Seniors Need, And Want, Better Care Coordination

By the year 2050, there will be nearly 86 million people in the US over the age of 65, effectively doubling the current senior population. As this population continues to grow, providers are tasked with serving more patients in an environment already facing pressures to reduce costs. As care coordination continues to be at the forefront of care quality conversations, providers have the opportunity to fit together all of the aspects of patient care to keep this population healthy.

Many seniors today face multiple chronic conditions that make their care plans even more complex. In a recent survey of patients aged 65 and older, 85% of respondents reported having at least one chronic condition. Aging seniors, especially those with chronic conditions, need closely-managed care and often get it in multiple places. About two-thirds see three or more providers annually. This ongoing management from multiple caregivers creates an opportunity to streamline patient care, achieve efficiencies, and avoid harm. Yet, 70% of seniors reported needing better care coordination, and more than one-third reported that no one coordinates their care at all.

In addition to clinical resources, community resources are also extremely important to manage senior care. For example, many older adults, especially those with limited mobility, experience loneliness and sometimes depression. Because mood can have a significant impact on health outcomes, these patients often need additional socialization support. It is important that providers help connect seniors with the appropriate avenues through which they can interact with peers. Similarly, pointing seniors to resources that help with diet and nutrition can help successfully manage diabetes, curb heart disease, or just ensure that they are eating the right foods.

But, with already-burdened providers and an increasing number of seniors needing these resources, implementation can prove challenging.

In the past decade, accountable care organizations (ACO) and patient-centered medical homes (PCMH) have sprung up with aims to increase care coordination and community resources to help address not only the medical, but also the social determinants of health. With seniors needing and wanting these resources, some senior-focused communities have partnered up with ACOs to improve care and quality of life.

Like other ACOs and PCMHs, this model focuses on the primary care provider (PCP) at the helm of patient care, and perhaps with good reason. A recent study of Medicare data found that when PCPs drive care, Medicare spending goes down by 9%. PCP-driven care for seniors also resulted in fewer hospitalizations, lower outpatient costs, and lower mortality rates.

As PCPs lead the charge in prioritizing care coordination among the senior population, every provider will start to see the benefits–as will patients.

Click here to learn how one ACO is managing their population