Springwell has been redefining possibilities since our founding in 1977. In the beginning, the work of helping seniors age-in-place was a new alternative to the institutionalized nursing home care that had become commonplace. Today, helping people maintain independence is the foundation from which our work grows.
Over the last 39 years, we strengthened our core expertise of assessing needs for in-home care, identifying public and private resources to meet those needs, helping individuals access services and coordinating and monitoring services. At first, we focused on seniors who received public services from one of the Commonwealth’s many subsidized programs for low-income, frail seniors. Over time, data showed that these in-home services not only helped seniors live in the community longer but, also increased their quality of life and reduced the cost of care. It was a win-win situation for all.
Eventually, it also became apparent that the benefit of these in-home or post-acute care services, now known as long-term services and supports (LTSS), could be applied to non-senior populations. Ensuring that all people had housing and heat, were meeting their nutritional needs, and were able to obtain necessary prescriptions for example, were important goals regardless of age. As the health care landscape changed, and the Triple Aim of improving quality and satisfaction while reducing cost became the mantra, health care providers asked Springwell to bring their expertise with LTSS to all of their patients.
Our focus remains the same – helping individuals maintain independence and live in the setting of their choice with the appropriate supports. But our reach has expanded. Today, in addition to contracting with the Commonwealth to work with low-income seniors, Springwell works with housing authorities and housing owners to provide LTSS to their residents. The agency works side-by-side with acute-care staff in physician practices and Accountable Care Organizations, of health insurers and hospitals to evaluate the LTSS needs of all their patients regardless of age. From pediatric patients to seniors, Springwell’s LTSS Care Coordinators assist individuals with addressing the social determinants of health that impact their health care goals.
As we look over our work in 2016, the strength of our history makes our path for the future clear. I am pleased to share an update on a touching story from our past that provides context and insight into the philosophy that informs our current and future work, and an overview of our newest projects, and a summary of our 2016 results.
Ruth Beckerman-Rodau, Chief Executive Officer
In December of 2008, it seemed impossible that 83-year old Jeanne would ever return to the home she loved. A bad fall months earlier sent her first to the hospital and then to a rehabilitation facility. Though long-term symptoms of post-polio syndrome meant Jeanne used a wheelchair, she had managed independently for years and was even famous for being able to vacuum from her wheelchair. But after her fall, Jeanne was unable to transfer herself into and out of her chair. Her physician and the staff at the rehabilitation facility were dubious about a return home, but Jeanne, a fiercely independent woman, was determined. Her determination was matched by the convictions of Springwell’s Jo White, a social worker who helped Jeanne enroll in the Community Choices program, a newly created program that mandated nursing-home-eligible seniors be given the option of receiving care at home.
Jo led an interdisciplinary team comprised of Jeanne, Springwell nurses and social workers, staff at the rehabilitation facility, Jeanne’s physician, and a local in-home services provider. As she facilitated these meetings, Jo ensured that all discussions focused on how to honor Jeanne’s choice to return to her home.
The coordination and planning took seven months, but in July of 2009, the impossible became possible when Jeanne spent her first night in her own apartment. With the support of a worker who assists Jeanne with her personal care and homemaking needs, some important adaptive equipment, and a comprehensive emergency back-up system, she’s been happily living independently for the past seven years.
Springwell has stayed by Jeanne’s side the whole time ensuring that the coordination between her needs and her service providers is seamless. Springwell care advisors understand the range of issues that seniors face as they seek to age with independence, and they address new challenges as they arise.
From the beginning, Springwell’s mission has focused on helping people live at home for as long as they can. Jeanne is one of nearly 9,500 people the agency helped last year with services ranging from home-delivered meals, to the coordination of in-home services, and to the respite that family caregivers need to support their loved one’s continued independence.
After working with Jeanne for nearly three years, Jo White moved on from her role as a care advisor. While she would miss working directly with clients, Jo was interested in the ways Springwell could expand our work alongside changes in the health care delivery system.
Health care reform and the adoption of the 2010 Affordable Care Act created a new health care objective referred to as the Triple Aim:
To improve the quality of patient care and satisfaction while also reducing the costs of delivering care.
This reform provided Springwell with the opportunity to play a crucial role in helping health providers reach that goal.
Physicians, nurses, and other members of a healthcare team often treat patients with health problems that cannot be remedied by medicine alone. A physician can prescribe a medication, but if the patient won’t take it, does not have access to it, or lacks the capacity to open the prescription bottle, the patient’s health is in jeopardy. Community supports like those managed by Springwell care advisors often clear away barriers that can impede good medical care. By helping health care providers integrate long-term services and supports (LTSS) as a core component of patient care, Springwell knew that we could help address the multi-layered, complex needs of patients.
The opportunity was evident. It would take data to convince payors that addressing the LTSS needs of their patients was necessary for their patients to reach their health goals and for a health provider to achieve a reduction in cost while increasing quality and satisfaction.
Springwell piloted several partnerships to test models of integrated service delivery. Four years ago, the agency formed a relationship with Beth Israel Deaconess Care Organization (BIDCO). At the time, Marilyn Wright, BIDCO’s Director of Care Management integrated Springwell LTSS Care Coordinators into BIDCO’s existing RN Case Management program. In this partnership, a Springwell staff member works on-site at BIDCO, alongside RN Case Managers, assessing their patient’s LTSS needs and helping them access services to meet those needs. Marilyn was a champion of this integrated care model from the beginning, “Springwell staff are true and full members of our care team,” she said, “I don’t know how we did this work without them.”
On a typical day at BIDCO, Springwell Care Coordinator Shauna Caffrey walks into the BIDCO office, opens her email and sorts through new referrals from BIDCO nurses, nurse practitioners and primary care doctors. She triages them, assesses what needs to be done for each. Shauna might make a quick phone call to a patient who needs transportation to a critical medical appointment, or she may spend hours assessing the needs of a 47-year old woman with complex medical issues who recently become homeless. As she works through her day, more referrals come in, and BIDCO nurses and nurse practitioners come in and out to consult on other cases in which Shauna’s expertise on LTSS services will play a key role in a patient’s treatment plan. Last year, Springwell responded to more than 700 referrals of patients for case management that ranged from a few hours to many weeks of support.
Jo White is now Springwell’s Director of Health Partnerships. In this role, she provides clinical supervision to a team of four Care Coordinators who work with patients of BIDCO and Atrius Health. After successfully negotiating the pilot stage, both partnerships are providing a wealth of information on the impact on patient outcomes. This data and our experience continue to inform our work to expand the ways in which we collaborate with new health partners to develop new models of holistic care.
2016 in Review
Springwell’s history is one of building creatively on our experience in order to help people maintain their independence and live in dignity. We believe in people – in their choices and in their vision for themselves.
Whether a Springwell social worker meets an 83-year old woman in a nursing home who uses a wheelchair and wants to live at home, or a Springwell community care coordinator meets a 47-year old woman in a health care system who is homeless and wants to start all over, Springwell helps people get the support they need. Our staff members look for the possibilities and respond.
Springwell’s finances remained strong in fiscal year 2016 with revenue increasing by nearly 5%. Contracts with government and private entities continue to make up the largest source of the organization’s revenues, but Springwell is engaging existing and new donors in the work of closing the gap between contractual funding and the cost of providing services. Funds raised through individual donors increased by 14%, and institutional funders increased by 8%. The number of donors who joined the Springwell community increased by more than 30%.
In 2016, after years of double digit growth, we reached a record 9,366 people with programs and services that provide the long-term services and supports that make an independent life possible for people seeking to live and age with health and in dignity.
FY16 Board of Directors
- Judy Singler, President
- Richard Jefferson, Vice President
- David Frischling, Treasurer
- Yolanda Rodriguez, Secretary
- Simonne Berard
- Margaret Cassidy
- William DeVasher, Jr.
- Adele Hoffman
- Gerald O’Keefe
- Mary Quilty
- Mary Elizabeth Weadock
FY16 Area Agency on Aging Advisory Committee
- Lisa Baragwanath
- Pat Connor
- Cecilia Lenk
- Gary Marchese
- Mary Quilty
- Yolanda Rodriguez
307 Waverley Oaks Road, Waltham, MA 02452