Each May, the U.S. observes Older Americans Month, a time to highlight the achievements of older adults and consider how our healthcare system may better serve them. Value-based care (VBC) models offer an effective framework to improve the quality of care for older Americans. Across the country, healthcare organizations are putting these models into action to deliver more personalized care that meets seniors where they are physically, socially, and clinically.
Why Value Based Care Matters for Senior Health
Older patients often have multiple chronic conditions, rely on multiple providers, and require complex medication regimens. Under traditional fee-for-service models, these patients often fall through the cracks, receiving fragmented, reactive care. Instead of focusing on volume, VBC emphasizes outcomes, preventive care, and long-term health improvements. These goals align directly with the needs of older patients, improving senior health.
Building Stronger Connections Through Care Coordination
One of the most effective tools in improving care for older adults is care coordination. Accountable Care Organizations (ACOs) and Medicare Advantage plans are investing in care teams who serve as the link between specialists, primary care providers, and community services. These nurses, social workers, and community health workers help manage transitions between care settings, schedule follow-ups, track medication adherence, and ensure patients understand their treatment plans.
For example, CHESS operates a Transitions of Care clinic where, within two business days, transitional care nurses follow up with seniors after hospital discharges, reducing readmissions and boosting recovery. CHESS is also using predictive analytics to identify high-risk patients early and intervene before a crisis occurs.
Addressing Social Drivers of Health
Improving care for older adults also means addressing the non-medical factors that affect their well-being — like food insecurity, isolation, transportation, and housing. CHESS and other organizations are using value-based incentives to fund programs that connect seniors to local resources. Community health workers, in particular, are playing an increasingly important role in screening for social needs and facilitating referrals to services like meal programs or home modifications.
Take North Carolina’s NCCARE360, for instance—a statewide coordinated network that connects healthcare providers with social services. This helps to ensure that referrals don’t end up at a dead end, but lead to real support for seniors in need.
Enhancing Engagement Through Technology & Access
While older adults are frequently labeled as tech-averse, many are embracing tools like remote monitoring, patient portals, and telehealth. These tools are especially successful when designed with accessibility in mind. Simplified interfaces, one-on-one tech support, and involvement of family caregivers are helping organizations bridge digital divides.
Patient engagement does not stop with technology. Medicare wellness visits, tailored care plans, and shared decision-making conversations are all touchpoints that improve trust and communication, which are key ingredients in value-based care.
Looking Ahead
Older Americans Month serves as a reminder that healthcare transformation must prioritize our aging population. Value based care offers a path forward, rewarding compassion, connection, and coordinated care. Continuing to invest in these models will not only improve outcomes for older adults, but it will also build a more sustainable, patient-centric system for all.