Partnering to Improve Outcomes for Seniors

· 5 min to read

You can’t think about better care outcomes for older adults without considering chronic conditions: Nearly 80 percent of older adults have at least one chronic disease, and 77 percent have at least two, according to the National Council on Aging.

But how can you address all the complex health issues these patients are facing in a short office visit, and how do you ensure their well-being outside of your facility’s walls?

This conflict between a physician’s ability to provide adequate attention in the exam room with a patient’s ability to maintain their complex care needs at home is the focus of a new report from Quest Diagnostics, Hidden Hazards: Closing the Care Gap Between Physicians and Patients with Multiple Chronic Conditions, which surveyed Medicare patients and primary care physicians.

Among its key findings, the report suggests:

  • Nearly all physicians (95 percent) surveyed say they entered primary care to care for the “whole patient,” yet 66 percent say they don’t have time to address social and behavioral issues that could affect health.
  • Fears related to medication nonadherence, falling at home, and being a burden on caregivers were cited as concerns by physicians and patients — but often not discussed during the physician visit.

Effective chronic care management takes time and resources, but should the burden fall solely on the physician to provide it? Today’s technology — from telehealth to mobile tech to artificial intelligence (AI) — combined with the right clinical expertise and support, may offer a viable complementary solution and partnership.

How Baltimore Is Fighting Falls with Data

As the Hidden Hazards report suggested, the fear of falling at home was one of the top concerns among both physicians and patients — though it’s one that’s rarely addressed.

But falls at home are one of the biggest drivers of increasing hospital costs and frequent ER visits: in Baltimore alone, nearly 5,000 older adults visited the ER in 2017 after a fall at home, to the tune of $60 million dollars in hospital costs.

Since these numbers were considerably higher than statewide averages, city health officials took notice — and took the next step towards prevention: launching a strategy tasked with reducing the number of falls by 20 percent over the next decade.

Using a data surveillance system to identify “hot spots” for falls (the system can identify neighborhoods with higher incidences or pinpoint the exact location of a fall), city health officials and community partners — such as the housing department, social service providers, and local academic institutions — will tailor interventions accordingly.

Once these hot spots are identified, providers will go into homes to fix lighting, install railings, or make other home modifications to prevent future incidents. Public education is also part of this collaborative effort, which is on track to save nearly $14 million in medical costs.

The Finer Insights of AI

Baltimore’s data surveillance system demonstrates the partnership opportunities AI fosters. It also creates connections to what’s happening at home that clinicians can’t always make during the office visit. “AI and related machine learning techniques allow data scientists to integrate and analyze a wide variety of data points relevant to the specific problem at hand, in this case fall prevention,” says Amit Misra, PhD, Vice President of Data Science and Advanced Analytics at naviHealth. “It can provide finer insights to clinicians about the causes of falls, some of which might not have been readily apparent even to seasoned practitioners.”

While AI and other collaborative technologies offer these finer insights, the clinician still plays a vital role, says Misra. “Technology can enable better decision making, but ultimately the decision about a patient’s care — and any fall-prevention action plans or policies — must be guided by the skills and experience of the practitioners.”

Why Fall Prevention Matters for Better Outcomes

Falls are not just a problem in Baltimore: Across the country, fall-related injuries (falls that did not result in death) alone cost $50 billion in 2015; Medicare and Medicaid shouldered 75 percent of the bill. By 2020, costs are expected to escalate to $67.7 billion. (1)

Despite these rising costs, a future or even previous fall is not likely to be discussed in a doctor’s office — and a physician cannot follow a patient home to ensure a fall-free environment. According to the Quest Diagnostics report, 27 percent of older adults worry about falling outside and 22 percent about falling at home. That places the fear of falling, and the risks thereof, among the “hidden hazards” troubling many older patients.

But the hidden hazard of falling is also related to complex social behavioral issues which are not likely to be shared with a physician, such as loneliness, isolation, transportation barriers, and the fear of being a burden on adult child caregivers. While the physician can recommend resources, community support and follow-up are vital. Synergistic partnerships like the Baltimore example demonstrate the importance of bringing health providers and community organizations together to uncover these hidden hazards and better meet complex care needs at home — and hopefully prevent unnecessary hospital visits and repeated admissions.


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