Primary Care for Older Adults by Michael Wasserman & James Riopelle

Author:Michael Wasserman & James Riopelle
Language: eng
Format: epub
Publisher: Springer International Publishing, Cham

One reason for concern is Medicare alone won’t be able to cover healthcare needs for seniors given that influx. Those projections indicate that nearly one-fifth of the US adult population will be over 65 by approximately 2040. The traditional fee-for-service model will collapse under the weight of all those seniors.

Senior living communities that desire to stand apart have started to catch on to the idea and are now building “neighborhoods” that are servicing all types of care within that community. Newer housing developments for seniors are steering away from exclusively assisted living, independent living, or skilled nursing and instead working within a framework like that of continuing care retirement communities (CCRCs) . These communities set aside space for a percentage of skilled nursing beds in relation to independent living, assisted living residences, and memory care. For the model to embrace continuity, at the helm, there is a physician with a handful of physician assistants and nurse practitioners delivering all of the hands-on care, alongside a designated care coordinator—oftentimes a social worker—who is coordinating the services those patients may need, e.g., labs, X-rays, dentistry, durable medical equipment, etc.

National organizations have also been instrumental in proposing several descriptions of what constitutes ideal transition of care service. The American Geriatrics Society has identified four best practices in transition of care: clinical care needs, policy needs, education needs, and research needs. In their report, they emphasize communication between the providers involved and unobstructed access to patient records containing problem lists, allergies, medications, advance directives, a baseline physical and cognitive assessment, and contact information for both professional care providers and a point of family contact [6]. Models, such as that described above, have taken root in places like Minnesota. The Reducing Avoidable Readmissions Effectively (RARE) campaign was a collaboration of 86 hospitals in the state of Minnesota [7]. Ultimately, more than 7000 readmissions were prevented through this campaign.

In Minnesota, there was a focus on five key areas during the transition of care :Comprehensive discharge planning

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