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 Care Coordination for Older Adults: The Critical Link to Improved Health care

 

 

 
Consolidation is nothing new in health care. For years, managed care companies have purchased other managed care companies, and hospital systems have done the same. For those in senior health care, the same thing is happening today as organizations join forces. There’s consolidation among hospices and home care agencies, and some health systems are bringing together PACE (Program of All-inclusive Care for the Elderly) programs under the auspices of a single organization. This consolidation is driven by the need to:
 
•    Reduce readmissions to hospitals; and
•    Provide additional health care services to individuals and families.
 
Both issues really add up to a single, consolidated effort in senior-focused health care: care coordination. Care coordination, bringing together of multiple health care services—including post-acute rehabilitation—to create a holistic view of an individual, has been shown to improve outcomes, which advances health and reduces hospital readmissions.

Why Now?

Baby boomers are driving these changes in the senior care industry. They are creating a new demand on services due to their vast numbers and the fact that many have co-morbid health conditions. But they aren’t demanding just any kind of health services. They want “service” and “quality,” and how each individual defines these measures is different. Gone are the days of remaining under the care of a specific doctor even if the person doesn’t like his or her bedside manner. If someone has a bad experience, they’ll switch. Quality is a big factor, too. People will spend time seeking out and getting quality service.

So ensuring health care services are top-notch is more critical than ever. To do that, many health care organizations consolidate to bring disparate, but related services under one roof with the goal of providing coordinated care through an interdisciplinary team. Care coordination has the ability to bring a holistic view to every individual and ensures that anyone involved with providing health care services is aware of the other services being provided. It takes a complicated process and provides the resources in a simplified way.

Care coordination assists individuals with one of the most difficult aspects of health care—navigating the complex system in which it exists. At InnovAge’s call center, which serves the caregivers of older loved ones who need services, the most common questions often asked are short and simple, yet very complex: “I don’ know where to begin...” and “What do I do?”

How It’s Done

With care coordination it’s important to have high touch along with high tech. No matter how technologically advanced health care becomes, it’s still a people business. And people want high-touch health care services as well as those delivered through a portal or by phone.

Clinicians must take this leap from their comfort zones in clinics and offices to the comfort of an individual’s home, whether that’s a family home, nursing home, or assisted living facility. This type of care coordination is very similar to what health care providers did years ago: the house call.

Individuals can access care coordination services—depending on how one pays (private pay, Medicaid, or Medicare) for services—at PACE centers, through various types of adult day programs, a skilled nursing facility, or home care. Each service provided needs careful and considered care coordination to ensure the best outcomes possible for the individual.

The shifting volume of patient care from the acute care environment to outpatient care has redefined care coordination. Drivers to this change are fiscal pressures, including reimbursement shifts, coupled by the results of investments in technology that allow providers to follow their patient population across multiple environments. This shift in philosophy to the patient-centered medical home allows the coordination of care in the environment where patients reside.

By including post-acute providers, such as assisted living facilities and nursing homes, in the care
coordination continuum, a number of benefits are realized. Within assisted living or nursing home facilities, these efficiencies include:

•    Assistance following protocols already in place;
•    Streamlined communication through a common technology platform; and
•    Use of terminology familiar to all providers.
 
When care coordination is wrapped around patients, it typically leads to improved patient satisfaction and increased market share as word spreads about the facility and its holistic view of care.
With so many people just trying to understand the health care system, care coordination is the critical link that brings it all together.
 
Phillip W. Heath is chief marketing and sales officer at InnovAge, a provider of health care services for older adults in Denver, and a board member of the Alzheimer’s Association – Colorado Chapter. He has worked in senior health care for more than 25 years. He can be reached at pheath@myinnovage.org.
 
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