Exploring Care Coordination Among High-Risk Seniors

Almost 95%¹ of older adults in America have at least one of nine chronic conditions, with nearly 80%² having two or more. Because of this, many older adults receive medical care from multiple providers. Unfortunately, fragmented care³ can lead to negative outcomes⁴ like medication errors and preventable hospitalizations.

Produced in partnership with Aetna, this 2019 white paper explores effective care coordination strategies as well as challenges that must be addressed to facilitate successful scaling.

Key Findings

• Care coordination has three key elements.
  • Interdisciplinary Team: Responsive, interdisciplinary teams offer a range of services to patients with complex needs, ensuring smooth transitions between clinicians and care settings. A care coordinator acts as the main point of contact between the patient and the care team.  
  • Patient-Centered Approach: The patient is placed at the center of their care plan, ensuring that medical decisions reflect their needs, goals and preferences. 
  • Risk Stratification: Risk stratification helps identify older adults with chronic conditions who would benefit most from community-based care coordination. This approach reduces costly emergency visits and hospitalizations.
• Several effective models of care coordination exist. This report offers examples of models in which care providers partner with community-based organizations to improve the health and well-being of older adults. Examples of such models include:
  • The Bridge Model helps high-risk patients safely transition from hospital to home by connecting them with community resources and ensuring follow-up care.
  • Care Management Plus (CM+) supports high-risk Medicare patients and other populations in managing multiple chronic conditions through education and one-on-one support.
  • ChenMed serves Medicare Advantage recipients by enhancing access to coordinated, preventive care and addressing social determinants of health.
  • Guided Care is a team-based model in which specially trained nurses educate and support patients and their caregivers. 
  • Insights from these care delivery programs and others can guide future efforts to improve the health and well-being of high-risk older adults.
• Challenges remain in sustaining and scaling these models. According to the SCAN Foundation,⁵ such challenges include:
  • Aligning Financing and Payment Methods: Care coordination is most effective when payments are streamlined and based on patient needs. Finding successful avenues for financial alignment and moving from fee-for-service to value-based care can create more sustainable care models.
  • Compatible Infrastructure: Having compatible technology systems, like electronic health records, enhances care coordination by reducing service duplication and lowering costs.
  • Quantitative Evidence: While many programs improve care quality, not all save costs. Further research into opportunities for cost savings can support scaling efforts.

In reproducing any excerpts of this report, please provide a credit that recognizes Meals on Wheels America, such as: Meals on Wheels America. (2019, April). Exploring Care Coordination Among High-Risk Seniors. https://www.mealsonwheelsamerica.org/research/exploring-care-coordination-among-high-risk-seniors/