Healthy Aging in the Community

On the last day of Healthy Aging Month, ACHP is considering some of the initiatives our member plans are undertaking to bolster healthy aging in their communities. Many are detailed in our May report, Taking Better Care: Supporting Well-Being for An Aging Population, which highlights efforts and narratives from Kaiser Permanente, Geisinger Health Plan, Presbyterian Health Plan, Priority Health and Fallon Health.

In 2011, 76 percent of seniors living with multiple chronic conditions ranked independence as their top health priority. ACHP’s member plans offer myriad options for at-home care for seniors. Kaiser Permanente’s PATHWAAY program focuses on prevention, while Geisinger Health Plan helps seniors return to their homes after receiving inpatient care. Presbyterian Health Plan and Priority Health offer long-term at-home care for elderly patients with numerous health needs; Fallon Health integrates at-home and communal care to give seniors both individualized and community-based care.

Kaiser Permanente’s PATHWAAY – Proactive Assessment of Total Health & Wellness to Add Active Years – program regularly screens Medicare patients to assess their risk for falls, urinary incontinence, malnutrition, pain, frailty and mood disorders. With the results, medical professionals create a prevention plan to review with patients, ensuring providers and patients work together to address underlying concerns and issues. The program enables physicians to understand, answer and anticipate seniors’ health questions and needs, making sure seniors are active participants in maintaining their health.

Geisinger Health Plan offers transitional care, helping seniors return to their homes after medical procedures. Geisinger assigns high-risk medically complex elderly members a nurse case manager and a community health assistant, who oversee their transition from a hospital or skilled nursing facility to their home, and ensure that the patient understands his or her health plan and receives follow-up care. The team typically monitors patients for three to six months, sometimes longer if patients remain high-risk.

Presbyterian Health Plan designates patients for their Hospital at Home program. Eligible seniors live with stable medical conditions and require inpatient but not intensive levels of care. In the Hospital at Home program, these members receive hospital-level care at their own residence, with physicians and nurses visiting at least daily. They may also opt for services including speech and occupational therapy, nutritional advice, X-rays and lab work at home.

Priority Health works with community organization Tandem365 to identify and treat patients facing barriers to hospital care, including isolation, poverty, frailty and lack of transportation. Tandem365 is a collaboration among five non-profit skilled nursing facilities and emergency medical technicians from a local ambulance company, who work together to design methods that provide comprehensive – behavioral, medical and social – at-home care. Priority Health refers seniors to the program, with nurses, social workers and physicians collaborating to assess each person’s needs.

Fallon Health’s Summit ElderCare and NaviCare programs help seniors remain in their own homes and communities as they age. Summit ElderCare is a Program of All-Inclusive Care for the Elderly (PACE) open to all nursing-home qualified people ages 55 and above. Summit ElderCare provides coordinated care focused on retaining home-based independence, and provides care at PACE centers, inpatient settings and one’s home. NaviCare offers a Special Needs Plan for dual-eligible seniors and Senior Care Options for Medicaid recipients over the age of 65. Both plans include team care and home visits.

With around 10,000 Americans turning 65 each day from 2011 through 2031, it is vital that the U.S. addresses the growing needs of our elderly population. Healthy aging means making an individual and collective effort toward taking better care of ourselves and those around us. ACHP and our member plans are engaging the older population and their loved ones in their health and their communities.


Zoya Haroon