Meals on Wheels tests high-tech health checks for seniors
Just after he finished delivering a meal to 70-year-old Anne Stillman of Vista, a question popped up on Christopher Topper’s smartphone screen.

Meals on Wheels is now not only delivering meals to geriatric clients, but checking after their healthcare.

Just after he finished delivering a meal to 70-year-old Anne Stillman of Vista, a question popped up on Christopher Topper’s smartphone screen.

Before getting into his truck to head to his next delivery, the Meals on Wheels courier took just a second to respond to the query.

“The app asks me if there is a change in condition, meaning, is there anything that needs to be reported about her wellness? Anne looks great, I’m going to hit ‘no’ and, boom, on to the next client,” Topper said just before sliding back behind the wheel.

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That quick tap puts Meals on Wheels on the edge of a revolution in health care that seeks to take action on potential problems in homes before seniors end up in the back of an ambulance.

This kind of work, experts say, is becoming more vital as baby boomers enter retirement age and advances in health care mean that their parents have a better chance than ever of celebrating their 100th birthdays.

Those age 65 and older were already consuming significantly more of the nation’s emergency department visits in 2014 than they were in 2006, according to an estimate from the U.S. Agency for Healthcare Research and Quality. During that year span, seniors jumped from 16.8 percent of all visits to 18 percent nationwide, an increase of more than 4 million visits in eight years. And demographers expect that trend to accelerate.

San Diego has recently become something of a hotbed for efforts to stem the tide through prevention, either on the front end by stopping accidents before they happen or on the back end by reducing the chances that hospitalized older patients will be readmitted once they are sent home.

Meals on Wheels, for example, has asked its volunteers and paid couriers to keep an eye on the senior clients they see many times per week. But that oversight has been largely ad-hoc.

Here is the classic opportunity for data-driven change, said Dr. Zia Agha, chief medical officer at San Diego’s West Health, a research and philanthropy non profit.

Dinner with a side of health

West helped add a module to the “SERVtracker” software that many Meals on Wheels operations use to guide their drivers from one home to the next and confirm that each delivery has been made. That “has the client’s condition changed” question is asked each time a driver confirms delivery, and, if they say yes, then the system automatically moves through a list of ever more precise follow-ups, helping to triage the specific problem that needs attention.

Once that problem is identified, drivers can hit send and the information moves electronically back to headquarters where a care coordinator can take a look often before the driver has left the driveway.

Though Topper did not find anything amiss at Stillman’s mobile home, he said he has had a few cases over the last two and a half months where the software made a difference. In one case, a female client had extreme dental pain and no way to get to a dentist. In another case, he noticed that a woman’s home, which was always meticulously kept, was a mess, indicating she may have been experiencing a mental or physical problem.

“As soon as you hit the button, lots of people know that there is an issue, and they can get right on it,” Topper said.

Some might wonder what the clients make of the idea that the people who are delivering their meals are also scoping them out for health problems and reporting any that they might observe.

Standing in the doorway of her mobile home, Stillman said she doesn’t consider this kind of observation intrusive. A while back, she said, she would have died due to undiagnosed diabetes if her nephew hadn’t happened to come check on her and saw that she was too weak to walk outside. The paramedic, she said, told her she wouldn’t have lasted another day.

“I don’t think it’s invasive if you’re truly concerned about somebody, you know,” she said.

Debbie Case, president of Meals on Wheels of San Diego County, said having the incoming information pre-sorted into categories helps elicit a rapid connection to the right resources, whether it’s social services, health providers or transportation networks.

The system started this spring on single North County delivery route and was used with only a handful of the program’s full-time paid couriers but expanded this summer to include about 40 volunteers serving six routes around the county.

Case said that, in eight weeks of trial operation, volunteers reported 60 changes in condition on 22 of their clients, using the software to immediately send a report which can bring about a response in less than a day in non-emergency situations that otherwise might take several days to sort out.

Now, she noted, the challenge is to expand electronic delivery tracking to the thousands of volunteers who deliver meals across San Diego, and across the country. Most are seniors themselves, and many aren’t that interested in using smartphone apps.

“We can’t just pull the bandage off or we lose 3,000 volunteers. You have to do it strategically over the next couple of years,” Case said.

Emergencies not the whole story

Still, these kind of problem-interceptor programs are not a panacea, says Dr. Daniel Waxman, a UCLA Los Angeles emergency department doctor and health policy researcher.

Preventive programs, he said, can certainly help reduce visits and costs.

But most senior emergency visits, he said, are appropriate. In many cases, an older patient may come in with a condition — vague chest pain, say — that could be a heart attack or simply the kind of pain that comes with aging blood vessels. People with these kinds of symptoms, Waxman said, need to come in for an immediate workup, even if most will not turn out to be heart attacks.

It’s what happens after a workup like that where costs can soar, he said. Even if a full workup in the emergency department, complete with electrocardiogram, shows there is no heart attack happening, doctors know that vague chest pain is often reported hours or even days before a heart attack.

These patients need follow up the next day and if doctors are not confident they’ll get what they need outside the hospital, they admit.

In 2008, a government report estimated that one in 10 hospital admissions was preventable and that 60 percent of those estimated 4 million hospitalizations were for Americans age 65 and older.

Just over a third of health care expenses for those age 65 and older were on in-patient admissions compared to only 2.3 percent in the emergency room, according to a 2013 report by the Agency for Healthcare Research and Quality

Following up

This reality has not been lost on San Diego health care providers.

San Diego County’s Aging and Independence Services Department received funding in 2010 to run a local care transitions team that focused on follow-up care after hospitalization for patients with chronic diseases.

That work, according to a 2015 report, resulted in a 24.7 percent drop in hospital readmissions overall and a 72 percent drop for high-risk Medicare patients.

Though the federally-funded program lost its grant in 2016, many local hospitals have continued the practices they honed while they were in the program. Sharp Grossmont Hospital, for example, tries to connect seniors with whatever services they need after they leave right down to issuing them food bags at discharge.

Kaiser Permanente San Diego often creates follow-up appointments before its members leave the emergency department and sets up what it calls “bridge clinics” for patients who have complex needs to visit after they have an emergency.

UC San Diego and West Health are taking things one step further with a pilot program called Acute Care at Home. It identifies stable patients who need attention that might otherwise have meant hospitalization — say a requirement for intravenous antibiotics to take care of an infection.

Dr. Vaishal Tolia, who runs the program, said that about 70 patients have been enrolled in Acute Care at Home since it started last summer. Nurses are assigned to visit the patients in their homes as often as necessary and Tolia said that, so far, there have been no readmissions to the hospital for the same health problem that they were enrolled for.

“We’ve found that we’re able to mimic the care that they would be receiving in the hospital, and some end up getting visited by a nurse three times per day,” Tolia said.

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paul.sisson@sduniontribune.com

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