Integrating Medical Care and Social Services Can Improve Care Quality for Elders

By Fulmer, Terry; OBrien-Suric, Nora | Aging Today, May 1, 2016 | Go to article overview

Integrating Medical Care and Social Services Can Improve Care Quality for Elders


Fulmer, Terry, OBrien-Suric, Nora, Aging Today


The world of healthcare is slowly acknowledging what communitybased social service workers have known for decades-health happens at home. Helping to maintain and sustain older adults' highest possible level of functioning and the best quality of life has been the undertaking of communitybased services. Yet, the medical world has little knowledge of the array of services that can and should be provided, which would not only complement medical care, but could help to improve it.

A 2011 Robert Wood Johnson Foundation survey (Health Care's Blind Side: The Overlooked Connection Between Social Needs and Good Health) of 1,000 primary care physicians revealed that 86 percent felt "unmet social needs are leading directly to worse health" across all socioeconomic groups, and that it is as important to address these factors as it is to address patients' medical conditions (http://goo.gl/RQsfql).

Healthcare System Must Address Social Service Needs

To meet older adults' health needs and support their well-being, the healthcare system, which encompasses hospitals and health plans, must address the critical social service needs that will ensure better health outcomes, including the need for adequate nutrition; transportation to medical appointments, the pharmacy and the grocery store; assistance with medications; personal care in the home; and caregiver support. To foster this integration in the new and fast-changing healthcare landscape, social service agencies must create business partnerships with the healthcare system to identify and integrate social services.

Seizing this dramatic opportunity for system redesign will require new business relationships between the social service and healthcare sectors. Both must be readied for this change. The healthcare sector will benefit from knowing the value of social services to their patients' health and to the health system's bottom line. The social service sector, including area agencies on aging and other local aging and disability organizations, must be prepared to demonstrate that they can deliver the quality, volume, confidential- ity, geographic coverage, data and reporting needs of the healthcare system.

The mission of The John A. Hartford Foundation is to improve care for older people. For more than 30 years, the Foundation has provided funding to increase the number of healthcare professionals trained in geriatrics, as well as to develop models of care for older adults.

One thing we have learned is that older adults need a combination of expert geriatric medical care and skilled supportive social services to be healthy and independent for as long as possible. Three years ago we developed a new strategic focus that seeks to break down the silos in healthcare and meet the needs of older people through comprehensive, continuous, coordinated and age-expert care. We funded a project that helps support a national movement to do just that-integrate medical care and social services to improve the health of older people.

Historically, the medical community and the social services network have not connected in any formal way. Now, both entities are seeking to partner to realize better health outcomes for older people, while maintaining a sustainable service delivery model.

To help make these integrated networks successful, social service agencies need help building organizational capacity to deliver high-quality services, bring them to scale and participate in new, complex financial arrangements. The John A. Hartford Foundation provided support for the development of two integrated medical and social networks.

The Partners in Care Foundation developed one prototype in Southern California, and a collaborative co-led by Elder Services of the Merrimack Valley and Hebrew SeniorLife developed the second prototype statewide with a contracting hub for six regional networks as the delivery system. …

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