naviHealth CEO Clay Richards challenges the industry to create a new ecosystem of care around seniors in the new year in these latest Essential Insights.
Last year, a 79-year-old woman (“Mary”) suffered an acute incident resulting in skilled-nursing facility admission. Prior to that, she lived alone in a low-income, independent living apartment by herself. She had a past medical history of multiple chronic illnesses, as well as a long history of socioeconomic issues.
For 39 days, Mary was under skilled care and fought hard to recover — determined to move and live with her granddaughter. As her care team worked diligently to create a discharge plan that aligned with her personal wishes, it was clear that Mary’s family was not going to be able to adequately care for her, given monetary and time constraints.
While trying to find an alternative plan that would meet Mary’s wishes, she was readmitted to the hospital. Given her continued decline, the woman and her care team agreed that hospice was her best option. They also agreed to abide by Mary’s wish to be able to eat what she wanted to eat in what time she had left. While not the discharge goal originally desired, Mary settled into a great facility with excellent care. This positive ending to Mary’s story would not have been possible without close collaboration across the care teams, Mary’s family, and Mary — which was led by her care coordinator and social worker.
The complexity of enabling quality, affordable senior care, particularly for patients like Mary, is daunting. Still, it is no longer an issue we can look to solve in isolation. Instead, we must look collectively at this issue that affects our parents, grandparents, loved ones, friends, and, eventually, ourselves. Now is the time for us — as an industry — to come together to drive innovative ways to create a new, senior-centered ecosystem to care for the nearly two billion people worldwide who will be 60 or older by 2050.
Optimizing total health for seniors
Emphasis is starting to be placed on the need for new models of managing long-term care for seniors, but many of these approaches are still missing insight on the full picture of all the issues seniors are dealing with both as a patient and as a person.
In order to maximize outcomes, caregivers across the spectrum of services must not only consider seniors’ health-specific issues, but also social determinants of health ranging from access to quality, affordable healthy food and housing to their ability to pay for monthly prescriptions.
To make holistic care a reality, providers and health plans also need to equip and empower primary care physicians (PCP). As the “quarterback” of care, PCPs are simply not resourced or supported appropriately to provide the type of hands-on, value-driven care that leads to high-quality outcomes and, more importantly, high-functioning seniors. In an ecosystem designed to care for seniors, a new hybrid model of care is needed.
This model must both empower the PCP to lead and balance integration of the positive attributes of quality managed care plans — like smart cost control enabled by narrowed network access.
Arming seniors and caregivers with transparent health care insights
For too long, we’ve been discharging seniors into post-acute care “black boxes” and not arming them with the insights needed to make intelligent decisions that will impact their health. Clearly, post-acute care (PAC) management must be considered as an integral part of this new senior-centered ecosystem.
The work our organization does is focused on this critical puzzle piece of senior care. As a team, we’ve seen the seniors we serve at some of the most vulnerable times in their lives as they transition to PAC. In a senior-centered ecosystem, these patients would have “guardians” to guide them on the best care path forward. They would not be left all on their own to make decisions that impact their health outcomes — like which facility to choose or what doctor is best suited to care for them. Instead, they would have a skilled and trusted clinician to help inform and guide them as they coordinate the integral next steps of their recovery — a clinician who respects the uncertainty and anxiety of patients in transition and is able to empathize and offer both clinical and emotional support.
Luckily, pieces of this “black box” issue are beginning to be addressed with the implementation of the Centers for Medicare and Medicaid Services (CMS) Final Discharge Planning Rule. A key mandate of this rule is the requirement that providers focus on a patient’s goals and treatment preferences as part of the discharge planning process.
While this mandate is certainly a step in the right direction, there is more work to be done by CMS to support seniors. CMS must further leverage quality standards to help narrow networks and, in turn, offer seniors access to providers with a strong track record of care processes and procedures that lead to positive patient outcomes. The answer to a senior-centered ecosystem is not more care options, it is access to only the best possible proven care options.
Embracing a home-based approach to care
In a senior-centered health ecosystem, home-based care for seniors must also be redefined, both in their actual homes and in skilled facilities, as well as for those who may be homeless and in need of support from shelters. At its most basic, home-based care should respect the choices of seniors and the goals they have in relation to their own health and well-being. Instead of focusing on merely monitoring and managing the issues that seniors face in the short term, home-based care needs to focus on long-term solutions that enable seniors to live healthier, happier lives by appropriately managing the natural ailments associated with aging and respecting their personal wishes.
To make home-based care a reality for seniors, we must also look to adopt and reimburse innovative technology that provides seniors and their caregivers with the support they need — whether it’s a ride to an appointment or having medications and groceries delivered to their doorstep. Health plans like Aetna are taking a leadership stance on this need for home-based senior support.
Most recently, they entered into a strategic partnership with Papa, Inc., a service that connects college students willing to provide support for seniors. Just this month, Humana also took a notable step in supporting home-based care by providing their Medicare Advantage members with 24/7 access to remote patient care services. These technologies and services must also be easy to use for seniors and caregivers alike, and we must consider how best to educate seniors and caregivers on the emerging technologies covered by their health plan that will allow them to age with grace at home.
In 2020, we must commit to making the changes needed to create a new, senior-centered ecosystem. The creation of this end-to-end ecosystem focused on total health enablement, transparency, care coordination, and human connection is the only way we can feasibly tackle care for a vulnerable population — people like Mary — dealing with myriad health and personal issues. This ecosystem must also be infused with empathy as it is our duty to repay the kindness and respect these older generations have provided and continue to bestow upon us.