Benefits of holistic health

Bluestem PACE (Program of All-Inclusive Care for the Elderly) is a Bluestem Communities service partnering with participants age 55 and better to support them living safely and independently in their own homes for as long as possible. 

These individuals have complex medical needs, so how can it be that they don’t need the services of traditional residential care homes? The answer is the Bluestem PACE Interdisciplinary Team.

The interdisciplinary team is made up of primary care providers, nurses, physical and occupational therapists, dietitians and social workers, who collaborate to create a holistic care plan for each participant’s individual medical, psychosocial and functional needs. While participants of the program are continuously monitored and cared for, the interdisciplinary team re-evaluates a participant’s individual care plan and adjusts it accordingly to provide the highest quality care and support. 

“This coordination of care reduces the burden of managing schedules for participants and their at-home care givers,” said Emilie Rains, Bluestem PACE Interim Executive Director. “Together, the comprehensive services work to prevent gaps in care and result in better outcomes for participants.” 

The success with participant outcomes of the Bluestem PACE program points to the benefits the interdisciplinary team provides. Some of that care, including physical therapy and social work services, aren’t always as readily recognized for their contributions to overall health as direct medical services are, but they play a vital role in each participant’s holistic well-being.

PHYSICAL & OCCUPATIONAL THERAPY

“Because of the way PACE is structured, participants receive exponentially more physical and occupational therapy than if they were not a part of PACE,” said Chris Deck, Bluestem PACE Director of Physical Therapy Rehab. “Physical therapy and occupational therapy have found that getting participants as strong as possible prevents the need to go to the hospital or a nursing facility.”

Strategies that are commonly used in the Bluestem PACE therapy clinic with high levels of success include metabolic equivalent testing, lactate testing, and Blood Flow Restriction.

“Metabolic equivalent testing shows us a person’s ability to carry out daily tasks, illuminates the risk of all-cause mortality and provides direction for using exercise to extend healthspan,” said Deck. “Based on this metric, we are able to rough-in what their exercise program should look like. Lactate testing is similar to measuring someone’s blood sugar, and gives us a granular look at their metabolism and strength at the microscopic level. Blood Flow Restriction therapy helps participants gain more strength while lifting lighter loads, which reduces the overall stress placed on the limb, and allows us to target the muscle fibers that are often the first to atrophy as we age.” 

Bluestem PACE’s therapy services focus on tailoring a rehabilitation program to each participant’s unique needs, teaching them how to progress the program and make sure that they cultivate an atmosphere of fun with it.

“The quantity of therapy takes on a quality of its own, and we see remarkable outcomes,” said Deck. “It’s important to note that exercise is medicine. Regular intense exercise conveys health benefits that go beyond the musculoskeletal system, so we see improvement with depression, dementia and chronic diseases like diabetes.”

SOCIAL WORK

Social work is often some of the “invisible” work that happens in health care. It can be helpful to think of the social worker as the person that tends the human network. Social workers support the interdisciplinary team by helping to de-escalate challenging situations, as well as bringing to light psychosocial factors that may be impacting an individual’s functioning or care.

“We help participants navigate practical issues like housing, access to food, advance directives, community resources and Medicaid renewals,”  said Marla Schmidt, Bluestem PACE Director of Social Work. “We also support participants with difficult emotions and decisions, family situations, loneliness and much more. The list is long and varied. Additionally, we are able to provide individual therapy in-house through our therapist, Suzanne Wolcott.”

With a focus on guarding the dignity of each individual, supporting relationships and making sure basic needs are met, the Bluestem PACE social work team has worked diligently to refine its approach to serving participants well.

“We have recently initiated use of both a loneliness screener at pre-enrollment, as well as an assessment of adverse childhood experiences,” said Wolcott, a Licensed Specialist Clinical Social Worker. “These assessments allow us to be more thorough and responsive to people’s needs and pain. Assessing people’s experiences of loneliness and the ways that past experiences may be impacting them in the present day, makes it possible for the social work team to educate the interdisciplinary team and provide appropriate supports and interventions to improve people’s quality of life.” 

Bluestem PACE social work was recently recognized by researchers from Columbia University (New York, N.Y.) and Columbia West Health to be one of the only PACE programs nationally that is proactively screening for past trauma and crafting responses to the issues that arise from it. 

“Participants often report feeling less isolated and alone when they become a part of Bluestem PACE,” said Wolcott. “Many of them express feeling a greater sense of support and well-being due to their participation in PACE services.” 

Walking through the upbeat buzz of Bluestem PACE day centers in McPherson or Hutchinson, Kansas, is a glimpse into the success of the interdisciplinary team and the overall positive outcomes participants experience as they interact with one another and staff. 

To learn more about Bluestem PACE, visit bluestempace.org or call
844-588-7223 (TTY: 800-766-3777).