Senior Community Links Hospitals With Care Visits to Reduce Readmissions

A partnership between an affordable senior housing community and nearby health system has significantly reduced the senior housing residents’ visits and admissions to the emergency room.

Harrisburg, Pa.-based Presbyterian Apartments’ residents were frequenting nearby health system The PinnacleHealth System’s ER for primary care purposes, prompting both organizations to discuss targeted ways to provide primary care for residents.

Since Presbyterian Senior Living (PSL) partnered with The PinnacleHealth System, data show that between January 2012 and December 2013 there was an over 50% reduction in ER visits from residents of the 165-unit community, and an over 70% reduction in admissions, says Diane Burfeindt, vice president of Operations/Residential and Community Services at Presbyterian Senior Living Pennsylvania.


Partnerships between senior housing communities health care providers are the “new thing,”  Burfeindt says, noting that hospitals are under increased pressure to lower patient readmissions.

While PSL is not in an Accountable Care Organization (ACO) with The PinnacleHealth System, the health system is in an ACO and is able to learn from its partnership with PSL, which creates a mutually beneficial relationship.

“The partnership coincided with all the changes going on in health care,” she says. “We’re using this project as the basis to demonstrate how we can apply this model to assist other [PSL] populations.”


Many of the housing community’s residents have chronic conditions and complex health needs, she says. 

“We wanted to find a way to help these individuals a bit more,” she says. “We found that having access to transportation, knowing how to read medication — these were all factors in good health.”

While the original pilot started with a once-weekly on-site clinic with a physician, nurse and social worker, it has since evolved into home visits, supplemented with a weekly clinic. The home visits are conducted by a physician and nurse and allow them to assist a resident much like a typical office visit, but also provides the professionals with a better understanding of their living arrangement, medications and other social issues that may be impacting their quality of life and health care.

“This inter-relationship between the medical and social components of health is one of the hallmarks of the partnership,” Burfeindt says, adding that the supportive services coordinator who is on-site at Presbyterian Apartments knows the residents well and works closely with the clinical team and the social worker to identify services and programs available to support their ability to receive preventive care, obtain transportation and access available programs in the community.

Now in its fourth year, Burfeindt says the program’s success is the result of a lot of hands-on work. 

“We set out with small goals, and over time we developed something that got to be really good,” she says. “[Providers] should create a program that can create good outcomes so people want to become a part of it.”

Written by Cassandra Dowell