Revolutionizing Care for Older Adults: Addressing the Challenges of Hospitalization Through Value-Based Care

As we consider the development of comprehensive portrayal of the “Lived Experience” for older adults, a particularly compelling part of that narrative is acute care, and in particular, the revolving door of Emergency Department visits, hospitalizations and post-acute stays in nursing homes. Of course, hospital-based care may be needed in many cases, but it is not necessarily the best option for the inevitable episodes of instability that are a consequence of frailty, chronic disease exacerbations, and social determinants of health.

In the U.S., adults aged 65 and over account for more than 42% of all hospital utilization, despite representing less than 20% of the population. For older adults, hospitalizations are specifically associated with adverse clinical outcomes including delirium, hospital-acquired infections, and medication errors. More generally, hospital-based care for chronic disease management takes patients away from the homes and communities where they live, compromising their dignity, quality of life, and independence. Hospital-based care for older adults is also costly, with 47% of hospital costs in the United States being borne by Medicare.

The Value Based Care team at the West Health Institute is focused on finding and scaling evidence-based solutions spanning care delivery, clinical practice and payment policies that lower costs and improve care for older adults. Historically, most of our efforts have been heavily weighted in data-driven improvement efforts focused on care delivery within organizations participating in value-based payment model, and these efforts have always overlapped with practice and policy. Our data-driven efforts comprise of distinct micro-level and macro-analytical approaches.

At the micro-level, we collaborate directly with individual care delivery organizations as well as our own West-affiliated PACE clinic. The PACE model has proven to be particularly compelling in terms of providing evidence that interdisciplinary team-based care delivery approaches can manage very complex populations with lower utilization of hospital-based care.

In all our collaborations, we define quantitative aims (e.g., lower hospital utilization and associated spending) with structured improvement methodologies such as the Model for Improvement (MFI) as adapted by the Institute for Healthcare Improvement. One of the unanticipated bright spots in all our collaborations has been the remarkable level of cooperation, support, and creativity in terms of innovation teams from different organizations coming together to advance tangible solutions with measurable outcomes.

In our current value-based care collaboration, for example, Integra Community Care Network, University of North Carolina Health and Cleveland Clinic have collectively garnered more than $6 million from reducing unnecessary hospitalizations while providing the high-quality care patients need.

Not every experience in our efforts has been seamlessly successful, and our mentors on the MFI encourage us to embrace and shine light on what does not work well. Broadly speaking, we learn more from what does not work, and early identification of challenges helps us course current to accelerate achieving positive outcomes.

We are at the point of readiness to spread and scale effective strategies both intramurally (i.e., within the different service lines of clinically integrated networks) as well as extramurally (i.e., having care delivery innovations diffuse from one system to another).

In our 2025 efforts, we intend to confront these challenges by working more holistically with policy specialists, both in our West Health Policy Center, and with affiliated organizations and researchers. We also expect to coordinate our efforts more closely with the Centers for Medicare and Medicaid Services (CMS), coordinating our efforts with the CMS’ Innovation Center on Learning Systems.

We are also complementing the above micro-level research with macro-level data, machine learning, and analytics. Much of our research here is specifically directed toward computational economic studies that are at the intersection of healthcare delivery and actuarial payment policy.

These national level perspectives can build a quantitative picture of patterns of hospital utilization, for example, informing how to materially develop or validate new models of care for health professionals, policymakers, and other stakeholders. In 2025, we expect to fill out both out micro- and macro-analytic capabilities and also fill out the continuum in between.