Care coordination refers to the team of care providers who work together to ensure a senior’s needs are met, often by using a collaborative care plan. The care team is often directed by a nurse, social worker, or a staff member at the senior living facility. It may also include the senior’s primary care physician, medical specialists, physical and occupational therapists, and mental health counselors. By integrating essential services, care coordination in senior living facilities and nursing homes enhances the senior’s quality of life, reduces caregiver stress, and ensures that the senior receives reliable health care access.
Our free tool provides options, advice, and next steps based on your unique situation.
Care coordination involves multiple team members who create a care plan to synchronize a senior’s care services and medical appointments. The National Council on Aging estimates that 78% of seniors have two or more chronic conditions, and these often prompt a move to senior living.[01] Coordinating care for multiple conditions is challenging, which is why care coordination involves a written care plan.
Rachel Levy, an account manager at A Place for Mom who previously worked in senior living communities, adds that care coordination isn’t just about coordinating medical care. Rather, it’s about coordinating how a senior wants to live their life. “The community’s goal [when using a care plan] is to remove the guesswork for seniors and their families and to meet seniors’ needs in a resident-focused way,” says Levy.
Care coordination teams are led by a care coordination director. This person can be a social worker or someone who works in the community, such as a nurse or caregiver. They’ll serve as a liaison for the rest of the team, which includes the following people:
The care coordination model gives loved ones peace of mind and gives seniors access to reliable and more effective care after they move, because all players are kept on the same page about their personal care and health care needs.
Note: Approximately 89% of A Place for Mom’s partner assisted living communities and 92% of memory care communities offer these on-site health care services from weekly or frequently visiting health care providers:
Our free tool provides options, advice, and next steps based on your unique situation.
Nursing homes and other senior living communities have their own unique methods of facilitating care coordination, but any method should revolve around the senior and their needs. Below are the care coordination model’s key initial steps for success:
Once these pieces are in place, the team creates a care plan. An organized care plan explains which services residents should receive based on their health and personal needs. From there, an effective care coordination model will include each of the following elements:
At Manors of the Valley, a network of communities in Pennsylvania, all care concerns are registered through a digital “wellness hub,” says director Loren Morgan. Their assisted living, memory care, and nursing home employees are trained to notice, report, and respond to changes in a senior’s health or habits.
“We get incident reports that tell us what’s going on,” says Morgan. “We make a list and ask the nurses to follow up, whether it’s a family concern or someone not feeling well. We then match them with the best provider.”
Brookdale, which manages more than 600 senior living communities, takes a similar approach. The care coordination tool Brookdale HealthPlus uses an electronic care record to keep track of a resident’s care plan and related treatment. Seniors and families can use the interactive software to log their concerns. It can also be used to make decisions about preventive appointments, treatment for chronic conditions, and more.
Care coordination offers several fundamental benefits to seniors, according to an American Nurses Association report:[02]
Having a wide range of health services available can also enhance mental and social well-being. A study of 508 patients receiving care coordination found that psychological distress decreased by 62%, while just under half observed a social benefit.[03]
Additionally, common caregiver problems, like burnout and communicating with family members, can be improved with care coordination.
Rachel Levy, A Place for Mom account manager and senior living specialistCare coordination is a great way to take a burden off of a family. Now, they have the expertise of everyone in the community.
Our advisors help 300,000 families each year find the right senior care for their loved ones.
Families often find the added communication from the care team to be a big help. “We have some families that want to go to every appointment,” says Morgan. “For families who can’t make it, they call me after the visit and we go over what the doctor said. We call every resident’s family to let them know that the senior has an appointment on a certain day with a certain provider.”
Depending on a senior’s health conditions, community staff will also recommend and coordinate care with medical specialists. For instance, a nursing home caregiver or physician may connect with the senior’s primary doctor or their physical therapist.
Overall, a community’s ability to meet a diverse array of senior health needs can relieve caregivers, increase care transparency, and forecast longer lives for older adults. Each benefit of care coordination makes it a key component to consider when touring senior living.
National Council on Aging. (2023, August 31). The top 10 most chronic conditions in older adults.
Scholz, J. & Minaudo, J. (2015, September 30). Registered nurse care coordination: Creating a preferred future for older adults with multimorbidity. The Online Journal of Issues in Nursing.
Isaacs, A., Beauchamp, A., Sutton, K., & Kocaali, N. (2019, August 9). Care coordination can reduce unmet needs of persons with severe and persistent mental illness. Frontiers in Psychology.
The information contained on this page is for informational purposes only and is not intended to constitute medical, legal or financial advice or create a professional relationship between A Place for Mom and the reader. Always seek the advice of your health care provider, attorney or financial advisor with respect to any particular matter, and do not act or refrain from acting on the basis of anything you have read on this site. Links to third-party websites are only for the convenience of the reader; A Place for Mom does not endorse the contents of the third-party sites.
Make the best senior care decision