Connecting Social, Clinical, and Home Care Services for Persons with Serious Illness in the Community

Abstract

The medical, psychological, cognitive, and social needs of older adults with serious illness are best met by coordinated and team-based services and support. These services are best provided in a seamless care model anchored by integrated biopsychosocial assessments focused on what matters to older adults and their social determinants of health; individualized care plans with shared goals; care provision and management; and quality measurement with continuous improvement. This model requires (1) racially and ethnically diverse healthcare professionals, including mental health and direct service workers, with training in aging and team collaboration; (2) an integrated network of community-based organizations (CBOs) providing in-home services; (3) an electronic communication platform that spans the system of providers and organizations with skilled technology staff; and (4) payment models that incentivize team-based care across the continuum of services, including CBOs, with adequate salaries and academic loan forgiveness to recruit and retain highquality team members. Assuring that this model is effective requires ongoing quality assurance measures that include not only quality of care and utilization data to demonstrate cost offsets of service integration, but also quality of life for both the older adults and the family members caring for them. Although this may seem a lofty ideal in comparison with our current fragmented system, we review models that provide the key elements effectively and cost efficiently. We then propose an Essential Care Model that defines best practice in meeting the needs of older adults with serious illness and their families. J Am Geriatr Soc 67:S412-S418, 2019.

Connecting Social, Clinical, and Home Care Services: Where Healthcare Needs to Go

“…Golden et al have highlighted for us a direction of where healthcare needs to go, the key principles, and examples of successful models that incorporate those principles. 1 Our nation faces three converging public health challenges: (1) There is a progressive increase in the number of Americans older than 75 years. While this represents a huge US success story, it also brings a rising need for personal care services, hospital days, and nursing facility stays.…”

“…Golden et al 1 have provided key principles for success in caring for persons with serious chronic disabling disease, while lowering total costs of care. These principles include: We know the converging challenges, we know the target population who represents a substantial and increasing proportion of those who account for half of healthcare costs, and we know models with demonstrated success in increasing access and improving care while lowering total costs of care.…”

“…The VA may provide relevant experience on the likely outcome of widespread adoption of the principles and integration of models recommended by Golden et al 1 As our nation's largest integrated healthcare system, in meeting the needs of Veterans of any age with serious chronic disabling conditions, the VA both purchases and provides a comprehensive spectrum of geriatrics and extended care services that surpasses all other US healthcare systems. Most of the principles of Golden et al 1 are incorporated into this spectrum: has comprehensive longitudinal interdisciplinary team care delivered in all care settings, including the home; interdisciplinary teams develop a unified care plan driven by each Veteran's goals and preferences; addresses mental health and social determinants of health; provides training to two-thirds of the US healthcare workforce in all disciplines with geriatrics expertise; offers interdisciplinary training experience that includes physicians, social workers, nurses, rehabilitation therapists, dietitians, psychologists, and pharmacists in all care settings (hospital, clinic, nursing facility, home, and hospice); integrates care with community-based organizations; has an electronic health record that is integrated across all VA care settings, although not yet with community providers; and has one principle not directly depicted by Golden et al 1 -equitable access for those living in rural and highly rural areas.…”

“…The benefit to taxpayers is that models, such as those depicted by Golden et al, 1 have demonstrated net reductions in total costs of care-reducing costs to state and federal government, reducing the rise in healthcare costs, and yielding total taxpayer savings. Perhaps we can strengthen support for the changes Golden and team 1 recommend by helping our system leaders, our policy makers, and the public understand who will benefit from these interdisciplinary models and the geriatrics-trained workforce needed to provide the care.…”

Introduction to the Special Issue on the Workforce for Seriously Ill Older Adults in the Community

“…This special issue of the Journal of the American Geriatrics Society presents these papers, along with a summary of the recommendation developed at the summit. The articles address a range of pertinent topics: advance care planning and integration of care planning into primary care, clinician communications regarding prognosis and patient preferences, strategies for building a culturally competent workforce, a vision for the palliative care workforce, supporting family caregivers and direct care workers, and linking patients with social services …”