Helping Seniors Stay Healthy at Home in Pittsburgh

How care coordination keeps seniors in their home

The LIFE Pittsburgh model of care comes from PACE, a national program pioneered in the 1970’s. The idea was to keep people safe at home, rather than have frequent visits to the Emergency Room or wind up in a nursing home. The program was so successful, there are now over 116 such programs in the country.

Home Health for Seniors

LIFE Pittsburgh provides all necessary health care, home care, medications, therapy, recreation and more for Participants with multiple chronic health conditions to live safely in the community.

Caregivers, including a social worker, nurse, physician, physical therapist, occupational therapist, and dietician, work with Participants and their families to create a Care Plan. This plan describes medical, social, and daily living support, all to keep Participants in their homes. LIFE Pittsburgh goes beyond simply “treating medical problems” to actually improving the quality of life for most of our Participants.

Team Approach

Team Approach to Senior Healthcare
LIFE Pittsburgh’s team approach is unique. Every Participant has a team of people looking after him or her. The team includes a doctor, registered nurses, master’s-level social workers, licensed physical and occupational therapists, personal care aids, registered dieticians, the center manager and others. This team meets every morning to discuss all Participants in need.

The key ingredients of LIFE’s model of care are:

  1. being proactive and
  2. coordinating/integrating care from different professional perspectives.

The care team is what makes this possible.

Being Proactive

Every LIFE staff member is trained to notice any changes in Participant’s health. For example, a driver notices that Miss Elizabeth is looking very tired today, or that Mr. Johnson’s speech is a little slurred. He then reports any indications to the team. As the team is meeting every morning, they immediately identify any actions to evaluate and treat health concerns.

Coordinating/Integrating Care

The benefit of the care team is the different perspectives. For example, suppose Miss Christine has a fall. The doctor will pursue medical reasons why she fell; the dietician will try to figure out if her fall was due to dietary issues; the physical therapist will work on her balance issues; and so on. This is what differentiates LIFE Pittsburgh from the traditional healthcare model. Coordinating and integrating the knowledge of the whole team allows for a remarkable improvement in the level of care.

Coordinating and Integrating Care Makes the Difference!

Our Participants receive most of their health care services at our Day Health Center, where our team is based. A Participant’s driver provides transportation to and from the center. When necessary, services are also provided in an individual’s home, in a hospital, or a nursing facility.

Our primary care physicians are participating members of our health care team and will manage all specialty and hospital care. In addition, we have agreements with physician specialists (such as cardiologists, urologists, and orthopedists), with a pharmacy, laboratory, and diagnostic testing services (X-rays, etc.) and with hospitals and nursing facilities. Services may be provided at their respective locations. Drivers are also able to provide transportation to the hospital and other appointments the interdisciplinary team arranges for our Participants.