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After Hospital Discharge, Seniors Can Go Anywhere . . . So How Does Your Site Stand Out?

JacquelynKung's picture

By Jacquelyn Kung

One of the most read articles this year has been the one extolling Jimmy Buffett opening a retirement community in Florida in 2018. The link to that piece is here.

Dan Rexford and Tony Mullens were quick and brilliant to point out that his Margaritaville properties will only be active adult / age 55+. They will not be traditional senior housing, which includes independent living, assisted living, memory care, skilled nursing, and/or life plan CCRCs. 

So true. Now, let's take it further.

FAMILIES AND SENIORS CAN OFTEN GO ANYWHERE. Value-based contracts often opt for at-home options, skipping nursing home stays. So we need to both keep our residents from an ER transfer in the first place AND be attractive options for a post hospital setting.

The business results can be transformative.

How do we get them?

The Four Key Points

Here are the four things that we feel make our sites safe and great for seniors after a hospitalization—and below that are the performance results that some communities have achieved with these components in place:

1. Service-rich housing

After a hospitalization, seniors need things like housing, food, transportation and social engagement/activities. These services are built into independent living, assisted living, and other types of seniors housing. But we cannot rest on our laurels. Services are being added to at-home and other housing options.

For instance, NORCs, or naturally occurring retirement communities, or apartments and condos are adding services. At most Four Seasons apartments, you can take the elevator down to the second floor for an all-inclusive fine dining experience with great service, including servers who notice changes in your condition. Greystone is reportedly building multi-family apartment buildings with some services, targeting older adults.

2. Primary care with care management

After a hospitalization, seeing your primary care provider within 3 days significantly decreases the risk of readmission. But for those of us who have worked with seniors, we know that it's also care management—or helping to coordinate the litany of specialists, primary care physicians, prescriptions, car rides and family dysfunctions that enhance primary care. 

More and more senior living sites are adding primary care practices on site. Those that do it with care management—in the form of a medical concierge or hands-on social workers—see much better results in their lengths of stay and care outcomes.

3. On-site ancillary services

Hospitalizations trigger a myriad of physical and internal changes for seniors. Having on-site rehab is critical, as is access to same-day medication changes. We would further argue that home health, non-medical home care and restorative nursing are good ancillary services to build in (outside non-medical home care and many to all of these services have Medicare A and B reimbursement options that help increase your site revenues).

4. Good data and communication for the care team

By now, you probably see how it's a full care team that makes hospital discharge a success for seniors. (Many in academia and the clinical world will call this an "interdisciplinary" team.) What most people miss, though, is the flow of data and communication that stitches together the good care.

Having records stored electronically is one big step. But not enough. Everyone should have access to the data in real-time form. This way, the physician or nurse practitioner can see what has happened in physical therapy that may be related to an unexpected embolism or UTI. Treated right away, we avoid another dreaded hospital stay. Seniors, referrers, and families all appreciate knowing this—and data and communication makes it possible.

Business results you can expect

If you've been hiding under a rock, you may have missed the good work that Juniper Communities has been doing quietly. Fortunately, Lynne has presented on her program. Anne Tumlinson did the analytics, and they published the clinical results. 

The program is called Connect4Life, and it includes all of the four elements above, sewn together with a nurse practitioner through Redwood Partners and a medical concierge who orchestrates the care team and who residents fondly call their "emcee."

You can watch a 2 minute video on the bottom half of the homepage at JuniperCommunities.com 

In short, the clinical results are astonishing:

  • 80% decrease in hospitalizations versus a similar group of Medicare seniors
  • 50% decrease in readmissions alone

Wow, huh?

As you can imagine, referrers have taken notice and business metrics have improved significantly:

  • Across Juniper Communities, referral volume has shot up over 20%
  • Move-outs have decreased because fewer residents need to leave for medical reasons: average length of stay has increased by 1 month across all residents

Do the math on all that, and you will see that seniors can go anywhere after a discharge—so you can benefit by making your site meet their needs.


Dr. Lynne Katzmann is CEO of Juniper Communities, which is known for creating and spurring innovation in our sector. Her PhD is from London School of Economics, and she was a leader in the 1970s in helping to start the movement for alternative delivery service care models.

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