How LIFE evolved from a pioneering concept in academic nursing practice to become a self-sustaining enterprise that provides care to vulnerable elders
It stands four stories high at the corner of 45th and Chestnut, surrounded by rows of turn-of-the-century brownstones and engulfed by a fleet of white vans aligned in front of its entrance. Inside, men and women mingle over lunch, and a handful of gentlemen gather around a billiards table, ready to play their third game of the day. A woman swivels in her chair, mirror in hand, to admire her new hairstyle, while four ladies wait in line to meet with the visiting optometrist. Black and white photographs adorn the walls, beautiful portraits of people who have spent the last years of their lives coming here each day. Some of them can still be seen walking through the building.
Welcome to LIFE. Modeled after the national Program of All-inclusive Care for the Elderly (PACE) plan, the mission of Living Independently For Elders (LIFE) is to advance a unique, interdisciplinary system of all-inclusive healthcare for frail seniors in West and Southwest Philadelphia, 95 percent of whom are African American. Funded by Medicare and the Commonwealth of Pennsylvania’s Department of Public Welfare, LIFE offers these seniors, faced with probable nursing home placement, the choice to instead remain in their community, live in their homes, and receive care in the LIFE center, newly housed at 4508 Chestnut Street.
Studies on the PACE model have repeatedly shown improved quality of care, patient and caregiver satisfaction, and savings of 15-30 cents on the dollar compared to nursing home care. “Living independently – and safely – while receiving the best quality of care is really the goal of our administration in terms of long-term living in Pennsylvania,” explains Rosemarie Greco, director of the Governor’s Office of Health Care Reform and current chair of Penn Nursing’s Board of Overseers. “Many people would benefit greatly if we had more LIFE centers throughout the Commonwealth.”
The program at 4508 Chestnut is one of 11 PACE models in the state. It was the first and remains one of the few sites in the nation to be owned and operated by a school of nursing. September 2008 marks the 10-year anniversary of LIFE at Penn, but its story begins more than a decade ago.
In many ways, this is a story that started when some of the most creative minds in nursing realized the need for academic nursing practices to provide direct care to patients, learning opportunities for students, and rich sources of data for researchers studying a range of health concerns. Under the direction and support of then-Dean Norma Lang, who was renowned for her work on nurse-led care, a variety of practices emerged at Penn Nursing, such as a community-based practice for incontinence; a center for stroke victims; a partnership with the Philadelphia Corporation for Aging to help elderly patients who suffered from dementia; the Health Annex, which provided primary healthcare to an underserved southwest Philadelphia community; and finally, the Collaborative Assessment & Rehabilitation for Elders(CARE) Program, modeled after the British geriatric day hospital to offer specialized short-term rehabilitation to older people following hospital discharge or illness.
CARE collected data in its nurse-focused electronic health record system to illustrate improved outcomes for patients and highlight the effectiveness of advanced practice nurses, but it closed in 1998, after the Balanced Budget Act restricted Medicare funding. While housed in a small space that could accommodate no more than 20 people at a time, CARE served more than 800 older adults over its tenure. It was one of the School’s earliest and longest-running examples of a researchbased academic nursing practice.
In fact, says Professor Lois Evans, PhD, RN, FAAN, chair of the Family and Community Health Division and former executive director of the CARE Program and director of Academic Nursing Practices, “LIFE is, in many respects, an important culmination of our experiences with Penn’s gerontologic nursing practices of the ‘90s.”
In 1994, as Penn Nursing practices wereevolving, professors Mary Naylor, PhD, RN, FAAN, an expert in transitional care, and Karen Buhler-Wilkerson, PhD, RN, FAAN, an authority on community-based care, were awarded a $100,000 planning grant from The Ralston House, a small Philadelphia philanthropy dedicated to supporting research, education and services in the care of the elderly. Their goal was to explore community-based initiatives that would benefit West Philadelphia elders while showcasing evidence-based models of care. Together – and with the assistance of Dr. Lang, PhD, FRCN, RN, FAAN and Dr. Evans, the van Ameringen Professor in Nursing Excellence – they turned to the PACE model.
They researched PACE sites throughout the country, including the On Lok Senior Health Center, where the model originated in San Francisco’s Chinatown more than 30 years ago. On Lok grew out of the community’s concern for vulnerable, frail older adults living at home, and, true to the PACE model of care, it reflected the largely Asian population it served. For those elders, PACE represented a fundamental shift in the way health services were attained – participants had access to the entire spectrum of primary care, adult day care, hospital, nursing home, and home care, all coordinated and provided by a single organization. For Penn Nursing, the model, which was tailored to the culture of the heavily African American West Philadelphia community, supported the School’s vision and academic mission, and it enabled the full expression of nursing’s ideals and values.1
To avoid confusion between the elderlycare model and Pennsylvania’s pharmaceutical program of the same acronym, one of Dr. Buhler-Wilkerson’s many roles was to create a new name for PACE programs in the state. It was a task she approached by going into a senior housing center in West Philadelphia, meeting with nearly a dozen residents, and explaining to them this new model of care. “What do you think about this?” she asked. “What would you call it?” An African American woman, who had not spoken much, beamed and exclaimed, “It’s living independently, and we’ve been waiting for this for years.”
“They got it, and they wanted it, and they wondered where we had been,” Dr. Buhler-Wilkerson remembers. “As a totally integrated, interdisciplinary program, this was such an un-American approach to care, but it was our job to show that this model solved so many problems in delivering community-based care.”
It was also their job to find a way for such a model to thrive within an academic setting. Withstanding doubts from medical colleagues and others, the “founding mothers of LIFE” nevertheless secured funding and established the center as a legitimate practice. Penn Nursing has “always had an investment in academic practice,” says Dr. Naylor. “Our hope for LIFE was an environment that showcased best practices and simultaneously provided fertile ground for new scholarship where we could continue to raise questions for nurse scholars to answer.”
Their goal of creating a model of research, practice, and teaching began in the fall of 1998, when LIFE opened at 4101 Woodland Avenue. Nursing, medicine, social work, pastoral care, physical therapy, occupational therapy, and psychiatry all combined to provide onestop care to a vulnerable, local population. The site has since grown and twice moved– first branching out to 39th and Market Street, where it operated from the ground floor of a HUD building, and then, in May 2007, when it found permanent spot at the ironic site of an abandoned nursing home on the corner of 45th and Chestnut. Through all the changes and moves, one constant remains: LIFE is a team model with a nursing foundation.
“I believe from the inception of this program, there has been a different standard, a service-level commitment that springs from the School of Nursing,” says LIFE CEO Wayne Pendleton, LSW, ACSW. “This program of all-inclusive care for elders is what it says. It’s everything. And it works because of the interdisciplinary team.”
Tamara Zurakowski, PhD, RN, a gerontological nurse practitioner and practice professor at Penn Nursing, has worked at LIFE for the past three years on the Spruce Team, one of the four treatment teams named after West Philadelphia streets and comprised of fulland part-time nurse practitioners, a collaborating physician, and social worker.
All of the LIFE members are Medicaid eligible, and as Dr. Zurakowski explains, many have had limited access to healthcare throughout their lives. A large percentage, therefore, enter the program “with a lot of healthcare baggage.”
Diabetes is rampant. Other conditions include: end organ damage, high blood pressure, eye damage, kidney damage, and peripheral vascular damage. “You might not see these problems in a group of people of an equal age but who have been integrated into the health system,” she says.
Thankfully, Dr. Zurakowski adds, LIFE offers members high quality care to enhance their lives. “When Florence Nightingale talked about nursing care, she wasn’t thinking about hospitals so much. She was thinking about people living in their homes with nursing knowledge that helps them live healthier and more satisfying lives,” she says. “That’s really what we’re back to doing here. We had gone away from that for a while, but I think we’re really going back to a model of care that was successful and deeply satisfying to nurses as well as to patients.”
Members certainly agree. “LIFE has preserved me,” says William King, 81. “Everybody here knows me and watches over me. They take care of my medical problems, my hearing, my eyesight. LIFE has prolonged my life.”
And the lives of others. At 65, Lillie Mashore credits the program with improving her health. She has kicked a 30-year smoking habit, reduced her insulin from 75 units to 50, lost 24 pounds, and adopted other healthy behaviors. “I want to take care of myself better now,” she says. “We needed this program a long time ago. In the three years I’ve been coming here, it has already helped me so much.”
Seventy-one-year-old Bob Hale has attended LIFE for the past four years and shares this view. When Mr. Hale, a retired carpenter and masonry contractor, first came to the center, he could hardly walk and barely used his hands. “Now I can run,” explains this self-described “woodsman,” who likes to spend his free time building bird houses and jewelry boxes. “[The staff] took care of me the way I needed,” he adds, “and it made me feel even more independent.”
Members cite the treatment teams and interdisciplinary staff for making the center, as Mr. Hale describes, “a wonderful place to be.” Carol Patterson, a caregiver who assists the physical therapist, began volunteering for the program nearly a year after her mother passed away. “The way she was treated was so wonderful, I wanted to give back,” Ms. Patterson says of her mother, who attended LIFE for a year. “It’s a blessing to help.”
“The value of this model of care,” adds Michael Wert, chair of the LIFE Executive Committee, “is measured by how it improves peoples’ lives, how well it provides healthcare to a frail population, how well it survives, economically. LIFE performs on all of these fronts. All you have to do is walk around the facility and see the members’ faces and know that you’ve got something great.”
With members and their families at the heart of LIFE’s mission, the integration of practitioners, scholars, and students remain at the soul of advancing the delivery of care.
Boasting an annual revenue that exceeds $33 million, LIFE is able to reinvest in education and research, and “that leads to improved quality of care,” says Eileen Sullivan-Marx, PhD, CRNP, RN, FAAN, and the Shearer Term Professor for Healthy Community Practices. As Associate Dean for Practice and Community Affairs, Dr. Sullivan-Marx oversees the LIFE program.
In some senses, it is a place where Dr. Naylor’s vision of “fertile ground for new scholarship” has been achieved. Current and recent research conducted at LIFE include: Dr. Sullivan-Marx’s focus on exercise outcomes in frail, older adults; Associate Professor Stella Volpe’s study on exercise and weight management; Associate Professor Joseph Boullata’s research on psychogeriatric medications; Assistant Professor Lisa Lewis’ study of spirituality and hypertension self care; and Dr. Naylor’s scholarship on quality of life measures in older adults.
“We are a research-intensive school, so it is important that a school-owned practice like LIFE develops innovative care delivery models and innovative programs,” says Professor of Pediatric Nursing-Clinician Educator Jane Barnsteiner, PhD, FAAN, who, alongside Assistant Professor of Gerontological Nursing Christine Bradway, PhD, CRNP, RN, serves as faculty advisor to LIFE. “The population we serve at LIFE consists of frail elders,” adds Dr. Bradway, “which is why our scholarship must really say something big about how to best care for this vulnerable group of older adults.”
In addition to the scholarship generated, LIFE educates more than 200 students across disciplines each year, from nursing students who start clinical rotations there as sophomores to business majors interested in the self-sustaining, multimillion-dollar-revenue-generating operation.
It could be said that the story of LIFE is just getting started, but in its 10 years, there is already so much it has achieved. Its population has grown from less than a dozen registered members to an average daily census of 355 people, the majority of whom are transported to and from the center each day in LIFE-run vans that travel to nearly a dozen Philadelphia zip codes. For driver Clifton Nesmith, the job goes “above and beyond sitting in the seat and turning the wheel.” Whether he is delivering food and medication to members’ homes or escorting blind members to the triage area for their insulin shots, “I’m here to help them,” he says. And LIFE member Eddie Washington, 74, is always happy to see his face in the mornings. “If the van runs late, I get nervous,” she says.
As LIFE CEO Wayne Pendleton puts it, “We are part of the community in many different ways.” In addition to providing care for a frail, medically complex local population, the center is also an employer to the neighborhood, with 54 percent of the LIFE staff comprised from within the catchment area. “Sometimes we don’t realize the socioeconomic impact of the program – not just for the members, but for the people who live in the community,” adds Board Chair Rosemarie Greco. Serving as both provider and employer, she says, LIFE also allows family caregivers the option of working rather than remaining at home during the day to care for their ailing loved ones.
Since its inception, the Circle of Care – a section of the center designed to help those members with most limited cognitive function – has grown in both membership and activities. For example, the creation of an award-winning art therapy program that combines the potent resource of art with the creative process has helped stimulate memory and cognition in members, many of whom are most in need of such resources. For Ms. J, who began coming to LIFE shortly after losing her husband, moving into her daughter’s home, and being diagnosed with Alzheimer’s disease, art therapy served as a way to recreate the story of her life. Through drawings and pictures, she was able to recount her accomplishments and memories, ranging from her pride in her children to the beautiful rose bushes she grew.2
1 Mary Naylor and Karen Buhler-Wilkerson (1999). Creating Community-Based Care for the New Millennium. Nursing Outlook, 47, 120-127.
2 Johnson, C.M., & Sullivan-Marx, E.M. (2006). Art therapy: Using the creative process for healing and hope among African American older adults. Geriatric Nursing, 27(5), 309-316.