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How Care Coordination Promotes Senior Health and Longevity

Written by Kara Lewis
 about the author
6 minute readLast updated November 24, 2020

Whether your family member moves to assisted living or memory care, convenient and reliable access to health care stands out as a core — though often overlooked — benefit. In fact, deteriorating health is often what prompts a move to senior living, and the National Council on Aging estimates that 77% of seniors have two or more chronic conditions.

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Care coordination streamlines medical care and communication by connecting seniors with a variety of health care providers, arranging for transportation, and keeping caregivers informed. “Most of the time when you’re touring a community, care coordination isn’t thought of — but it really matters in a senior’s daily routine. It’s a major convenience,” says Rachel Levy, an account manager at A Place for Mom who has worked in senior living communities. Learn how care coordination works, the ways it enhances a senior’s quality of life, and how it can reduce caregiver stress.

What is care coordination?

Though care coordination may looks slightly different depending on the senior living community, it has several defining characteristics. Most notably, care coordination is a complex process that includes multiple staff members.

More specifically, the majority of care coordination models involve:

  • A social worker or nurse who directs the process.
  • A community needs assessment, which measures a resident’s memory, mobility, and general health to determine their level of care.
  • An organized care plan that details which services residents should receive based on their health needs.
  • A medical team of primary care providers, physical therapists, mental health counselors, specialists, and other professionals, who all collaborate to meet a senior’s needs.
  • Periodic care plan meetings, where staff reevaluate a resident’s treatment and address any new concerns. Levy emphasizes that these are the “parent-teacher conference of senior living,” and that families should be involved when possible.
  • Communication with insurance companies, including Medicare and Medicaid, to ensure coverage.
  • Long-term monitoring to assess whether the care plan is fulfilling the senior’s needs and to make necessary adjustments.

How do senior communities manage care coordination? 

Communities have their own unique methods of facilitating care coordination. They have in-house nurses and aides, who assist with activities of daily living, like medication management. Communities also maintain strong relationships with area physicians and other care providers. Physical therapists, podiatrists, dentists, and eye doctors may visit communities frequently, often on a weekly basis, to administer care to residents.

Most of the time when you’re touring an assisted living community, care coordination isn’t thought of — but it really matters in a senior’s daily routine. It’s a major convenience.

 Rachel Levy, A Place for Mom account manager and senior living specialist

Sometimes, health care providers lease space in assisted living and memory care communities. In fact, a George Mason University survey of 1,500 senior communities found that 78% coordinate treatment with at least one third-party provider. This number jumps to 88% among assisted living communities, specifically. The most common services coordinated for senior living residents are rehabilitation and physical therapy. 

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Though many communities provide referrals and on-site health services, residents may opt to continue seeing their long-time doctors. To meet this preference, facilities typically offer free van or bus transportation to nearby appointments — often up to 20 miles from the community. Transportation access also makes it easy for residents to see specialists, like cardiologists and oncologists.

Importantly, care coordination doesn’t end with setting up appointments. Communicating next steps to seniors and their families, processing paperwork, and discussing lab results are all part of care coordination. 

How are residents’ health care needs monitored?

At Manors of the Valley, a network of communities in Pennsylvania, all care concerns are registered through a digital “wellness hub,” says director Loren Morgan. “We get incident reports that tell us what’s going on,” says Morgan. “We make a list and ask the nurses to follow up, whether it’s a family concern or someone not feeling well. We then match them with the best provider.”

Because seniors interact with various staff members throughout their day, concerns may be noted by housekeepers, dining services staff, or care aides. Whether it’s eating less in the cafeteria or increased struggles with mobility, employees at assisted living and memory care communities are trained to notice, report, and respond to changes in a senior’s health or habits.

Brookdale, which manages more than 700 senior living communities, takes a similar approach. The care coordination tool Brookdale HealthPlus uses an electronic care record to keep track of a resident’s care plan and related treatment. Seniors and families can use the interactive software to log concerns, as well as to make decisions about preventive appointments, treatment for chronic conditions, and more.

What other services does care coordination provide?

Senior care coordination is highly personalized based on each resident’s needs. In general, residents in senior living can receive:

  • Physical, occupational, and speech therapy
  • Dialysis
  • X-rays and ultrasounds
  • Eye appointments
  • Dental care
  • Help with diabetes management
  • Hospice care
  • Medication refills via an on-site pharmacy

Depending on a senior’s health conditions, community staff will also recommend and coordinate care with medical specialists.

How does care coordination benefit seniors and caregivers?

Care coordination offers several fundamental benefits to seniors, according to an American Nurses Association report:

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  • Fewer emergency room visits
  • Reduced appointment copays and medication costs
  • Fewer hospital readmissions
  • Increased patient satisfaction
  • Later mortality
  • Improved quality of life

Having a wide range of health services available can also enhance mental and social well-being. A study of 508 patients receiving care coordination found that 62% reported less psychological distress, while just under half observed a social benefit.

Common caregiver problems, like burnout and finding time to go to appointments, can be alleviated through care coordination. A move to senior living means caregivers no longer have to arrange transportation or account for time off of work. However, this newfound assistance can be a difficult adjustment. “We have some families that want to go to every appointment,” says Morgan. “For families who can’t make it, they call me after the visit and we go over what the doctor said. We call every resident’s family to let them know that the senior has an appointment on a certain day with a certain provider.”

Overall, communities’ ability to meet a diverse array of senior health needs can relieve caregivers, increase care transparency, and forecast longer lives for older adults, making it a key component to consider when touring senior living.


American Nurses Association. “Registered Nurse Care Coordination: Creating a Preferred Future for Older Adults with Multimorbidity.” https://ojin.nursingworld.org/MainMenuCategories/ANAMarketplace/ANAPeriodicals/OJIN/TableofContents/Vol-20-2015/No3-Sept-2015/Registered-Nurse-Care-Coordination.html

Mullaney, Tim. “Senior Living Providers Positioned For More Managed Care Partnerships.”

National Council on Aging. “Top 10 Chronic Conditions in Adults 65+ and What You Can Do to Prevent or Manage Them.” https://www.ncoa.org/blog/10-common-chronic-diseases-prevention-tips/

U.S. Department of Health and Human Services. “Research on Care Coordination for People with Dementia and Family Caregivers.” https://aspe.hhs.gov/basic-report/research-care-coordination-people-dementia-and-family-caregivers

Meet the Author
Kara Lewis

Kara Lewis is a UX copywriter at A Place for Mom. She’s written dozens of articles related to senior living, with a special focus on veterans, mental health, and how to pay for care. Before writing about seniors, she worked in journalism, media, and editing at publications. She has a bachelor’s degree from the University of Missouri-Kansas City.

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