Case Study: How Riverside Health System Provides Preventive Care to Keep Older Adults Healthy in Their Homes

About Riverside Health System

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Riverside Health System began in 1915 and is a non-profit organization in Virginia dedicated to improving health and saving lives.  Starting with just one hospital, Riverside has grown to encompass six hospitals, cancer services, dialysis, health improvement and wellness, home care, retirement communities, and other lifelong health and aging-related services. Riverside serves more than 7,000 patients each day and is dedicated to caring for others the way they would care for their own families.

Through its Center for Excellence in Aging and Lifelong Health (CEALH), Riverside works to improve the quality of life for older adults.  They do this by integrating academic, clinical and health services research with the capabilities of local service providers to develop and implement innovative community-based and healthcare system initiatives that can be replicated and sustained by the health system.

CEALH’s vision is to lead the development of model communities that will promote the well-being and independence of older adults through translational research and widespread application.  CEALH's ability to bring community partners together with the common goal of improving healthcare for older adults is critical as the Baby Boomer age wave continues to grow and accompanying public policy is put in place to improve the nation's approach to healthcare.

Riverside also runs the ChooseHome program, a Continuing Care at Home program, which allows qualified individuals 60 and older to live in their homes, while providing them with the resources of a health system so they can stay healthy as they age.  

CEALH Key Services

CEALH makes a complex system of services more easily accessible through education, referrals and individualized, person-centered services, tailored to the unique needs of aging adults and their families. Specific services include:

  • Geriatric assessments
  • Driver rehabilitation clinics
  • Education for individuals with chronic conditions to manage their symptoms
  • Resources and education for caregivers


ChooseHome Key Differentiators

  • Coordinates and provides care while also helping to cover costs through insurance
  • Provides a personal services coordinator to assist members in developing a personalized plan to maximize active, independent aging. This coordinator helps coordinate many of the same things for members that their own children would, including navigating health care services and home improvements with area contractors.

The Role of LivWell Health

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LivWell Health has played a key role in Riverside’s ChooseHome program since the beginning.  The program has grown to more than 100 members, served by personal service providers.

LivWell helps the program monitor and track resources and caseloads to ensure they are allocated efficiently and effectively.  LivWell also measures how Riverside is communicating within its own health system and with other health systems.

Specifically, LivWell helps monitor hours spent with a member and how a member’s health is tracking over time.  Once a member joins the program, they receive a care plan and Riverside set goals for that member in different spheres (i.e., physical, mental, behavioral and spiritual). LivWell helps Riverside attach metrics to these goals so that personal service providers can see how they are doing; they also help with billing.

Moving From Reactive to Preventive Care

Riverside is committed to serving older adults and their caregivers and intends to stay on the cutting edge of innovation as this population grows.

With LivWell Health’s support, they plan to continue their focus on measuring the components of healthy aging, using a jointly developed care coordination algorithm.  They have developed a series of metrics tied to a care plan that shows whether an older adult is improving their health, maintaining it, or in some state of decline.

They do this by asking ChooseHome members a set of questions each month, which they analyze and use to provide preventive care.  Having this data allows Riverside to focus on preventive, rather than reactive services and better serve patients and their caregivers.