TriHealth Senior Link

Albert Feng, Summer 2012

TriHealth SeniorLink is a PACE (Program for All-Inclusive Care for the Elderly) program that provides comprehensive care to low income seniors while allowing them to live at home and remain independent. In order to qualify for the program, the participants must require nursing home level of care, be over age 55, and reside in Hamilton County or adjacent counties. There are two day health centers, Norwood and Court Street, which serve the needs of the participants.

TriHealth SeniorLink has many resources to provide a wide range of services for its participants, especially a great transportation system. Trained SeniorLink drivers utilize a set of vans to transport participants between their homes, one of the health centers, and other medical facilities. These drivers are vital for many of the patients who cannot drive around themselves and also have ambulation problems. As an intern, one of my responsibilities was to accompany and assist participants from vans to the health centers in the morning and then back onto the vans in the afternoon. This is very important as many of the elderly participants have impaired mobility, so they require assistance and are at more risk for injuries from falls.

The health center employs a large interdisciplinary team of professionals to care for the health and social needs of its participants. Physicians, nurse practitioners, and nurses see patients in the clinic for their medical care. Participants also receive specialty care at the day health centers, such as psychiatry and podiatry. Other members of the team include social workers, therapists (physical, occupational, recreational), dieticians, and aides. For those participants who do not make the trip to the day health centers, members of the care team provide home care. The majority of my responsibilities involved aiding the clinic in patient care. My duties included escorting scheduled patients to the clinic, checking vital signs, and shadowing the clinic staff. During my experience in the clinic, I learned about many common health problems facing geriatric patients and difficulties in addressing these problems. I gained valuable insight into the dynamics and factors involved in caring for geriatric patients.

SeniorLink has implemented the MOLST (Medical Orders for Life-Sustaining Treatment) program, which documents patients’ wishes regarding life-sustaining treatments as medical orders. Patients indicate their decisions regarding CPR, medical interventions, antibiotic use, and artificial nutrition/hydration. The program aims to prevent unwanted medical interventions that may arise from interpreting advanced directives from current documentation, such as a living will.

As an Urban Health Project intern, I worked on a project to evaluate the MOLST program. The previous intern conducted a pre-MOLST survey to assess the staff’s knowledge about topics related to advanced care planning. After the survey, many of the staff underwent training to learn more about end-of-life discussions and documentation. I conducted a post-MOLST survey to analyze the effectiveness of MOLST training and the initial implementation of the MOLST program. I also surveyed participants to assess the patient perspective. The results helped me address areas that needed improvement, especially patient education.