As our health care system transforms more quickly than ever from paying for volume to paying for value, providers have strong incentives to ensure that their patients’ care plans are reinforced and supported outside the clinical setting in people’s homes and communities.
This is particularly important for older adults with multiple chronic conditions, who comprise 66 percent of Medicare fee-for-service beneficiaries and account for 93 percent of total Medicare expenditures. In addition, it is well known that individuals with both chronic conditions and functional limitations requiring long-term services and supports are at highest risk for poor outcomes and high health care expenditures.
For these individuals to achieve better health, providers must be able to connect their patients to social supports and human services while focusing on prevention and wellness in ways that emphasize behavior change. By partnering with community-based organizations (CBOs), such as Area Agencies on Aging (AAAs), providers can help individuals manage their chronic diseases and meet their often overlooked social needs.
CBOs can improve patient outcomes by activating patients, avoiding both short- and long-term nursing facility stays, and preventing unnecessary hospital admissions.