Commonwealth Care Alliance® (CCA)

The literature is replete with tools and workflows that have been trialed and measured to promote the safety and wellness of an older adult at home. For many, long-term services and supports, as well as numerous community-based resources, are available. However, for someone who may have special needs (such as medical and behavioral complexities, limited access to care, or social determinants of health), the availability and utility of more resources alone may not lead to better care or outcomes. The appropriate and individualized utility of resources available for older adults requires the craftsmanship of a fine tailor to generate a “suit of care” that is personally styled, comfortable, and travels well.

In the coordination and delivery of older adult care, organizations like Commonwealth Care Alliance (CCA) are ‘tailoring many suits’ to meet the needs of older adults living at home by structuring programs that are 1) modeled after the Age-Friendly Health Systems framework; 2) fueled by predictive analytics and action boards; 3) use innovative services—such as consultative palliative care.

"The healthcare system needs to recognize that care for older adults must be dynamic"

The Right Team that Drives Individualized Care

Optimal coordination of older adult care—that “perfect suit”—does require the actions of a team working toward an individual’s healthcare goals. Given that older adults typically have multiple medical issues, medications, multifaceted social and financial dynamics, and transitions in care, they are constantly challenged to maintain their independence within the community. As an industry, it is critical we recognize that older adults are unique in their needs—one size suit does not fit all—and the primary care provider today cannot “go it alone” when delivering care. To help older adults stay well in their own homes as they age, primary care providers, specialists, behavioral health supports, social work/care coordinators, community resource leads, and health plans must come together to promote high-quality, individualized care.

The Best Approach for High-Quality Care Delivery

Teams often struggle in creating that perfect suit of care because of difficulties in establishing a framework for developing or maintaining standards of care that will decrease variability or reinvention; preventing silos of redundant care; and identifying outcomes, or key performance indicators, that can be measured. To help the nearly 84 million adults over the age of 65 that are expected by 2050, the Institute for Healthcare Improvement and the John A. Hartford Foundation developed a framework to meet the challenge of an aging population based on evidence-based practices for high-quality care. The ‘Age-Friendly Health Systems’ framework relies on four elements, or the ‘4Ms’: What Matters, Mentation, Mobility, and Medication. This organizing framework helps maintain focus on the needs of older adults, such as: goals and wishes for care, fall risk and cognitive assessments, polypharmacy, and deprescribing.

The Innovative Technology that Tailors Better Outcomes

How can the healthcare system address or predict an older adult’s needs in real-time? Can an individual’s unique care plan be tailored to prevent hospitalization, trip to the emergency room, fall, or social determinant need? CCA uses information technology platforms—predictive analytics—to address these questions.