For frail older adults with complex care needs, an inpatient hospital stay is destabilizing and often marks the beginning of a decline in functioning. For these older adults and their families, the post-hospital period is a risky, confusing, and stressful time. Providers, payers, hospitals and health systems should look for ways to innovate their care delivery models and to manage and improve care for their patients.

The time constraints of the typical primary care practice often do not allow providers to take a comprehensive look at all of their patients’ needs each year. Getting to the bottom of the checklist of preventive screenings and evaluating all ongoing chronic care needs simply takes time. Enabling office staff to assist in this work, under the direction of the supervising provider, presents a tremendous opportunity to create a patient-centered and comprehensive care plan that matches each patient’s unique needs and desires.

From continued enrollment growth to expanded flexibility to offer non-medical supplemental benefits, Medicare Advantage (MA) plans are playing an increasingly important role in the lives of older adults.

Christine Schaeffer, MD, medical director of Northwestern Medicine Transitional Care, describes the core components of its transitional care program. She also shares important considerations for health systems interested in implementing person-centered transitional care to address gaps in care and reduce costs.

Special Needs Plans (SNPs) are a type of Medicare Advantage (MA) plan for individuals with special needs. This can mean an institutionalized individual (i.e., someone who lives in nursing home), a dually eligible individual (i.e., eligible for both Medicare and Medicaid), or an individual with a severe or disabling chronic condition.

Evidence is mounting about the importance of robust primary care in achieving the Triple Aim of advancing quality of care, reducing costs, and improving the patient experience. Primary care initiatives across the country have shown that enhancing primary care can coordinate service delivery to the benefit of both patients and clinicians. In Medicare accountable care organizations (ACOs), primary care transformation has been foundational for shifting to a team-based approach that reaps benefits for patients, providers, and payers.

The individual characteristic that contributes most to complex care needs is the inability to function in activities of daily living (ADLs), such as eating, bathing, and dressing. The winners in population health management will be the health plans and providers that figure out how to identify individuals with ADL impairment and address their needs with comprehensive care management and targeted non-medical services.

Although senior living organizations are primarily oriented toward housing and hospitality, there are many reasons they provide a great platform for value-based care.

HealthPartners of Minnesota, one of seven health plans in Minnesota’s state administered Minnesota Senior Health Options (MSHO) program, was highlighted for addressing a social determinant of health risk factor within their frail elderly population: lack of transportation. The report detailed both HealthPartner’s unique dedication to improving transportation quality and convenience for its members, and the benefits of state supported Fully Integrated Dual Eligible Special Needs Plan (FIDE SNP), like MSHO.