Care Coordination for Older Adults: The Critical Link to Improved Healthcare

Consolidation is nothing new in healthcare. For years, managed care companies have purchased managed care companies and hospital systems have done the same. For those of us who work in senior healthcare we see the same thing happening today. There’s consolidation among hospices, homecare agencies and some health systems bringing together PACE (Program of All-inclusive Care for the Elderly) programs under the auspices of a single organization. This consolidation is driven by a couple of things. The need to:

  • Reduce readmissions to hospitals; and
  • Provide additional healthcare services to individuals and families.

Both issues really add up to a single, consolidated effort: care coordination. Care coordination, bringing together of multiple healthcare services to create a holistic view of an individual, has been shown to improve outcomes, which advances health and reduces hospital readmissions.

Why Now?

Baby boomers are driving these changes in the senior care industry. They are creating a new demand on services due to their vast numbers and the fact that many have co-morbid health conditions. But they aren’t demanding just any kind of health services. They want “service” and “quality;” and how each individual defines these measures is different. Gone are the days of remaining under the care of specific doctor even if you don’t like his or her bedside manner. If someone has a bad experience they’ll switch. Quality is a big factor, too. People will spend time seeking out and getting to quality service.

So ensuring healthcare services are top-notch is more critical than ever. To do that, many healthcare organizations consolidate to bring disparate, but related services under one roof with the goal of providing coordinated care through an interdisciplinary team. Care coordination has the ability to bring a holistic view to every individual and ensures that anyone involved with providing healthcare services is aware of the other services being provided. It takes a complicated process and provides the resources in a simplified way.

How It’s Done

With care coordination it’s important to have high touch along with high tech. We in healthcare are still in the people business, and people want high touch healthcare services as well as those delivered through a portal or by phone. It’s essential to take the interdisciplinary team—nurses, physicians, rehab and other specialists—outside the building and into the individual’s home.

We must make this leap from our comfort zone—clinics and offices—to the comfort of an individual’s home, which allows older adults to remain at home and have healthcare services delivered right to their door. This type of care coordination is very similar to what healthcare providers did years ago: the house call.

Individuals can access care coordination services—depending on how one pays (private pay, Medicaid or Medicare) for services—at PACE centers, through various types of adult day programs, a skilled nursing facility or home care. Each needs careful and considered care coordination to ensure the best outcomes possible for the individual.

Care coordination assists individuals with one of the most difficult aspects of healthcare, navigating the complex system in which it exists. At our call center the most common questions we get are short and simple, yet very complex: “I don’ know where to begin….” and “What do I do?”

With so many people just trying to understand the healthcare system, care coordination is the critical link that brings it all together.

Phillip W. Heath
Phillip W. Heath

Phillip W. Heath, a board member of the Alzheimer’s Association – Colorado Chapter and an executive at InnovAge, a provider of healthcare services for older adults in Denver, Colorado, has worked in senior healthcare for more than 25 years




This blog is for informational purposes only, and is not intended to be a substitute for professional medical advice, diagnosis, or treatment. Always seek the advice of your physician or other qualified health provider with any questions you may have regarding your health or medical needs.



Why is care coordination important?

Improving Transitions of Care: Evidence-based models and effective implementation practices

“The intervention consists of five contacts between client and coach: one in the hospital before discharge, one during a home visit, and three follow-up phone calls. The intervention is complete within 28 days. Coached patients with complex medical needs are significantly less likely to experience a readmission for any cause within 30 days.”


Baby Boomers: Public Health’s Biggest Challenge


Eldercare Work Alliance

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