Inspīr’s Integrated Care Model (ICM) is an interdisciplinary, team-based, person-centered approach to whole-person health and wellness. This approach provides highly coordinated, data-driven, and outcome-focused care across providers, settings, and time. Built on a philosophy of vibrant, intentional living and meaningful connections, the ICM synthesizes the expertise of medical professionals across multiple disciplines for the best possible outcomes for our residents.
To explore the Integrated Care Model, we sat down with Brian Geyser, Chief Clinical Officer at Inspīr and VP Clinical Innovation & Population Health at Maplewood Senior Living.
Q: What led Inspīr to build the Integrated Care Model?
A: The fact is, the vast majority of people in assisted living communities today are older and frailer, and suffer from multiple chronic conditions, such as cardiac disease, diabetes, Parkinson’s, and various forms of dementia. Additionally, people in their 70s, 80s, or 90s can be very complex from a medical perspective.
We wanted to take a more proactive and holistic approach to managing our residents’ care—one that required a new way of thinking about how things are traditionally done in assisted living communities. Our Integrated Care Model exists within the larger Inspīr platform, which combines luxury accommodations, five-star hospitality, and cutting-edge technology with whole-person health and wellness, and world-class care. In order to truly deliver that last one, we needed to reinvent our care model.
Q: A key element of the ICM is the Interdisciplinary Team approach. Is there a person on the Inspīr team who takes the lead in delegating care? What are the benefits to this?
A: At the core of the ICM is the Interdisciplinary Care Team (ICT). This team is comprised of people on our staff (nurses, aides, social workers, dementia specialists, nutritionists, and lifestyle coaches) and hand-selected, highly vetted outside provider partners (physicians, nurse practitioners, pharmacists, therapists, wellness experts, and aging life care professionals), all closely collaborating to achieve optimal health and wellness outcomes for each resident.
At Inspīr, primary care, mental health care, pharmacy, rehabilitation services, dental care, palliative care, and hospice will all be highly integrated and available on-site. We will also offer a variety of other on-site services like podiatry, mobile imaging, phlebotomy, and home dialysis.
The person who ties all of this together is our Care Manager. At Inspīr, every resident has a dedicated RN Care Manager who performs comprehensive assessments, drives the development of multidimensional care plans, proactively monitors health status, and intervenes and advocates through care transitions. The advantage of having this role is that each resident has a single highly trained professional who is laser-focused on positive outcomes related to care and service delivery.
Q: With the many different factors that go into a person’s health and well-being, how does the Inspīr team work together to coordinate the services and care that residents receive?
A: Everything starts with our 360 Assessment. This assessment, built into our Electronic Health Record (EHR) and completed by the resident’s RN Care Manager and other members of the ICT, is designed to create a comprehensive health and wellness profile of each resident, along with their specific care requirements and service desires. This results in a multidimensional service plan that serves as the roadmap to optimal health and wellness for each resident. The service plan covers everything from personal care and medication to how best to incorporate each of our Nine Core Elements.
Inspīr’s life enrichment programs incorporate modalities that nurture the mind, body, and spirit. Our Wellness Team builds each resident a custom wellness program, integrating daily offerings like yoga, meditation, brain fitness, water aerobics, balance training, and spiritual practices based on interests and abilities. In addition, our Culinary Team curates healthy, nutritional, and sensory-stimulating dining experiences with locally sourced ingredients.
We also incorporate into every assessment a discussion about “goals of care,” ensuring that the care we provide aligns with each resident’s unique desires and preferences. Members of the ICT, each with different professional credentials and backgrounds, contribute to the service plan and are responsible for delivering the highest quality service in their area of expertise. The RN Care Manager monitors health outcomes and holds members of the team accountable for their piece.
Q: How is Inspīr’s Integrated Care Model different from what other assisted living communities offer?
A: For every resident to have a dedicated care manager at the RN level is completely unheard of in assisted living and should not be understated. These nurses develop long-term relationships with residents and their families over time. They have a deep understanding of anything that may be getting in the way of optimal outcomes and have the ability, knowledge, and skill to intervene accordingly.
Inspīr’s strategic partnerships with top health systems and local providers that understand our vision is key. We work closely with our provider partners to align goals, define roles and responsibilities, share ideas and information, and hold each other accountable to ensure smooth transitions and excellence in care delivery.
Finally, we’re incorporating technology into our care and service offerings to enhance the quality of care we provide. Our Care Concierge service, for example, uses Amazon Alexa to give residents quick and easy access to staff. Residents can simply say, “Alexa, call the concierge,” and immediately get the help they need.
Q: In some instances, the Interdisciplinary Team approach may involve multiple medical professionals working with the same resident. How does Inspīr maintain consistency of care?
A: We maintain consistency of care by offering very comprehensive, geriatric-focused on-site primary care alongside our care management services. The key to effective geriatric primary care is care coordination. You need a central person coordinating all aspects of care delivery, and we have that with our RN Care Managers.
Q: How does family come into play when planning for a resident’s care at Inspīr?
A: One of our Nine Core Elements for health and wellness is Family. We involve family right from the outset by including them in the assessment process. Family members often have a wealth of information and insights to share, which can be critical when building a service plan.
We also believe that maintaining loving relationships with family is critical for good mental health. Inspīr encourages family involvement, and helps spouses, adult children, grandchildren, and extended relatives stay connected to their loved ones. We use platforms like Skype for virtual visits, and even a mobile app to keep families informed.
Inspīr’s Integrated Care Model centers around total well-being and optimal outcomes for each resident and supports our philosophy of vibrant, intentional living. We hope this blog has offered some insight into how we bring our elevated senior care experience to life.