Connect Healthcare and Aging Services to Improve Care and Reduce Costs

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Let me tell you a story that many healthcare professionals and social workers know all too well.

A 78-year-old man we’ll call Jack is a kind soul with a knack for storytelling and a hearty laugh that echoes through the walls of his small home. He lives alone without reliable transportation. Whenever he felt unwell or needed assistance, he resorted to calling an ambulance to take him to the emergency department. During these hospital visits, Jack found solace in more than just medical attention. He would strike up conversations with the nurses who lent a compassionate ear, and he would eat a warm meal. However, after examination, the doctor explained that his minor ailments could be managed at home or through regular doctor visits rather than emergency care.

Jack’s story highlights a common issue faced by many seniors: the intersection of healthcare and social services. The vast majority of health happens outside of traditional healthcare settings—at home and in the community, where social services can support an individual’s care and wellbeing. In fact, researchers estimate that only 20 percent of a person’s overall health is due to healthcare; the other 80 percent is due to social and economic factors, or the social determinants of health (SDOH).

Bridging the Gap Between Healthcare and Aging Services

According to the Robert Wood Johnson Foundation, nearly 90 percent of physicians indicated they see their patients’ need for social supports, but unfortunately 80 percent of doctors said they don’t fully know how to connect them to community options.

For Jack, how can his health be better supported at home? What options does he have for home and community-based services?

As I discussed in last month’s blog, the state of Indiana has thoughtfully considered the intersection of healthcare and social care in developing PathWays for Aging, a new program for older adults rolling out in July. PathWays brings together the social care long-term services and supports of the Medicaid Aged & Disabled waiver and the healthcare coordination of insurance benefits such as Medicare.

The Role of Area Agencies on Aging

Area Agencies on Aging (AAAs) like CICOA are the backbone of support, providing specialized services to older adults for five decades now. CICOA’s services include the Aging & Disabilty Resource Center, person-centered care management, transportation, senior nutrition, caregiver support and home accessibility modifications. These essential services are funded by federal and state public assistance, such as Medicaid, Older Americans Act funds and CHOICE. But this funding is not enough, and donations from community supporters help to sustain these vital programs.

CICOA has successfully partnered with health systems in our area to address social determinants of health for patients who demonstrate a need for in-home services. Healthcare staff can refer a patient to CICOA’s dedicated Healthcare Collaborations options counselor, who can quickly assess needs and develop a care plan, as well as assist with the transition to home after discharge. This model has significantly transformed and improved the quality of life for many seniors, and the seamless communication between providers and our agency results in improved care outcomes.

CICOA and other AAAs in Indiana also partner with healthcare providers through enlivIN, Indiana Association of Area Agencies on Aging’s solution to integrate healthcare and homecare for Hoosiers.

Benefits of Integration

Why is integrating healthcare and aging services so crucial? By narrowing the gap, we can pave the way for a healthier aging community.

Improving health outcomes can be approached and measured by reduced visits to the emergency department, better chronic disease management, improved nutrition, strengthened preventive care, and increased health equity. Plus, fostering a healthier population reduces the overall costs to the healthcare system.

From FY22 to FY23, we saw a 44% reduction in emergency visits for our care-managed clients. This likely indicates better preventive care and seeking care in a more appropriate setting. Less emergency care visits also result in substantial cost savings for the healthcare system, health plan and taxpayer-funded programs.


Overcoming Challenges

USAging states in its Policy Priorities: “Unfortunately, access to home and community-based services that support the health and well-being of older adults and caregivers outside of the medical system have historically been inadequately funded and, as a result, these services are unable to meet the growing needs.”

AAAs like CICOA have been around for 50 years and are the experts in their communities when it comes to addressing older adults’ SDOH needs. Yet, our contributions to overall health are too often overlooked by health systems, payers and policymakers. By recognizing and funding the important work of AAAs, we can ensure that older adults age with dignity, independence and improved quality of life.

Now, let me share an update on Jack. Recognizing Jack’s lack of transportation, regular meals and social interactions, the hospital staff collaborated with a CICOA liaison to address his social determinants of health. He now has reliable rides to regular check-ups, nutritious meals delivered to his doorstep, and a friendly volunteer offering companionship. While he still goes to the emergency department for true emergencies, his visits have significantly decreased.

As you can see, healthcare and social services are an essential partnership for the wellbeing of our cherished seniors. We must work to ensure that older adults and caregivers have sufficient access to social services.

As policymakers discuss ways to bridge this gap between social services and healthcare, it is crucial that the national network of area agencies on aging—the well-established specialists on aging well at home—are included as champions and key partners in the overall health and wellbeing of older Americans.

I will continue to advocate for connecting healthcare and aging services because individuals like Jack are depending on us for better care, better health and lower costs, which benefit us all.

Do you have an idea for collaborating with health systems, or do you want to explore Healthcare Collaborations in your health system? Connect with me, and let’s chat.

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