The silver tsunami: Challenges and opportunities in creating a seamless care continuum
Many health systems struggle to consistently provide appropriate care and services for seniors throughout their healthcare journey. Complexity of care, involvement of multiple specialists and fragmented systems have created challenges for older adults and their caregivers. Creating a seamless care continuum strategy for seniors is especially important as the population rapidly increases.
Seniors face various obstacles in navigating the healthcare system. On average, seniors see at least five specialists and spend three weeks in the year receiving care outside the home. Primary care appointments often are too short to address all their concerns, including comorbidities, cognitive impairment, medication use, social determinants of health resources and long-term planning.
The lack of coordination and fragmented care leads to conflicting care plans, overuse of medication, poor patient experience, unnecessary hospitalizations and readmissions. This vicious cycle of functional decline and multiple readmissions results in loss of independence and poor quality of life — and is taxing for caregivers. It also exacerbates the financial burden on the healthcare system of caring for these complex patients.
Developing a senior health strategy is vital for health systems to provide more streamlined care for older adults with complex needs. This effort benefits providers participating in fee-for-service and alternative payment models (APMs) by avoiding hospitalizations, creating access for more acute patients, reducing length of stay and improving quality metrics. The age-friendly hospital measures the Centers for Medicare and Medicaid Services published in the 2025 IPPS final rule is a perfect example of how senior-specific protocols and interventions will be required for hospitals to avoid a reduction in their annual Medicare payment.
Establishing a longitudinal senior-focused care model
Governance and alignment on the value of managing complex older adults across the organization is crucial. Doing so requires a commitment to use a geriatric-focused perspective. Geriatrics explains how the unique physiology of aging and its impact on disease is different in older adults than in other populations. Providers must always take this into consideration as they assess the impact of aging into an already complex care situation (medical, cognitive, functional and psychosocial). Health professionals trained using this model can address these layers of complexity and are better equipped to serve older adults with complex care needs.
The components concurrently needed across settings to create a seamless care continuum for complex older adults include:
- Visibility to the patient’s individualized plan of care: Implementing a
senior-focused care plan based on a geriatric perspective — agreed to by the primary care provider, patient and
their involved caregivers — is critical. It is equally important to ensure this perspective and plan is
accessible throughout the medical network and shared across all settings where an individual could encounter the
healthcare system, like the emergency department, skilled nursing facilities (SNFs) and with care management
teams. The framework of an Age-Friendly Health System suggests the key
elements of a geriatric care plan by
acknowledging the 4Ms: What Matters, Medication, Mentation and Mobility. The 4M framework should be embedded and
updated in the EMR on an annual basis or as changes in health or social issues arise.
Geriatric focused care planning begins before a health crisis, either in the primary care office or in the home, to support seniors with the appropriate level of connection points and treatments. Effective models, such as the GRACE model, extend care beyond clinic settings to meet complex older adults where they live. This model uses nurse practitioners and social workers and is most effective under value-based care payment arrangements.
- Systemwide redundant medication review processes: As called out in the 4Ms, a geriatric model must have medication review processes in place at every point of care. As adults age, the risk of experiencing harmful side effects from medications increases. This risk is significantly higher in adults with severe cognitive impairment such as Alzheimer’s and other dementias. Potentially inappropriate medications (PIMs) are drugs that should be avoided by older adults due to the risks outweighing the benefits of the medication. Thirty-four percent of older adults in the U.S. are prescribed PIMs, leading to higher rates of hospitalization and higher costs to seniors and the healthcare system. Consider optimizing the EMR to ensure workflows include tactics to reduce the use of PIMs at the point of care. One tactic is to incorporate geriatric-focused evidence-based criteria such as the AGS Beers Criteria® with strategies for deprescribing PIMs.
- Direct care management interventions based on a consistent risk stratification and enrollment methodology: Care team roles across the continuum should be determined and deployed based on the right type of resource and matched to different levels of risk. Tracking and monitoring complex older adults throughout the health system is a key component to understanding how to intervene at the right time. The methodology should use multiple data sources such as SDOH, frailty and cognitive assessments, ADT feeds and claims for a comprehensive predictive model for this population. This model should indicate which seniors are at risk of rehospitalizations, have limited mobility and are socially isolated. From here, a geriatric-focused multidisciplinary care team can address needs both proactively and upon acute encounters.
- Population-specific measurement and reporting: Model analytics should align with other quality and APM performance metrics under an organizational value-based care strategy. This will provide insights to maximize the revenue opportunity and care coordination improvement within Medicare fee-for-service through billing codes such as annual wellness visits, advanced care planning, and transitional care management or advanced primary care management as appropriate. Implementing these improvements also will support efforts to better manage Medicaid and Medicare Advantage populations by focusing on a consistent delivery model, criteria for success, downside risk parameters and the infrastructure to support the strategy.
- Consider a geriatric-focused hospital unit: When acute care is necessary for complex older adults, a dedicated environment within the hospital has demonstrated results. Acute care for elders (ACE) units have existed since the early ’90s — but now more than ever, they can help reduce hospital costs by improving function, using less PIMs, and incorporating early planning for discharge to facilitate the transition of care within a prepared environment designed to foster independence. If expense or other resource constraints prevent investing in this model, at the very least, begin by implementing the essential ACE principles. These include comprehensive discharge planning focused on transitions to home, early rehabilitation and daily interdisciplinary rounds with a geriatric medical perspective.
- Maintain a clear post-acute strategy: Discharge planning will preferably result in transitioning back home with home health, therapies and other additional resources to prevent readmissions. When a short-term rehab stay is needed, having a pre-established SNF network based on quality and cost metrics is key. By establishing care coordination touchpoints between the care team and the patient, caregivers and post-acute providers will bring continuity of the individualized care plan throughout the post-discharge process until the patient’s condition has stabilized.
Developing a comprehensive senior health strategy will take time and thoughtful evaluation of alternative care models. Incorporating innovative geriatric models to supplement primary care visits, such as integrating telehealth, home-based care partnerships, SNF and/or hospital at home and other opportunities identified through population health analytics should be built into a strategic roadmap. Building a three-to-five year plan supports gradual implementation of these innovative solutions based on organizational priorities, value transformation roadmap and market demographics.
Incorporating sensitivity to the priorities of seniors as consumers as well as patients will greatly improve the quality and experience for complex older adults. This, in turn, will enable achievement of the health system’s market, financial and clinical goals.
If your senior health strategy needs assistance, the Vizient Value Transformation & Payer-Provider Alignment practice can assist with unlocking your potential and utilizing data in creative ways to illuminate and improve your value as a care partner.