Spotlight on Innovations and Achievements: Springwell

We're proud to highlight the award-winning work of the 2019 winners of n4a's Aging Innovations and Achievement Awards in this weekly spotlight feature. This week, we are focusing on Springwell's Partnering with Chronically Ill Patients to Improve Health and Well-Being program. The agency was a 2019 Aging Innovations Award winner in the Health-LTSS Integration category.

In order to help older adults manage chronic diseases like diabetes, hypertension and COPD, Springwell, an Area Agency on Aging, partnered with a well-known health care provider in Massachusetts. The program, Partnering with Chronically Ill Patients to Improve Health and Well-Being, has proven to have a positive impact on chronic illness and has received high patient satisfaction scores. As a result of the program's success, it will likely reduce health care costs in the long run. Beyond yielding good data points, the program has engaged older adults and encouraged them to take responsibility for their health.
The disease management program includes a comprehensive assessment, patient-centered goals and education on the causes of the health conditions faced by program participants. Over a period of six-to-eight weeks, coaches work with patients to address their specific needs and provide greater communication and coordination among the primary care team, pharmacists and coaches, as well as community resource coordinators and nurse care managers when appropriate. The program coaches also work closely with the pharmacists to help participants learn to manage the side effects of medications and understand and manage Rx costs.
Participants are referred to the program by primary care physicians or are identified via claims-data algorithms as being at risk for negative outcomes. Once referred, participants gain access to the dedicated coach and, in a larger sense, access to personalized health care.
Program participants have reported that they appreciate that doctors' offices offer this virtual service that takes place outside of a clinical setting. They value the non-judgmental, practical advice their coaches give them and especially like that it is personalized to them and their chronic illness. More than 400 older adults participated in the program and of those who responded to a post-program survey, 93 percent reported a satisfaction level of “excellent.”
For other AAAs that like this idea and think it could work in their communities, Springwell advises that, before starting, AAAs get buy-in from a health partner looking to provide a new layer of support for their patients struggling with chronic disease. The partner may need to be convinced that non-medical staff are able to provide this service in an effective and efficient way. The AAA must recruit coaches who not only have strong health education backgrounds, but also have the social skills to engage patients telephonically and a commitment to a patient-centered approach.
To learn more about Springwell's Partnering with Chronically Ill Patients to Improve Health and Well-Being program, contact Josephine White, Director of Health Partnerships at

Want to learn more about the 2019 AIA Innovations winners? REGISTER NOW for our new four-part webinar series, n4a Lunchtime Innovations, to hear your peers' secrets to success for these award-winning programs.
For more information about the 2019 winners, read our press release and check out our book of winners to learn how your agency can implement this or similar programs in your community!



USAging Fact: Learn about your peers’ work—and how it can fit into your agency’s goals! The AIA Awards recognizes successful and innovative programs that USAging members have developed to serve older adults. Get inspiration from our 2023 winners!