The Alphabet Soup of Care Models

A conversation with Steve Buslovich, MD, CMD, MSHCPM, Co-Founder and CEO of Patient Pattern

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Each setting in the “alphabet soup of care models”– from NHs and CCRCs to ALs and from PACE to MA to I-SNPs, accommodates the needs of some older adults, but not others; and most models lack innovative approaches to health care while falling short of creating an atmosphere to improve outcomes and satisfy residents and beneficiaries.

These challenges were magnified during the pandemic. It has become painfully clear that the status quo must be changed not only to accommodate the deficiencies in the current facilities but also those in our understanding of what it will take to meet needs, avoid another crisis, and provide more than one vision of aging well, accompanied by living arrangements to accommodate those different aging trends.

What are a few of the hard truths that have been learned from the pandemic?
#1: Modernizing the design is required and models exist for improvement.
The traditional American nursing homes are designed for a medicalized approach to aging modeled basically like a small hospital. During the pandemic, the current medical care model was not sufficient to stem the flow of COVID-19 deaths where more than 1 in 5 of the nation’s pandemic fatalities occurred.

Residents left facilities to live with their families, and the reluctance to return continues. Many influential organizations are diligently examining the findings and failures of the nursing home industry and sweeping change is anticipated.

#2: The pandemic highlighted how little we accommodate for the social determinants of health in the nursing home setting.
According to the World Health Organization, “Social determinants of health are the conditions in which people are born, grow, live, work and age.” Data on the impact of social determinants on health vary, but one recent notes that as much as 80% of health outcomes are related to social factors.

We witnessed frailty deficits increasing as a result of the psychosocial factors, imposed by the pandemic, that weren’t (and aren’t) adequately addressed:

• Social exclusions or isolation
• Environmental factor related to mobility
• Lack of control or autonomy
• Food – lack of culturally relevant choices
• Not feeling safe
• Lack of understanding the plan of care
• Loneliness from lack of social supports

Going forward, no matter the setting, these factors need to be addressed. Their impact on health outcomes is too great to ignore and so when we plan for environmental change we also need to plan for all the factors we can change, setting the stage for a less medicalized model where frailty is mitigated and managed and decline is slowed.

#3: Population health management has come become a clear focus.
Another concept mentioned more during the pandemic was that of population health management. This area of focus is related to the health outcomes of a group of individuals, including the distribution of such outcomes within the group. It is an approach to health that aims to improve the health of a broader population based on defining characteristics or geographies and recognizes that disparities often exist within groups based on race/ethnicity, socioeconomic status (or social gradient), geography, gender, other characteristics. Population health management recognizes the social determinants and incorporates them into programs in order to improve outcomes.

How does frailty impact care models?
The lessons learned must be re-examined and incorporated into future health care for the entire population of older adults and those with chronic illness and frailty. As the number of older adults increases, models of care are revised, degrees of physiological decline vary, we will benefit from considering the needs of all populations and plan care that is both satisfactory and sustainable.

As a country, we must realize that we cannot approach complex care by treating a single diagnosis, like a strand of “spaghetti,” rather we need to look at the entire “spaghetti ball” of conditions and appreciate the multiplier effect of diagnoses on an individual’s level of function, cognition and psychosocial domains. As an example, tightly controlling high blood pressure may be medically important, though may not be the priority for an individual if that means that they cannot enjoy a social activity due to imbalance, lightheadedness, or fear of falling. A holistic approach to the spaghetti ball can yield a favorable outcome, as researchers have well-validated. New models of care, particularly risk-bearing structures, will require a frailty-driven care pathway to provide proactive interdisciplinary interventions that can bend the cost-trajectory while taking a patient-centric approach.

What are a few key takeaways leaders should consider?
A virus has thrown health care for older adults into chaos, especially in nursing homes.

• Innovative change is required and underway across the continuum of care.
• New models of aging need to move away from the medicalized model for many.
• An alphabet soup of care models will always need to exist for a heterogeneous group.
• Accommodating the social determinants of health and population health must be considered.

As leaders, wherever we practice professionally, we owe it to the setting to work towards change. With the industry in crisis, many options are on the table; and the time to act is now. There is a need for aging in place, assisted living, home care, post hospital care, and nursing home care, and we owe it to the entire population needing or anticipating a need for services, to make every setting the best possible. The science behind population health principles and the social determinants of health are real and carry consequences to millions.

Pathway Health’s team of experts is available to support your organization. Contact us to learn more.