A new care coordination program to predict and address the health needs of North Memorial's elderly patients is different from prior attempts, its leaders said, in one key way.

"This time its going to work!" proclaimed Joel Theisen, chief executive of LifeSprk, the St. Louis Park-based elder care provider that has joined with North Memorial in the effort.

Under the new program, a group of North Memorial's elderly patients is screened for risks of chronic diseases and complications, and high medical spending. High-risk patients then receive home visits from LifeSprk nurses to identify solutions to maintain or improve their health, even if those solutions have nothing to do with medicine.

"This is true anticipatory guidance for our senior population," said Dr. Carolyn Ogland, North Memorial's chief medical officer.

Care coordination has been a buzz term in Minnesota health care for years, and with good reason. Elderly and chronically ill patients often don't realize or don't tell doctors the underlying reasons for health problems, and they often struggle after hospitalizations to follow new prescription regimens and make follow-up appointments.

The result is that they get sicker or end up back in hospital care.

North Memorial and other health systems have tried everything from check-in phone calls to paramedic home visits, but costs and preventable diseases and hospitalizations continue to be a problem for these patients.

The new alternative is being used for now with 5,700 elderly patients who receive primary care from North Memorial and Medicare Advantage health coverage from UCare.

Theisen said it will work because LifeSprk has the funding flexibility to pursue whatever solutions patients need, and because North, LifeSprk and UCare all have shared in its financial risk.

In one case, a man hospitalized with an electrolyte imbalance received a mobile phone after a nurse visitor found his home full of pizzas and hot dogs, and learned that he had become reclusive. The nurse taught him how to order healthy meals online and Uber rides to get around. Relatives said the man's change in mood and health was immediate, and his medical spending declined from $31,000 in the prior fiscal quarter to less than $4,000.

"That is the ultimate win," said Ogland, adding that she would like to expand the concept beyond UCare patients if it proves its worth. "If we can demonstrate improvement in our overall results and overall engagement [with patients], and a decrease in hospital readmissions, I think we would love to see this spread."