FEATURE
FEATURE
New Models of Care
for Older Adults
Earlier this year, Baylor Health Care
System Foundation received a $6.9 million
grant from the Deerbrook Charitable
Trust. This significant grant will help
Baylor Scott & White Health test a new
model of care that aims to keep one of our
most vulnerable groups of patients, older
adults, out of hospitals by focusing on prevention and wellness. If proven successful,
the model could be adopted by other health
care systems across the country to improve
patient outcomes while reducing health
care costs, readmission rates and mortality
rates.
The nation’s need for change in the health
care model for older adults stems in large
part from poor care coordination – especially as patients transition from one setting
to another, such as from the hospital to
their homes. Many of these patients have
multiple chronic conditions and take
numerous medications. Poorly coordinated
care for these patients leads to poor outcomes, more hospitalizations and higher
costs.
Filling the Gap
“Historically, to improve the coordination of care and access to care, we’ve always
used advanced practice nurses,” said Mae
Centeno, vice president for Chronic Care
Continuum at Baylor. While there were
some savings, this is an unsustainable
model because of the increasing numbers
of older adults with health issues, increased
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COMPARISON OF CARE MODELS
Current Process
Future Process
Mary visits primary care provider
Mary visits primary care provider
Mary’s medications adjusted
Primary care provider refers to care team
Mary attempts to make appt.
Care team coordinates care
Mary goes to Emergency Dept.
Community health worker provides education
Mary given new medications
and support
Mary has questions
Community health worker coordinates care
Mary returns to Emergency Dept.
Mary follows up with primary care provider
Mary is admitted to hospital
Mary’s daughter coordinates care
Mary admitted to skilled nursing facility
health care costs and decreased Medicare
reimbursements.
This new model would help expand the
capacity of primary-care practices for highrisk older adults in Baylor-affiliated primary care practices by adding clinical pharmacists, licensed social workers and
community health workers, the newest
players in health care. Community health
workers (CHWs) are laypeople in the community, often transitioning to second
careers, who complete 160 hours of
state-mandated training, plus additional
training as needed; in this case, working
with older adult patients.
“The strength of community health
workers is that they’re non-clinical, and
they have a strong connection to the
communities they are serving,” Mae says.
“They serve as a liaison between a health
care practice and the patient.” The CHWs
will also receive training in educating
patients and helping them navigate the
health care system.
“Because they are seen as a patient’s peer,
they can speak and translate in a manner
the pat Y[