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October 6, 2017 – Grand Rapids Business Journal

Tandem365 nurses, social workers give high-need patients specialized care to prevent emergency room trips.

A local home-based health management program created by five senior and medical service companies has significantly reduced hospital visits for its high-need patients.

According to recent statistics, Tandem365 has reduced its more than 1,000 patients’ emergency room visits by 52 percent and their average cost of health care by 35 percent since its inception in 2014. Inpatient visits are down 38 percent, and specialty visits are down 46 percent.

That’s because Tandem365 acts as a “safety net” to its patients, who are all adults ages 55 and older who have complex medical needs and live in their home, according to CEO Teresa Toland.

The program began in 2014 after the partnering organizations — Life EMS Ambulance, Clark Retirement Communities, Holland Home, Porter Hills, and Sunset Retirement Communities and Services — decided to tackle ongoing communication problems and lack of support that forced at-risk seniors to return to the hospital with preventive issues.

The discussion began when St. Mary’s Hospital leadership reached out to the four retirement communities that now are Tandem365 partners. The hospital was on the verge of being fined because of high readmission rates.

Toland said leadership from St. Mary’s and the four retirement communities reluctantly came together to discuss their issues and find a solution. After weeks of meetings, they came to a common conclusion.

“At the end of the day … we realized we all had the same issues,” Toland said. “The communication streams were bad. We were getting incomplete information on patients.”

She said that conclusion was the “very first step in this journey” toward creating Tandem365. And 18 months into the program, Toland said St. Mary’s readmission rates decreased from 22 percent to 4 percent.

The main issue was these at-risk patients had little support and no ongoing plan that kept them out of the hospital, she said. Often, communications about medical issues and history were dropped between paramedics, hospitals, specialists and other medical professionals. Navigating these day-to-day issues can be daunting for many of the patients. As Toland said, Tandem365’s main purpose is to “connect the dots” and keep patients from landing back in the hospital.

“Generally, if you don’t have somebody in your family who knows how to traverse the system, it’s challenging if you have complex needs,” said Laura Kasperski, one of 10 registered nurse navigators who work for Tandem365.

The navigators each have a caseload of the nearly 600 patients. The patients are in continuous contact with their assigned nurse, and they begin the program in communication with a social worker.

The nurses receive patients’ phone calls and coordinate medical needs, but sometimes, nonmedical issues need to be addressed to prevent medical ones. And that’s where social workers come in.

There is more than 200 years of medical experience among Tandem365’s leadership, and they know the importance of addressing all those issues.

“Those kinds of connections that may have nothing to do with traditional health care, but those of us who have been doing this for a long time know are critical to a patient’s success,” said Mark Meijer, president of Life EMS Ambulance.

One of Kasperski’s patients, Grand Rapids resident Ken Sanford, 72, is unable to drive to his kidney dialysis appointments three times per week. So, his social worker coordinated transportation through GO!Bus, an Americans with Disabilities Act paratransit service through The Rapid bus system, a service Sanford didn’t know existed.

“They already have the answers for what your needs are,” Sanford said. “I’m blessed to have them.”

Sanford recently was given a pacemaker, and he said no one had a chance to look at a toe injury that occurred among the busyness of that procedure. When Kasperski saw the injury, he said she immediately arranged a visit for someone to take care of it.

Kasperski said the staff solves individual problems that keep patients out of the hospital on a weekly basis.

“There’s a lot of times when we know we’ve prevented them from going to the hospital or going to the emergency room because we were able to get to them soon enough or solve their problem before it became a crisis,” she said.

Each patient has an individualized plan of services that can include in-home support and health management, transportation, respite care, home delivered and cooked meals, primary care and specialist physicians, behavioral health, rehabilitation, grocery shopping and socialization. The navigators work with the patients to create the best plan for them.

“We get to know them very well. We get to know their needs and their family life and what their home is like,” Kasperski said. “I find the longer they know me and the more they trust me, the more they’ll reveal and the more in-depth we can work in different areas that they’re struggling in.”

Kasperski and the other nurses also are important in keeping patients out of the emergency room. Rather than being forced to call 911 even when an issue may not be urgent or life-threatening, patients can call Tandem365 any time of the day. The nurses already have their records on file, and they work with the patients to solve the issue, only calling paramedics contracted through Tandem365 if necessary; this way, everyone involved knows the patients’ medical history, and potential lack of communication is avoided. In the end, it saves the patients money and relieves some burden on the health care system.

Each month, the RN navigators review their patients’ cases and ensure they’re being cared for effectively. Every morning, the team reviews calls made the night before and considers whether those patients need more care.

From the beginning, Meijer said the founders’ purpose wasn’t to streamline patients to their own services. The goal is to work with patients to meet their needs. Their current physicians and medical professionals are not replaced, but Tandem365 can assist patients in accessing those services.

“Our default is always in the patient’s best interest,” Meijer said.

The services are covered and available only for Priority Health patients, but there will be an option to register directly with Tandem365 early next year. The service is for adults ages 55 and older who have serious medical needs and live in their homes.

The standard monthly package of $350 includes two complimentary visits, phone calls, physician coordination, six-month reassessment, comprehensive care management, 24-hour emergency service, service coordination and advance care planning. The monthly $450 package includes the standard services, plus up to two monthly medication setups. Another main objective is for each patient to have an advance directive, which documents their medical wishes should they become unable to make decisions on their own.

Toland said some patients require a lot of care and some not as much, but they all want to be safe and comfortable in their homes.

“Some people don’t need a lot, but what they need is someone to call, and they need someone they can count on being there,” she said.

The program is available for those in Kent, Ottawa, Allegan, and Kalamazoo counties.


September 26, 2017

Non-traditional, Integrated Model Points to a 52% Reduction in Hospital ER Visits, 38% Reduction in Inpatient Visits & More

Keeping at-risk seniors in their homes and out of hospital emergency rooms has been a daunting and often expensive task.  In fact, individuals who are 55 and older with little or no social support and who need assistance managing their medically complex health issues, are among the heaviest users of health care services.

That’s exactly why five local organizations (Clark Retirement, Sunset Manor, Porter Hills, Holland Home and Life EMS Ambulance) joined forces in 2014 to create Tandem365 – an entirely new model of integrated care designed to help older adults navigate the complexities of health care while enabling them to remain in their homes.

Three years later, Tandem365 participants are reaping the benefits of the non-traditional model, pointing to impressive outcomes from Tandem365’s three-year relationship with Priority Health members.  Specifically, here are key findings of the Tandem365 integrated care model:

  • ER visits down 52%
  • Inpatient visits down 38%
  • Specialty visits down 46%
  • Average health care cost per member decreased by 35%

Tandem365 delivers medical, behavioral and social services not typically reimbursable, with a focus on patients who are isolated, in poverty, frail health and lacking transportation, explained Teresa Toland, CEO of Tandem365.  Many Tandem365 patients are seniors, although the organization’s approach is not exclusive to this population.

“Tandem365 is shaking up the status quo for health care delivery by offering an entirely new approach to keeping our senior population at home as long as possible by improving their health and quality of life,” she said.

To do that, Tandem365 tackles all of the barriers that often get in the way, such as a person’s ability to buy groceries, create meals, travel to doctor appointments, take regular medication and more. Tandem365 offers a team of navigators, nurses, social workers, paramedics, therapists, aides, etc., to provide interdisciplinary wrap-around services and advanced-level case management tailored to each client’s needs – right in their own homes.

Through a pilot program with Priority Health, Tandem365 has cared for approximately 1,000 patients, and reports a 38% decrease in inpatient stays, a 52% decrease in emergency department visits, a 35% decrease in total cost of care, and 46% fewer specialty care visits.

 “We’re pleased to share a proven, new model of care not only for Grand Rapids, but communities beyond,” said Toland.

“We are very encouraged with the results of Tandem365 and the quality of life it affords to the senior population,” said Greg Gadbois, M.D., medical director, Priority Health.

Tandem365’s model with Priority Health has been cited in numerous publications, including, LeadingAge, Alliance of Community Health Plans and Managed Healthcare Executive.  Additionally, Toland recently presented at the National Academies of Sciences, Engineering and Medicine (NASEM) Roundtable on Quality Care for People with Serious Illness.

“We’re looking forward to building on our success, serving even more individuals,” said Toland.

Karen Kirchenbauer, APR
SeyferthPR 616-776-3511



May 23, 2017

Molly Rayman, MSW, TANDEM365’s Director of Operations was recently featured on WZZM discussing senior wellness and the importance of Advance Care Planning.  Click below to see the segment:


Video: How acute/post-acute integrated care improves patient experiences while significantly reducing costs

In this video, part of our “The Bottom Line” series, Teresa Toland, Tandem365 CEO and Mina Breuker, Holland Home CEO, discuss how their partnership with acute providers and payors provides significant value across the entire continuum.

See Video Here



Tandem365: Michigan nursing home joint venture delivers better care at lower cost

July 12, 2016 Article 3 min read
A young joint venture delivers complex care management services to vulnerable seniors, with encouraging outcomes, high client satisfaction, and strong growth. Learn from their success.

Five years ago, Mina Breuker of Holland Home and Teresa Toland of Porter Hills sat on a panel with other nursing home administrators to tackle the problem of hospital readmissions. Examining root causes, they realized “the problem is bigger than transition of care,” Toland recalls.

Case in point: Henry, an 80-year-old patient, socially isolated and unable to manage his medications or get to appointments. Toland and her colleagues pondered, “How could we close the gaps and create interventions for someone like Henry?”

The solution: Tandem365

People like Henry were lost in a fragmented system where “no one was holding the story of the patient,” Breuker says.

Their solution? Form a joint venture — Tandem365 — to deliver complex care management services to vulnerable seniors. The business model hinges on a role that has worked for other case management programs: the navigator. Each Tandem365 team includes a social work navigator and a nurse navigator.

Tandem delivers better care at lower costs, using:

  • A robust network of volunteers, visiting with clients and doing chores
  • Paramedics, providing care in patients’ homes whenever necessary
  • An interdisciplinary team, meeting daily to discuss activity with current members (such as after-hours calls) and new enrollments

This team works with each participant to create a life plan, coordinating with family members and healthcare providers to advocate for that person.

The results

In early 2014, Tandem365 piloted a project with commercial payer Priority Health. Priority targeted their most expensive members first — those costing over $25,000 per year.

The results are encouraging. Among the 150 pilot members, by the end of 2015, Tandem365 found:

  • Average healthcare cost per member — down 30.2 percent
  • ER visits — down 46.2 percent
  • Specialty visits — down 22.8 percent
  • Outpatient visits — down 13.4 percent

One roadblock: Not everyone agrees to participate. “Sometimes it’s hard to convince someone that they need something, even when it’s free,” says Toland, who is CEO of Tandem.

Tandem has improved its conversion rate to about 70 percent, up from 50 percent, largely due to a strong network of case managers.

Tandem has improved its conversion rate to about 70 percent, up from 50 percent, largely due to a strong network of case managers. Toland projects Tandem will hit 537 participants by year’s end, up from 302 in March. With such strong growth, and 98 percent client satisfaction, Tandem and Priority recently entered a three-year contract.

Currently, Tandem365 receives from Priority a per-member-per-month (PMPM) payment of $625 for its care management services, but it plans to move toward risk sharing. The tipping point will be “once we know for sure that we are impacting outcomes,” Toland says. To reach that point, Priority must identify a cohort of people against which they can measure the Tandem population — a challenge, “because our people have a lot of social determinants that don’t show up on claims.”

Keys to success

Meanwhile, the pilot’s success is yielding more opportunities. Tandem is starting a pilot program with health maintenance organization Blue Care Network of Michigan that will target 100 eligible members.

Tandem365’s keys to success so far:

  • Custom training. Tandem University, taught by two professors from Grand Valley State University, provides training on topics such as aging, discrimination, and creating a life plan. “We found through our pilot that we have to prepare our staff very differently,” Breuker says. The focus is on enabling members’ independence. “It’s so much broader than healthcare.”
  • Financial accountability. Team members must balance financial realities with client needs. An electronic scorecard highlights how much money each team has for the month.
  • Collaboration. Breuker and Toland encourage other senior care providers to collaborate — even with competitors — to solve common problems together. That way, “you have a lot more power and ability to learn best practices from each other.”


Video: New collaboration care model drives readmission rates from 23 percent to 4 percent

January 13, 2017 Article 8 minute watch
In this video, part of our “The Bottom Line” series, Mina Breuker, CEO of Holland Home, and Teresa Toland, CEO of Tandem 365 discuss how acute/post-acute collaborations can deliver better outcomes for patients and providers.