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Contributor: Improving Seniors’ Health and Outcomes With a Value-Based Care Team Approach


A value-based care team approach can be utilized to adequately treat patients’ medical problems, particularly by addressing the social, economic, and environmental challenges they’re facing in their everyday lives.

Over the past several years, CMS has been expanding the types of supplemental benefits that can be offered by Medicare Advantage plans, extending beyond traditional medical services and providing the flexibility to address various social determinants of health (SDOH). The recognition that psychosocial factors may severely impact a person’s health, as well as the benefits of a more holistic approach to caring for seniors, has been pushing the practice of medicine toward a value-based care model. The pandemic has only made the need for this change more essential.

There is plenty of evidence that treating a patient’s mental health and social needs might be more important to their overall well-being than treating their medical conditions. It is estimated that clinical care only accounts for about 20% of health outcomes, while the other 80% is based on social, economic, and environmental factors.

As a physician whose practice focuses solely on caring for older patients, I am confronted daily with the life circumstances that are at the heart of my patients’ health. I see patients dealing with food and housing insecurity, transportation issues, and mental health problems, notably depression and anxiety. All of these factors can cause health problems, exacerbate existing ones, and prevent patients from receiving proper treatment.

For example, I recently saw a patient who had been doing well on a diabetes medication he had been taking for quite some time. However, during this visit, I learned that he had stopped taking the drug because his daughter, who had been paying for it, lost her job due to the pandemic and was unable to continue to cover the cost.

To treat patients’ medical problems adequately, it’s essential to help address the challenges they’re facing in their everyday lives. A value-based care team approach makes this possible.

Identifying the factors affecting a patient’s health requires building a rapport and gaining their trust, both of which take time. The average 15-minute appointment is not enough. However, when the focus is on the quality of patient care and not the quantity of patients seen, sufficient time can be allotted for having those in-depth conversations with patients. In my primary care practice, the average visit lasts 45 minutes.

In addition to time, it takes resources to address these problems. A holistic approach to patient care is only possible with the support of a care team who provides a full spectrum of services and the staff and systems that can reduce the physician’s normal administrative burdens.

In the case of my patient who had stopped taking his diabetes medication, our staff pharmacist found an assistance program to provide him the medicine at no cost. When patients have trouble affording food or housing, our social worker connects them with community resources to address those needs. When a patient is depressed or anxious, our behavioral health specialist evaluates their mental health and provides counseling and other necessary treatments.

During the pandemic, the care team has become even more critical in providing care beyond the walls of our medical center, keeping in frequent contact with patients through telehealth and even curbside visits.

These are the essential elements of a successful value-based, care team approach. Unfortunately, this model is often poorly understood, and in many cases, the focus is on performance metrics without having the necessary support and resources in place.

Leveraging this approach, CenterWell Senior Primary Care, a network of senior-focused medical practices primarily located in underserved areas, has worked to fully commit to the “whole patient” model and the positive outcomes it can produce. Although a recent study showed that 43% of Americans have missed preventive care appointments during the pandemic, 87% of our patients made at least 1 visit, and they averaged 4 visits to their primary care doctor in 2020, more than in 2019.

This model can also help keep patients out of the hospital. Data from our South Carolina centers show that in 2019, 30-day hospital readmission rates for our patients were almost 60% lower than those of the general Medicare population and our rate of hospital admissions was significantly lower than the national rate for this age group.

Done right, value-based care benefits patients, clinicians, and payers.

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