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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.  

Medicare Payment Reform Needed to Support Care Coordination for All Beneficiaries
Inadequate Medicare reimbursement for geriatric-based services -- such as care coordination and geriatric assessments -- is among the leading disincentives to beginning and continuing a career in geriatrics. Dramatic discrepancies in reimbursement across other medical specialties further exacerbate difficulties recruiting physicians and other professionals into geriatrics. In these and other ways, our nation's current unworkable and outdated reimbursement policy threatens older Americans’ access to appropriate care.

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.

Models of Care that Encompass Geriatric Assessment and Care Coordination

Geriatric Resources for Assessment and Care of Elders (GRACE)
The GRACE model of primary care provides home-based, integrated geriatric care by a nurse practitioner and social worker who then work with a larger interdisciplinary team to develop an individualized care plan which incorporates protocols that have been developed for the treatment of 12 targeted geriatric conditions.

Program of All-Inclusive Care for the Elderly (PACE)
PACE is a managed-care program that was developed to enable individuals to live independently in the community and with a high quality of life.

The Guided Care Model
Guided Care is driven by a highly skilled registered nurse in a primary care office, who assists three to four physicians in providing high quality care for patients with complex and chronic conditions. The Guided Care Model aims to improve quality, access, and self-care for these high-risk patients.

Patient-Centered Medical Home
The Patient-Centered Medical Home (PCMH) is an approach to providing comprehensive primary care for people of all ages and with all medical conditions. The PCMH facilitates partnerships between an individual patient, and his or her personal physicians, and when appropriate, the patient's family. The Collaborative's membership represents more than 1,000 medical home stakeholders and supporters throughout the U.S.

Working in Coalition: Partnership

National Coalition on Care Coordination (N3C)
N3C’s goal is to promote better coordinated health and social services for older adults with multiple chronic conditions. We believe care coordination should be an essential part of health care reform to improve the quality of life for America’s aging population and their caregivers, while more efficiently using limited health care resources.

National Transitions of Care Coalition (NTOCC)
The National Transitions of Care Coalition (NTOCC) was formed in 2006 bringing together thought leaders, patient advocates, and health care providers from various care settings dedicated to improving the quality of care coordination and communication when patients are transferred from one level of care to another.

Patient-Centered Primary Care Collaborative (PCPCC)
The Patient Centered Primary Care Collaborative is a coalition of major employers, consumer groups, patient quality organizations, health plans, labor unions, hospitals, physicians and many others who have joined together to develop and advance the patient centered medical home. The Collaborative has well over 500 members.

Partnership to Fight Chronic Disease (PFCD)
The Partnership to Fight Chronic Disease (PFCD) is a coalition of hundreds of patient, provider, community, business and labor groups, and health policy experts, committed to raising awareness of the number one cause of death, disability, and rising health care costs in the U.S.: chronic disease.

Visit AGS’ Working in Coalition page to view all of our partnership work.

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