A Case for Integrated Care in Senior Living

By 2030, nearly one-quarter of Americans will be over age 65, and almost half will be well beyond age 75. This monumental shift in our national demographic is driving change across almost every facet of the healthcare industry. From acute and primary care to senior living and ancillaries, healthcare organizations are shifting strategic focus, exploring new models of care and fundamentally altering the way they will both pay for and deliver healthcare in the next 30 years. Healthcare costs as a portion of gross domestic product have grown from a meager 4.4% in 1950 to a staggering 17.9% in 2011. Left unmanaged, it could exceed 30% by 2040, plunging our nation into economic chaos. For senior living providers in particular, this is a time both ripe with opportunity and littered with risk. The advent of the Affordable Care Act and shifting consumer demands about care and service have all but forced historically disparate providers to align their thinking, and ultimately their operational models, around improving national health.

Given the sheer size of America’s aging wave and the volume of chronic illness inherent in that population, it’s no surprise that much of the shifting emphasis is focused on senior healthcare. National expenditures for elder care alone are likely to exceed $1 trillion annually by 2025, and the current infrastructure for aging care and service is historically detached from other providers, largely uncoordinated and prone to highly variable use and costs. For senior healthcare organizations, achieving the Triple Aim of better health, better care and lower costs means thinking outside the traditional box. Providers can neither continue to move people from one physical setting to another along a “continuum of care,” nor focus on “optimizing length of stay” to “maximize reimbursement.”

What this means for senior living providers is a dramatic shift in how they manage and coordinate operations. They must develop new models, foster innovative connections to other providers and ultimately take risk, on their own and with others, to emerge as desirable partners in a greatly-integrated future landscape. Essentially, senior living must come of age.

Independent and assisted living (IL and AL) are emerging as an essential component of a comprehensive elder population health model:

• IL and AL typically support elders over much longer time frames than other health care settings (commonly 2 to 5 years)
• IL and AL provide a stable physical environment where supportive services and health management techniques can be introduced proactively to address multiple dimensions of health (e.g., physical, social, mental, and spiritual).

The concentrated population density of senior housing campuses is potentially appealing to both accountable and managed care organizations, who will inevitably pay for services to support proactive models and avoid higher-acuity, more-expensive settings in the future.

Senior living is positioned to support the Triple Aim on the front end – before an acute hospitalization episode might ever begin.

Key components for successful integrated care in senior living are three-fold:

• Intentional use of data and outcomes to drive quality, define performance and guide operations
• Integrating primary care physicians directly into AL settings via a patient-centered medical home model
• Cultivating wellbeing through therapy-driven physical wellness programming and seamless access to other services through strategic partnerships and alliances

For residents and prospective customers, this model offers a unique alternative to more traditional senior living providers – one that emphasizes a richly active and engaged approach to healthy aging. For accountable care organizations and similar at-risk organizations, this represents a delivery innovation for senior care that bears greater examination and exploration around improving beneficiary health while managing total cost of care.

Juniper Communities presents a real-time model of this evolution in senior living.
At Juniper, intentional use of data and outcomes has defined the organization’s operational practices and innovative program development for more than a decade.

Each Juniper community documents and trends more than 90 measures across five domains (including most of the NCAL Tier II measures), many focused on physical health intensities and conditions. Urinary tract infections, falls, wounds and changes in resident status – among many other measures – are central to monitoring each community’s clinical profile and identifying trends for intervention or improvement. Cross-tabulation comparisons are particularly informative. A decline in a particular outcome measure (like an increased number of skin tears) is usually informed by a shifting process measure (like volume of skin assessments completed). Using this data rather than anecdotes or speculation, community and regional staff drive to the root of problems and create proactive corrective actions.

As expanded data informs better care and outcomes, improving access to primary care is a fundamental adjunct to achieving better health. The primary care office visit represents one of the least expensive forms of elder care (typically around $120 per visit) and is seen by many as a keystone for truly integrated care. Emergency department costs, in comparison, can vary between $600 and $1,000 per visit. Physician services offered specifically in senior living are particularly compelling.

To accomplish the integration of primary care , Juniper has developed Redwood Health Partners – a comprehensive primary care practice organization with clinic settings based inside their senior living communities. Built around the patient-centered medical home (PCMH) model, Redwood practitioners keep regular office hours at on-site clinics and are specifically trained to care for senior living residents. Assessments and other planned visits are scheduled on a routine basis, and Redwood staff are integrated with other Juniper staff to coordinate service and care plan development. Redwood physicians, who document all patient encounters directly in Juniper’s Electronic Health Record (EHR) platform, can intervene early to avoid costly and debilitating escalation and mitigate the likelihood of an unnecessary emergency room visit or inpatient hospitalization. The inherent “medical concierge” function of the PCMH model is additionally desirable for residents and families, who have better access to health information and don’t have to worry about coordinating and communicating with other health professionals on their own.

Achieving better health for older adults (and ultimately decreasing costs) will depend heavily on cultivating wellbeing through expanded programs and partnerships, essentially crafting a multi-pronged approach to wellness – physical health, mental and spiritual wellness and social interaction are all interconnected. Physical wellness in particular, however, represents a core area, especially for current and future customers, who want to maintain a healthy quality of life that supports an active and independent lifestyle.

To accomplish this key component of integrated care, Juniper Communities has recently engaged in a national relationship with Genesis Rehab Services to integrate comprehensive therapy services into its physical wellness offerings. Working in tandem, Genesis therapists and Juniper staff are working together to create Theralink – a rehab and fitness culture that celebrates “active bodies.” Genesis and Juniper have collaboratively developed a series of physical wellness and therapy protocols that create specific measures and outcomes that, in effect, establish Juniper’s definition of “wellbeing.” As a resident’s condition changes and is reflected in a changed measure (e.g., well-being improves or declines), Theralink prescribes specific services or interventions to improve or enhance the resident’s status. Because Genesis therapists are integrated members of the community wellness teams, interventions are virtually immediate and preclude a slow accumulation of problems that might lead to an unnecessary or expensive hospitalization. The intensity of therapy services available via Theralink can replace rehabilitative therapies provided in a more traditional post-acute setting, like a skilled nursing facility or home health environment.

The Way Forward
Providers and payors across healthcare universally agree that American healthcare spending, in its current form, is unsustainable. Proactive management of health status, attention to outcomes and fundamental shifts in how we pay for care are essential in addressing the looming financial crisis. It’s interesting to note that, in the 1990s, healthcare spending as a portion of gross domestic product actually slowed – due in large part to the expansion of managed care and the shifting of financial risk from payors to providers. Nearly 25 years later, the results from that managed care explosion are driving present-day thinking about new models of care emphasizing integration and coordination among providers, and new approaches to payment that are shifting risk downstream via bundled payment, gain-sharing and, inevitably, capitation.

For senior living organizations across America, shifting with these changes will be critical in maintaining both market share and relevance in the future. Elder care providers can no longer stand outside the fray. They must think differently about long-standing relationships with customers and payor/provider organizations, as well as the roles they will play in delivering better care and better health, both today and tomorrow.