The conditions in which people are born, grow, work, live, and age, and the wider set of forces shaping the conditions of daily life, have a significant impact on health. Integrating health care and social services, such as accessible housing, meals and nutrition services, transportation, and caregiver training, is particularly important for those living with multiple chronic conditions including pain and other symptoms, functional dependency, frailty and significant family caregiver needs.

Integrating health care and social services is a way to improve quality of care and health outcomes for those with serious illness, or high needs.

To help address the challenges of integrating services and supporting family caregivers, the foundation’s Patient Care Program partnered with the National Academies of Sciences, Engineering and Medicine’s for a Roundtable on Quality of Care for People with Serious Illness – the fifth workshop in the series on serious illness care.  

The roundtable is designed for participants to learn from other stakeholders who share a vision of high-quality, community-based care. It includes a broad range of perspectives from patient advocates, clinical care team members and health care payers as well as researchers, policy analysts, family caregivers and representatives of federal agencies.

Participants explored a range of topics, including:

  • Challenges and opportunities of integrating health care and social services for people with serious illness.
  • Roles and unique needs of caregivers for those with serious illness.
  • Examination of innovative partnerships and collaborations for integrating services.
  • Policy challenges and opportunities for integrating health care and social services.

Proceedings of the workshop, Integrating Health Care and Social Services for People with Serious Illness, published in January 2019.

The role and unique needs of the caregiver

The caregiver can play a central role in ensuring integration of health care and social services for their loved one, yet they are in need of support. Richard Schulz, distinguished service professor of psychiatry at the University of Pittsburg School of Medicine, shared some profound statistics. There are approximately 18 million family caregivers of older adults in the U.S. who provide at least $234 billion of unpaid care. Caregiving responsibilities can contribute to depression, anxiety and poor health. And, many family caregivers take leave from their jobs to provide the necessary care for a friend or family member.

To address these challenges and more, the foundation launched the Family Caregiving Institute at the Betty Irene Moore School of Nursing at University of California, Davis. One of its goals is to create a suite of materials for families to promote safety and quality in caregiving and develop learning modules for health professionals to engage more effectively with caregivers.

Innovations for integrating services

The Academy’s roundtable also showcased partnerships and collaborations that integrate health care and social services. One example is the Program of All-Inclusive Care for the Elderly (PACE), which integrates medical care and financing to broaden care to include social supports for patients.

The PACE program is built around an integrated care team, which includes a social worker, a nursing assistant, a home care aide, a nutritionist and a registered nurse case manager, as well as a transportation coordinator. A physician and nurse practitioner, who are part of the team, play secondary roles to these social components. The successes of the PACE program include fewer premature nursing home placements and hospitalizations for enrollees, and less fragmentation of care. While PACE is successful in providing integrated care for patients, the relatively high start-up costs and finding the right workforce for the integrated care team are major impediments in the adoption and spread of the program. The foundation is supporting work to grow the PACE program in California.

Workshop participants were also introduced to the Community Aging in Place program – Advancing Better Living for Elders (CAPABLE) – that features a combination of a nurse, an occupational therapist and a repair person to address both the patient and their home environment. The CAPABLE program integrates both health care and social supports to help the individual devise solutions that address their chronic disease, address pain or depression, as well as any home repair work that might be needed to achieve the personal goals of the patients. The CAPABLE program has improved physical function and decreased depressive symptoms in patients. Additionally, the program has shown decreased hospitalizations and nursing home admissions for its program participants.

One unique feature of the CAPABLE program is that it perceives the older adult to be the expert in his/her care and rather than focusing on their chronic conditions. It focuses on what the patient wants to be able to do to age at home safely and independently. We believe that a patient’s ability thrive successfully at home is a key driver to improved patient experience and outcomes, so the foundation supports development of resources to help clinicians, patients, and family caregivers focus on what matters most.

Past roundtable workshops included:

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