How Care Coordination in Senior Living Promotes Health and Longevity

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 senior. As the center of the care coordination model, the senior is involved to make sure all of their care needs and priorities are met.
• Loved ones. These include the senior’s family, their friends, and anyone else who was a primary caregiver.
• Community staff. Caregivers and other senior living staff are essential to the team, because they work with the senior on a daily basis. For example, some communities have in-house nurses and aides who assist with activities of daily living, like medication management and personal hygiene.
• Medical providers. These include the senior’s primary care physician and other health care professionals, such as occupational therapists and medical specialists. Depending on the senior and the community, the providers will either be doctors they already have a history with or the community’s visiting health care providers. Those who move to a nursing home will have regular on-site access to licensed medical professionals.

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:

• Visiting physical therapists (PT)
• Visiting occupational therapists (OT)
• Visiting speech therapists
• Visiting podiatrists
• Visiting nurses
• Visiting dentists

Let our care assessment guide you

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:

• The senior undergoes a needs assessment. This tool measures a resident’s memory, mobility, and general health to determine their level of care. “A pre-move-in assessment is essentially the framework for the care plan,” says Levy.
• The team is formed. This is when the care coordination director and the senior’s medical team is identified.
• The team reviews insurance and payment sources. The senior’s insurance companies, plus their Medicare and Medicaid plans, are assessed to ensure coverage.

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:

• Daily monitoring. Because seniors interact with various staff members throughout their day, concerns may be noted by housekeepers, dining services staff, or care aides. For example, they can note and act on sudden weight loss or increased struggles with mobility.
• Long-term monitoring. Monitoring progress long-term allows the team to assess whether the care plan is fulfilling the senior’s needs. This also creates opportunities to make necessary adjustments to the care plan.
• Frequent communication. Communication logs and incident reports are key, according to Levy. The staff’s skilled observations allow the care coordinator to keep seniors’ families and health care providers updated in detail.
• Periodic care plan meetings. Team members will reevaluate a resident’s treatment and address any new concerns. Levy emphasizes that these are the “parent-teacher conferences of senior living,” and that families should be involved when possible.

Care coordination in practice

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.

Read more: Person-Centered Care and Its Role in Assisted Living: A Guide

Care coordination offers several fundamental benefits to seniors, according to an American Nurses Association report:^[02]

• Fewer emergency room visits
• Reduced appointment copays and medication costs
• Fewer hospital readmissions
• Increased patient satisfaction
• Increased longevity
• Improved quality of life

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.

Talk with a Senior Living Advisor

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.