1. Who is Tandem
We are a collaborationof 5organizations;Clark,HollandHome,Life EMS,PorterHillsandSunset
Retirement.
Our Goal
Improve the qualityof life forthe elderlypopulationwhile keepingthemintheirhome foraslongas
possible,decreasing unnecessary ERvisitsandHospital Admissions,andhelpingthemlearntomanage
theirhealthtothe maximumabilitytowhichtheyare able.
Who Qualifies
55 and Older,little tonosocial supports,needsassistance managingtheirhealth, generallyhave chronic
healthconditions, andlivinginKentCounty. (alsosome closerareasof AlleganandOttawaCounties)
How Does it Work
A referral isreceivedatTandem365. That participantisthenassignedtoan RN anda MSW Navigator
team. The teamsetsup the enrollmentdate withthe participantattheirhome. A comprehensive
assessmentiscompletedtakingapproximately3hours. The participant’sneedsare evaluatedboth
medicallyandsocially. Subsequentvisitsare setupas neededwitheachthe RN and MSW toaddress
needsandbuildthe relationship.
IDT (InterdisciplinaryTeam) meetingsare helddailytodiscussthe needsof ourparticipantsandwhat
servicestheywouldbenefitfrom. Those servicesare thensetupwithcontractedpartnersand
implementedinthe home.
What Services Does TandemProvide
Servicesprovidedare customizedtoeachparticipant basedonthe assessmentof ournavigators. Notall
participantsreceive all services. Everyone receivesCase Management. Otherservices mayinclude
telehealthmonitoring,PRSbuttons,meddispensers,chore services,personal care aides,volunteers,
transportationtoappointments,respitecare forcaregivers,companionship,andmore. Ournavigators
oftenattendappointmentswithourparticipantstoensure thatfollow uptakesplace asneeded,
medicationchangesare done inthe home,etc.
Who Will Their Doctor Be In Tandem365
Theywill keeptheirownPrimaryCare Doctor. Our nurseswill update physicianswithhealthconcernsof
the participantandwork to gettheminto see theirphysicianforanappointmentoraskfor ordersto
performbasictestingandinterventionsinthe home,(ieLab draws,urinalysis,IV fluids,etc).
How to Make Referrals
See referral request. If uncertainif theyare appropriate forTandem365,please call 588-5290 and we
can discussthe case.Fax the referral sheetto616-588-5291.

2. How MuchDoes It Cost the Participant
Our social workerisable togather communityresourcesforyouandsee whatyoucan qualifyforinthe
community.The social workercanevenhelpgooveryourfinancestosee whatyou can qualifyfor
throughTandem365 itself. Co-paysthatare requiredof medical treatments,medications,etcare still
the responsibilityof the participant.
Doctor for After Hours
Our Medical DirectorisDr. Iris Boettcher. From4:30 pm to 8:00 am the followingday,anyurgentcalls
that come in regardingaparticipantwill be handledbyourmedical director. She willgive ordersas
neededtocare for the participantduringthe evening. A follow upcall andpossible appointmentwith
theirownphysicianwill thenbe done inthe morning. Dr.Boettchermayalso call the primarycare
physiciantodiscussthe participant.
24/7
Tandem365 is available toourparticipants24 hoursa day/7days a week forquestionsandurgent
needs. Life EMS isour after-hourscall center. Everycall thatcomesinafter-hoursistriagedbyLife
EMS.
If there is a life threateningemergency,paramedicswillautomatically be dispatchedtothe home. If the
call is notof an urgentnature,the navigatoroncall will follow upwiththe participantandaddresstheir
needs.
Participant CenteredCare
One of ourgoals inthisprogram isto offerthe care the participantdesires,whatisimportanttothem,
and whattheirprioritiesare. OurRNsand MSWs focusheavilyonadvancedcare planning,getting
DPOAsinorder,and rapidresponse protocols(ex:if the participanthasanotherCHFexacerbation,what
will we doaboutit basedonthe participant’swishes).
Limit ER Visits toOnly Those Necessary
Nobodyenjoysgoingtothe ER. We can do manythingsinthe home that can deferan ER visit underthe
directionof the primaryphysicianorafter-hours,ourmedical director. Mobile xray,labdraws,
urinalysis,stool cultures,IV antibiotics,IV hydration,IV pushmeds,etc.,canall be done at the
participant’shome andwe have successfullypreventedseveral tripstothe hospital already. OurRNs
and Life EMS paramedics can assistwithmanyoptionswithouttransportingthemtothe ER, including
followupassessmentsasneededatanytime.
How Long Can The Participant Be Enrolled
Thismodel of care isa longevitymodel. Aslongastheymaintainthe insurance that participateswith
thisprogram,theywill remainenrolledinTandem365. Theymaybe enrolledfor manyyears. Once they
have the needforendof life care,hospice servicesmaybe addedincoordinationwithournavigators.