to incorporate more facilities into the program," Martin says. "We have commitments from the skilled-nursing facilities in the community—they are excited to have a voice to improve patient care."

She says On Site for Seniors also would like to eventually incorporate some home-health companies into the transition-care program that could help ensure a patient follows care instructions arriving back at home.

On Site for Seniors was established in 2008 by Dr. Susan Melchiore and Lynda Arnold, a nurse practitioner who specializes in wound care.

Martin says the two women founded the organization because they saw a need for a mobile primary care service to help the community's homebound elders who might have difficulties leaving their homes to receive medical care in an office setting.