Senior Consumer Experience, Quality, Cost and Revenue Go Hand in Hand: Hit the Mark with Prevention, Proactive Restoration and Support

By Rose Maljanian, Chairman & CEO HealthCAWS
and Chairman Emeritus Population Health Alliance

Senior consumers have been through so much in 2020, from fear of illness and even death related to COVID-19, to the social isolation and dramatic change in routine that new restrictions have thrust upon them. These changes for seniors are likely contributors to the doubled rates of loneliness among this population since 2018. With change in routine and social isolation comes the 50%  increased risk of dementia and higher rates of depression and anxiety – which impacted one in 10 seniors in 2018 and now affects a staggering one in four today.

Cognitive decline and depression can lead to loss of appetite, weight loss, increased falls and other safety risks. Unchecked, increased fall and safety risk can lead to fractures, hospitalization, pneumonia and so the cascade of events goes on.

The miraculously speedy vaccine development gave way to a slower than expected pace of vaccine administration, leaving us still months from a return to full normalcy. For some seniors the restoration of their physical, cognitive and mental health may take years.  Furthermore, because seniors are also fighting the gravity of the aging process, complete return to their pre-COVID routines and function may not be possible.

We can ease the collateral damage of COVID by making 2021 the Year of Consumers – especially senior consumers – through accelerating practices that hit the mark in compassionately meeting seniors’ needs and sunsetting outdated methods that may lead to decline in health or obstruct early recovery.  Below is a list of practices that must be accelerated and those that ought to be rethought or eliminated, several of which will be discussed in more detail as they relate to senior health.

Accelerate

• Well-integrated virtual care options – medical and behavioral
• Primary cares that take full accountability
• Timely home care and hospital at home
• Community-based one stop shops visits for diagnostics and medications
• Use of navigators and well-trained proactive care extenders
• Consumer-caregiver adoption of intuitive personal health records (PHRs)
• Use of early indicators from voice of the consumer and caregiver

Eliminate

• Physician offices that are only accessible during the 9-5 hours, with a break at 12 and busy phone lines throughout
• Emergency room as a default path to get attention and action
• Outdated medical necessity criteria ignoring early indicators
• Delays in care due to convoluted processes
• Staffing warm bodies versus proactive empathetic persons
• Disrespect for consumer and caregiver time and resources

Avoiding Pitfalls and Becoming Senior Focused

Not all of the above problems on the “eliminate” list are the practices of all health care entities. Numerous innovative models of care have emerged that include partnerships between payers and providers and the provision of primary care centers like those administered by ChenMed and Oak Street Health offering around-the-clock, concierge-style care and support to beneficiaries. Further, research shows higher spending on primary and preventive care in Medicare Advantage, correlating with fewer avoidable hospitalizations and fewer nursing home stays.

Still, outdated and convoluted processes persist. Eliminating this starts with Primary Care Provider (PCP) availability and expert evaluation through a geriatrics lens; advocacy for their senior patients by clearly expressing need to payers; and compassionate support for the senior and their families navigating the incomprehensive web of processes necessary for gaining necessary services.

For payers, with the help of the Centers for Medicare & Medicaid Services (CMS), outdated medical necessity criteria and other reasons for denial can be addressed. For example, if a senior sustains a fall and has a fracture that does not require acute care hospitalization but can benefit from aggressive therapy to quickly restore and prevent further decline in a short five day stay in rehab with rapid discharge to homecare, the investment may be well worth it.

However, today Medical Necessity Criteria are based on the CMS Medicare Benefit Policy Manual: “The beneficiary must have been an inpatient of a hospital for a medically necessary stay of at least 3 consecutive calendar days.” Alternatively, while the home is always the preferred setting, this only works if aggressive home-based rehab can start immediately versus long delays until the first session then limited therapy sessions per week.

Other examples are even more basic such as medication management and nutrition but can go a long way in helping seniors to recover or prevent further decline. Consider: if a newly-diagnosed dementia patient is recommended by their PCP for daily dosed medication packages but were previously filled as a 90-day supply, payment for medications can be denied and the consumer newly diagnosed with dementia will need to manage two systems until all 30-day periods sync up. Perhaps, in the near future,  a diagnosis of dementia, physical or mental health limitation will be enough to immediately get a senior on coordinated daily dosed medications – certainly less expensive and less of a quality-cost risk than complications from missed medications. The same is true for meal delivery, if coverage is limited to those that have a hospital or nursing home stay or high-risk chronic members enrolled in C-SNPs, we ignore the senior living borderline in their home that for a variety of medical, cognitive, behavioral, or social reasons has lost the ability to independently prepare or source meals resulting in rapid weight loss and sequelae thereof.  All of these scenarios, if not addressed proactively, are a setup not only for frustration or hopelessness by seniors and their caregivers but also an ER visit as the place for default action, recommended even by some providers, or worse an acute care or permanent long term care admission.

Accelerating Innovation in Senior Health Support 

In a previous article, I discussed the need to accelerate innovation for seniors and noted that seniors and caregivers prefer the home environment when possible. Digital technology and telehealth continue to rapidly expand in the senior health market and devices are becoming more senior need focused and easier to use. The Better Medicare Alliance commissioned research that shows providers in the Medicare Advantage Plans studied were able to quickly transition to telehealth in the wake of the COVID-19 pandemic because telehealth was already widely in place amongst these plans. Telehealth flexibility and waivers have been expanded and extended and gaining mainstream status as a standard of care optionality. Telehealth alternatives can further reduce trips to doctor’s offices when equipped with devices for full vital signs and auscultation transmittal or remote patient monitoring (RPM) leveraging connected personal device data as a growing number of seniors embrace smartphones. When it comes to care extenders, non-intrusive technologies such as fall detection with lightweight waterproof wearables, expanded voice command and air quality detection, to more holistic smart panels that capture gait, falls, breathing, and rest patterns in the home environment all have a promising role to play.

While sources of data have grown in volume and analytics in sophistication, the voice of the consumer and caregiver is critical to understanding change in condition. A set of first-time in-home visits may reveal two unique 82-year-olds with the same ability in activities of daily living (ADLs) and the same weight. However, upon further exploration with the consumer and caregiver, an assessor may come to understand that one has been doing well maintaining that baseline for the last five years while the other has had a sudden change in condition that requires work-up and restoration to pre-decline levels.

High risk and complex seniors tend to get enrolled in care management. However, the borderline seniors and those with a change in condition may not be picked up early and may require more than monitoring technology to prevent further decline. High-tech in the home paired with high touch support provided by proactive, well screened and trained personnel is game-changing to maintaining independence for borderline seniors. Formal training in exceptional customer experience in addition to personal care and safety is vital to meeting seniors’ needs, achieving high Net Promoter Scores, and managing total cost of care. CMS has placed renewed emphasis on this as well, recently increasing the weighting for consumer experience measures in Star Rating scores from a weighting of 1.5 to 2.0 in 2021 Star Ratings to a proposed weighting of 4.0 in 2023. This has significant implications not only for consumers but for the plans themselves as payments are tied to these performance metrics.

Access to care is another category gaining higher weighting in Star Ratings. Moving services out into the community where seniors live and offering one-stop integrated shops for primary and specialty care, diagnostics, and medication refills and other daily needs provides a better experience and reduces fatigue for both the consumer and caregivers who may be juggling care for multiple loved ones. Time spent away from work, spoiled holidays, nonstop phone calls and follow-up task lists lead to caregiver burnout that can be eased through convenient easy to navigate services positioned in local communities provided by respectful compassionate team members.

An unrelenting focus on consumer needs not only does right by consumers and caregivers, it is also smart business. Its ripple effect will be felt through positive outcomes and higher enrollment – trends already taking hold in Medicare Advantage, where nearly 27 million seniors and Americans with disabilities will receive coverage this year. Fortunately, new innovative approaches and devices are hitting the market on an almost daily basis. As healthcare leaders, we can drive their adoption and the integrated teams to provide the ultimate senior consumer experience.  Our collective efforts, at least in part, can help ease the pain of the losses seniors have experienced during this tragic time and give them back the best possible golden years they were hoping to experience.

Rose Maljanian is Chairman & CEO of HealthCAWS and Chairman Emeritus of Population Health Alliance, a BMA Ally organization.