Coordinated Care Centers: A New Care Model for Older Adults

Emory Coordinated Care Centers promote wellness in older adults. The goal of the care center model is to educate patients and promote quality of life.Leaders from Emory Healthcare and California-based Caremore published an article in NEJM (New England Journal of Medicine) Catalyst presenting early results and highlights from the coordinated care program both company’s worked to launch in August 2014.

So what is a coordinated care program?

Coordinated care programs seek to streamline healthcare for older adults. As people age, they may find themselves juggling multiple doctors’ visits, chronic disease treatment plans and a number of daily medications.

To simplify this process, the Emory Healthcare Network opened two Emory Coordinated Care Centers, as well as several satellite locations, which use multi-disciplinary health care teams to improve quality of life for its patients. These centers are part of Emory Healthcare Network Advantage, a program that focuses on high-risk Medicare Advantage patients who either have, or are at risk for, chronic health problems such as diabetes, congestive heart failure and chronic obstructive pulmonary disease (COPD).

“The goal of the Emory Coordinated Care Centers is to promote wellness in the older patient population,” says Anthony Nguyen, M.D., regional medical officer at Emory Healthcare. “Many older patients have multiple chronic diseases that affect their health over time. With many different medical problems, medications and providers, it may become difficult for a patient to understand everything that is happening with their health.”

A New Approach to Health Care

“Often times, patients have many medical conditions and require care from multiple physicians,” says Dr. Nguyen. “Unfortunately, it’s common that patient care becomes fragmented. The Care Center team works to bring all of the patient’s information together.”

He adds, “The coordinated care center approach is different from the standard model of care because it focuses on the continuum of care. Our goal is to educate patients to be active in their own wellbeing to promote quality of life.”

Many of the services in the Care Centers are provided at low or no cost to patients to remove barriers to care. The model promotes preventive and proactive care rather than sick or reactive care.

Nearly a dozen programs are offered at the centers, including Healthy Start , a comprehensive assessment that identifies a patient’s health risks. Each of the programs supplement care patients receive from their PCPs and specialists.

The Coordinated Care Teams

The coordinated care teams include medical professionals who educate patients and help them manage conditions such as diabetes, hypertension or heart failure. This team includes:

  • A physician
  • A registered nurse outpatient case manager
  • A social worker
  • Advanced care providers, such as nurse practitioners and physician assistants
    Staff at Emory Coordinated Care Centers get nearly two months of comprehensive, interdisciplinary training.

“To provide the best patient experience and great clinical outcomes, everyone must work together,” explains Dr. Nguyen.

“The care center works very closely with a patient’s primary care physician to ensure we have the same goals for their care,” he says. “The coordinated care center model works collaboratively with the primary care physician and everything we do in the Care Center is communicated back to them. We don’t replace the primary care physician, but rather supplement their care.”

Once patients are part of an Emory Coordinated Care Center program, the team follows up with them on a regular basis by phone and schedules Care Center appointments as needed.

“If the chronic diseases are managed well, the rate of disease progression may be slowed, leading to a higher quality of life,” says Dr. Nguyen.

How do people become patients

Patients who already see a primary care doctor in the Emory Healthcare Network and are members of a participating Medicare Advantage plan can talk to their physicians about the program or simply call to make an appointment for a HealthyStart.

In addition, Emory Healthcare Network patients may be referred to an Emory Coordinated Care Center by a physician who cared for them during a hospital stay

Read about the early results of this model at the Emory News Center.

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