Tailoring a Program of Carefor Older Adults

The literature is replete with tools and workflows that have been trialed and measured to promote the safety and wellness of an older adult at home. For many, long-term services and supports, as well as numerous community-based resources, are available. However, for someone who may have special needs (such as medical and behavioral complexities, limited access to care, or social determinants of health), the availability and utility of more resources alone may not lead to better care or outcomes. The appropriate and individualized utility of resources available for older adults requires the craftsmanship of a fine tailor to generate a “suit of care” that is personally styled, comfortable, and travels well.

In the coordination and delivery of older adult care, organizations like Commonwealth Care Alliance (CCA) are ‘tailoring many suits’ to meet the needs of older adults living at home by structuring programs that are 1) modeled after the Age-Friendly Health Systems framework; 2) fueled by predictive analytics and action boards; 3) use innovative services—such as consultative palliative care.

The Right Team that Drives Individualized Care

Optimal coordination of older adult care—that “perfect suit”—does require the actions of a team working toward an individual’s healthcare goals. Given that older adults typically have multiple medical issues, medications, multifaceted social and financial dynamics, and transitions in care, they are constantly challenged to maintain their independence within the community. As an industry, it is critical we recognize that older adults are unique in their needs—one size suit does not fit all—and the primary care provider today cannot “go it alone” when delivering care. To help older adults stay well in their own homes as they age, primary care providers, specialists, behavioral health supports, social work/care coordinators, community resource leads, and health plans must come together to promote high-quality, individualized care.

The Best Approach for High-Quality Care Delivery

Teams often struggle in creating that perfect suit of care because of difficulties in establishing a framework for developing or maintaining standards of care that will decrease variability or reinvention; preventing silos of redundant care; and identifying outcomes, or key performance indicators, that can be measured. To help the nearly 84 million adults over the age of 65 that are expected by 2050, the Institute for Healthcare Improvement and the John A. Hartford Foundation developed a framework to meet the challenge of an aging population based on evidence-based practices for high-quality care. The ‘Age-Friendly Health Systems’ framework relies on four elements, or the ‘4Ms’: What Matters, Mentation, Mobility, and Medication. This organizing framework helps maintain focus on the needs of older adults, such as: goals and wishes for care, fall risk and cognitive assessments, polypharmacy, and deprescribing.

The Innovative Technology that Tailors Better Outcomes

How can the healthcare system address or predict an older adult’s needs in real-time? Can an individual’s unique care plan be tailored to prevent hospitalization, trip to the emergency room, fall, or social determinant need? CCA uses information technology platforms—predictive analytics—to address these questions.

 By using historical data (e.g., claims, authorizations, and medical records), member geography, and other information, CCA finds patterns that help predict a member’s future needs. 

In addition, CCA created “action boards” to consolidate data and spotlight the most significant issues that a provider should immediately address. For older adult CCA members, there are data on healthcare utilization, social needs, medication adherence, and comorbidities that together, with an algorithm, can be used to understand what actions that individual might require—today.

The Tailoring of Programs to Help Address Critical Needs

Lastly, the healthcare system needs to recognize that care for older adults must be dynamic. Just as suit styles are updated over time—comorbidities, medicines, and needs in the community can change and require new ‘tailoring.’ Optimal care for older adults requires the implementation of innovative ideas. The provision of palliative care—earlier in some patients’ health journey—is an example of implementing a proven model in an innovative way. The understanding and appreciation of what palliative care is, and the benefit that palliative care can bring to an older adult with serious illness, is crucial to quality care. The application of palliative care earlier in a serious illness trajectory creates an opportunity to better educate patients, caregivers, and/or families about a serious illness. In doing so, early exposure to palliative care can benefit the healthcare system by addressing the individual burden of illness and lead to improved, or more appropriate, healthcare resource utilization in the future.

To innovate our palliative care programs, CCA uses artificial intelligence algorithms, based on data from over 1.2 billion patient events, to identify members with serious illnesses who are at increased risk for mortality, predicted functional decline, or admission risk. The addition of a Sankey diagram allows for monitoring of patient flow through the palliative care system, from referral to enrollment to discharge, with an update on member status available at any one point. With this innovative approach, the CCA palliative care team can implement specialty care (and even within the ‘4M’ framework) to “tailor a suit” that offers symptom management, advance care planning, and the ease of anguish or distress with spiritual support and guidance.

The assessment and management of older adult health and wellness need not be a healthcare mystery. For the 70 percent of its older adult members, who are nursing home certifiable, CCA delivers care that allows them to live safely and independently in their own homes. The collaboration of team members, both clinical and non-clinical, the application of best-practices from resources such as the Age-Friendly Health System, the inclusion of predictive analytics and action boards, and the implementation of innovative practices, like palliative care, can tailor a suit of care that reflects each member’s special needs and fosters a system geared toward the ever-growing older adult population.