In healthcare, we’re fond of talking about person-centered care. But in practice, many older adults don’t receive it—which impacts not only them, but also their loved ones and caregivers, and drives surging medical costs and low patient satisfaction.
Fragmented outpatient care is linked with increased morbidity, duplicate medications and drug interactions, redundant imaging tests, more frequent hospital admissions and increased hazards in hospitals and ERs. Meanwhile, uncoordinated care creates up to $78.2 billion in waste in the U.S. each year.
I’ve witnessed this crisis with my aging parents, who travel to multiple specialists a week, make too many visits a year to their local ER and take dozens of daily medications. My parents are covered by one of the nation’s largest Medicare insurers, yet a disconnected system has left them, and millions of other seniors, stranded and fending for themselves. I’ve also seen the systemic challenges on a professional level, having spent nearly three decades in leadership roles at healthcare and technology companies like Amwell and taking innovative solutions to market.
How can we radically evolve healthcare delivery for seniors, especially those like my parents? From my perspective, a truly collaborative, coordinated care framework would improve outcomes for high-need patients, particularly those with comorbidities and serious illness. For this fully integrated model to be embraced, it must be driven by strong partnerships between providers and payers—and led by a single, accountable clinical coordinator within a value-based payment approach. This model would incorporate technology, connected devices, tools and disease-specific programs to meet the unique needs of our aging population.
Filling a critical gap
Such a model would fill an important gap in the delivery of healthcare for seniors. In my previous roles, I’ve launched telehealth programs with some of the country's largest, most progressive Medicare health plans. Industry leaders invested millions of dollars leveraging telehealth to deliver programs and services to seniors. But most patients didn’t even realize what was available to them. Engagement, and ultimately utilization, fell far short.
While innovative offerings are available within our current system, they’re typically not quarterbacked by a single, accountable primary care provider (PCP) or other providers. And patient awareness and education rarely exist.
As I’ve seen with my own parents, and others around me who are aging and needing much more immersive care, no one is serving as a point person to champion the patient’s best interest, oversee treatment or coordinate the many clinical providers involved in even routine care. Every aspect of my loved ones’ well-being is disconnected, from their medications, diet and exercise to home health services, mental health and social involvement. Their care couldn't be further from collaborative or based on whole-person results.
A trusted patient advocate
A singular provider stepping into the role of trusted patient advocate is the critical missing link. Under this model, a single clinical coordinator, such as a trusted PCP, would convene, coordinate and guide a multidisciplinary team to envelop and empower the patient, offering:
- Coordination of medication, drug interaction and adherence
- Coordination of care plans and treatments
- Access to occupational and physical therapies as well as mental and behavioral health treatment
- Alternative, disease-specific therapies and programs
- Multimodal care and care teams that patients can access at home
- Compassionate care tailored to the patient’s needs
As a trusted healthcare leader, this PCP would guide and educate patients, share how patients will benefit by engaging in their own care, including the use of tools like telehealth, and prescribe the best care path. This would include:
- Reaching and caring for patients in their homes, both in person (including house calls) and via technology (from virtual care to connected biometrics to remote patient monitoring)
- Communication, education and more compassionate care that resonates with patients, factoring in language, culture, ethnicity and reading level
- Leveraging and incorporating caregivers
- Offering meaningful, tailored disease-specific programs and services
Ideally, this model would be driven by the PCP within the primary care setting. But in the absence of a PCP, the health insurance Medicare or Medicaid plan would assign a health advocate or care coordinator, especially for high-touch, high-cost patients, to ensure cohesive management.
The role of value-based care
This approach will only work if we arm these care coordinators with the right tools, empower them to assemble and oversee a care team, and equip and compensate them so they can deliver truly collaborative care. A critical element here is to incentivize these clinical leaders through a value-based payment system that rewards better patient outcomes and satisfaction.
Value-based care isn't new, but it’s not often embraced in practice. To change that, providers and payers must collaborate around optimal patient care and share in financial risk. Both sides must align key stakeholders on common objectives, such as better financial and clinical outcomes, lower admission rates and better quality of life for patients.
Let’s acknowledge that payers are in the driver’s seat to support and administer this model because they control the money, including how PCPs and other clinicians (including programs and tools) are compensated and reimbursed. Payers must commit to better reimbursement rates and incentives in exchange for better outcomes from providers.
As a natural next step, regional payers and regional health systems should align on delivery models and payment for their highest-cost, chronically ill older patients. This approach is gaining traction among payers and health systems acting as "payviders,” such as California-based Kaiser Permanente and Pennsylvania’s Geisinger Health System.
As a healthcare professional and the daughter of aging parents, I’ve seen the system cater to providers. But coordinated care requires us to put patients first—and ensure that holistic, collaborative care is available to everyone. In addition to expanding access to care, providers need to receive education and training to effectively factor in social determinants of health and address inequities in care among aging patients.
As trusted leaders, PCPs must also commit to offering and educating patients about digital health tools to drive awareness and adoption. The most effective tech solutions allow seniors and caregivers to become independent facilitators of their health, combat social isolation and support positive aging.
I work closely with several companies built at Redesign Health that prioritize belonging and purpose for seniors within tech-enabled communities. For instance, Together Senior Health empowers older adults with memory loss to maintain their health and independence; DUOS is a personal assistant service that supports fulfilling lives at home; and Keen combines trusted personal relationships and technology to deliver better Medicare plan selection and health outcomes.
As we’ve seen with telehealth, tech alone isn’t the solution to coordinated care—but it can be an important part of an integrated model that puts power back in patients’ and caregivers’ hands.
Envisioning a better way
Over the past decade-plus, we’ve built the digital rails for healthcare. Now, we’re overdue for a “coming of age” in healthcare for seniors. We must adopt a model that incentivizes better clinical and financial outcomes, quality of life and patient satisfaction.
Too many older adults, like my parents, aren’t getting the care, coordination and advocacy they desperately need. When I think of my mom and dad, sitting at their kitchen table, surrounded by pills and medical paperwork, I know from many years of experience at Amwell, Redesign Health and beyond that there’s a better way. It’s time to stand up for vulnerable seniors in America—and finally deliver on the promise of person-centered care.
Danielle Russella is a venture chair at Redesign Health. Russella, a 25-year healthcare tech executive, was a founding board member of the National Telehealth Network, was previously was on the ground floor, building telehealth leader Amwell, and held executive leadership roles at companies such as Medecision and Hewlett Packard.