How Care Coordination Promotes Senior Health and Longevity

Care coordination involves multiple team members who coordinate treatments, senior care services, and medical appointments according to a senior’s care plan. The team includes the senior, their loved ones, a community staff member, and health care providers. This model allows seniors to access reliable and more effective care, because everyone is kept on the same page about their senior living and overall health needs.

“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. She adds that care coordination isn’t just about coordinating medical care. Rather, it’s about coordinating how a senior wants their life to be.

Though care coordination may look slightly different depending on the senior living community, it has several defining characteristics. Specifically, the majority of care coordination models involve the following components:

• A social worker, nurse, or other community staff member. A person with one of these titles will direct the care coordination process. This care coordinator will act as a liaison to ensure that the resident’s needs and preferences are known and communicated to the right people.
• A needs assessment. This tool measures a resident’s memory, mobility, and general health to determine their level of care. “A pre-move-in assessment is essentially the framework for the care plan,” says Levy.
• A care plan.An organized care plan details which services residents should receive based on their health needs.
• A medical team. The team can include primary care providers, physical therapists, mental health counselors, specialists, and other professionals. They will all collaborate to meet a senior’s needs.
• Periodic care plan meetings. Team members will reevaluate a resident’s treatment and address any new concerns. Levy emphasizes that these are the “parent-teacher conferences of senior living,” and that families should be involved when possible.
• Communication with insurance companies. The senior’s sources of insurance, including Medicare and Medicaid, are reviewed to ensure coverage.
• Long-term monitoring. Monitoring progress long-term allows the team to assess whether the care plan is fulfilling the senior’s needs. This also creates opportunities to make necessary adjustments.

Read more:How a Senior Care Plan Manages the Care After the Move to Senior Living

Communities have their own unique methods of facilitating care coordination, but any method should revolve around the senior and their needs.

“The community’s goal is to remove the guesswork for seniors and their families and to meet seniors’ needs in a resident-focused way,” says Levy.

Senior living communities have in-house nurses and aides who assist with activities of daily living, like medication management and personal hygiene. Communities also maintain strong relationships with area physicians and other care providers.

According to Levy, key components of care coordination include communication logs and incident reports. The staff’s skilled observations allow the care coordinator to keep seniors’ families and health care providers updated in detail.

Some health care providers visit communities frequently, often on a weekly basis, to administer care to residents. In fact, approximately 89% of A Place for Mom’s partner assisted living communities and 91% of memory care communities offer the on-site health care services listed below:

• Visiting physical therapists (PT)
• Visiting occupational therapists (OT)
• Visiting speech therapists
• Visiting podiatrists
• Visiting nurses
• Visiting dentists

Though many communities provide referrals and on-site health services, residents may opt to continue seeing their long-time doctors. To meet this preference, some senior living communities offer complimentary or at-cost transportation to nearby appointments. 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.

Read more:Person-Centered Care and Its Role In Assisted Living: A Guide

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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. Employees at assisted living and memory care communities are trained to notice, report, and respond to changes in a senior’s health or habits. For example, they can note and act on sudden weight loss or increased struggles with mobility.

Brookdale, which manages more than 600 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 their concerns. It can also be used to make decisions about preventive appointments, treatment for chronic conditions, and more.

Senior care coordination is highly personalized based on each resident’s needs and care plan. In general, residents in senior living can expect coordination with the following types of care services:

• Physical, occupational, and speech therapy
• Mental health care
• Dialysis
• X-rays and ultrasounds
• Eye appointments
• Dental care
• Doctor or specialist appointments, like colonoscopy appointments
• 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.

Care coordination offers several fundamental benefits to seniors, according to an American Nurses Association report:^[02]

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

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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 psychological distress decreased by 62%, while just under half observed a social benefit.^[03]

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.

“Care coordination is a great way to take a burden off of a family,” says Levy. “Now, they have the expertise of everyone in the community.”

However, this newfound assistance can be a difficult adjustment. Loved ones might prefer different levels of involvement, and personal schedules might be challenging to work around.

“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, a community’s ability to meet a diverse array of senior health needs can relieve caregivers, increase care transparency, and forecast longer lives for older adults. Each benefit of care coordination makes it a key component to consider when touring senior living.