Care Coordination

Quality care for those complex patients with multiple chronic conditions requires development and implementation of individualized, coordinated plans of care. Such plans of care often call for further evaluation, treatment, referrals and patient or caregiver education or both. Typically, a team of geriatrics healthcare providers — which may include physicians, geriatrics nurses, pharmacists, psychiatrists, therapists and social workers — is involved and a primary care provider, such as a physician or nurse practitioner, handles care coordination. Coordination usually involves managing care transitions across settings — including nursing homes, hospitals, rehabilitation centers, home healthcare, and other sites.

80% of Medicare beneficiaries do not have access to Care Coordination
Under current Medicare policies, the 20% of eligible beneficiaries enrolled in Medicare Advantage plans routinely receive care coordination services. This leaves 80% of eligible Americans enrolled in traditional Medicare without access to care coordination services. It is essential that we ensure that appropriate care coordination services are available to older adults with complex chronic conditions regardless of their coverage option. Patients with five or more complex chronic conditions account for more than 75% of total Medicare spending.

The Role of a Geriatric Assessment in Care Coordination and in Improving Quality
A Geriatric Assessment is a central component of providing the necessary and appropriate care for older adults with complex and multiple health conditions. Geriatric assessment goes beyond the standard adult comprehensive history and physical exam, including evaluations of special significance among older adults.

Care coordination could improve health outcomes for many of these beneficiaries and also provide long-term savings to the Medicare program through reducing hospitalizations and eliminating duplicative services.