February 27, 2025

Successful Care Coordination Happens Day After Day After Day

About Brookdale Senior Living

Brookdale Senior Living offers multiple care levels for seniors in more than 600 communities nationwide. Brookdale helps you find the right care plan for yourself or your loved one. With amenities such as transportation services, salons and private dining rooms and activities such as gardening, fitness classes and trivia nights Brookdale caters to a wide range of interests and needs.

Care coordination can be a lifeline for many senior adults, particularly those managing chronic conditions. Effective care coordination is no accident or one-time occurrence: It’s a dynamic, ongoing process that thrives on consistent daily monitoring; steadfast support; and prompt, open communication to help coordinate that seniors receive the comprehensive care they need to help maintain their well-being.

According to the Agency for Healthcare Research and Quality (AHRQ), “Care coordination involves deliberately organizing patient care activities and sharing information among all of the participants concerned with a patient’s care to achieve safer and more effective care. This means that the patient’s needs and preferences are known ahead of time and communicated at the right time to the right people, and that this information is used to provide safe, appropriate, and effective care to the patient.”

Brookdale Senior Living values and understands care coordination, as evidenced by 2024 Argentum Best of the Best Award we won for our HealthPlus^® care model. This blog post will explore the reasons for care coordination; what effective care coordination means; how it benefits physician, patient and everyone else; and what it looks like on a day-to-day basis in a senior living community.

What Happens Without Effective Care Coordination?

Unfortunately, the importance of effective care coordination often becomes clear only in its absence. Many patients, senior and otherwise, have been frustrated by issues such as:

Unreasonable waits for test results
Conflicting information from different healthcare professionals
Redoing a test or procedure because the clinician did not have earlier test results
Having to return for a second visit because the clinician lacked appropriate medical information during the first one
Clinicians’ failure to communicate with one another about the patient’s care

Of course, these situations can easily develop into something worse than frustration. Repercussions can be more serious among seniors, who are more to have chronic conditions and other vulnerabilities.

Qualities of Effective Care Coordination

Effective care coordination helps ensure seamless transitions from one care setting to another. It helps facilitate ongoing patient support. It helps identify and close care gaps, including those stemming from social determinants of health. It helps prevent unnecessary emergency room visits and hospitalizations. It’s efficient, helping to reduce redundancies and waste, as well as confusion. And it constitutes a major difference between healthcare and “sick care.”

To accomplish these goals, care coordination must be:

Personalized: Every patient is an individual with unique needs and preferences, which should be reflected in a personalized care plan. That plan should be based on factors including diagnoses, dietary requirements, medications and mobility. Among seniors, management of chronic conditions is often a guiding factor.
Proactive and preventive: Preventing avoidable ER visits and hospitalizations helps improve seniors’ quality of life. Annual wellness visits are among the proactive steps that caregivers should incorporate into their coordinated care plans.
Thorough and ongoing: A patient’s health is not made up of isolated conditions; they are all interrelated. Effective care coordination looks at the whole patient, which requires coordination across disciplines and specialties, including between medical and mental health providers.
Collaborative: Collaboration, the engine that drives care coordination, requires communication among providers as well as between patients and providers. By making information easily accessible to one another, providers help keep everyone on the same page, working together to avoid problems such as overmedication, unwanted drug interactions and counterproductive treatments. By making information easily accessible to patients, the providers help them manage their own care and play an active role in its coordination.

Technology is an essential piece of the puzzle, as well. Electronic health records (EHRs), for example, help facilitate the reporting of test results and the capturing of other actionable information from multiple providers. Patient portals, whether part of the EHR or separate, help make it easier for providers to maintain timely communication with patients, answer their questions, share lab results, provide instructions and discuss potential follow-up steps.

Coordinating With Brookdale

Care coordination — along with related measures such as preventive care, chronic conditions management and a holistic approach — is a key aspect of value-based care, a care delivery model that puts patient outcomes at the forefront. This model incentivizes providers who prioritize these measures, a departure from the traditional fee-for-service model.

With Brookdale HealthPlus^®, we embrace value-based care and the opportunity to coordinate and partner with healthcare professionals to help deliver superior outcomes to our residents. Coordination begins before a patient’s transition to a Brookdale community. Our personal service assessment helps produce a detailed picture of the patient’s unique needs, both physical and mental, including medications. We collaborate with the patient’s entire care team to create a personal service plan that helps prevent or reduce polypharmacy.

Our daily support includes the ongoing management of medications and chronic conditions, as well as help adhering to physicians’ treatment plans. Because we see our residents daily and observe their habits, we have the ability to identify changes in mood or behavior that are potential causes for concern. This allows us to take proactive steps, in collaboration with caregivers, to address these issues. We track our residents’ care with an EHR and maintain regular communication among our community, patients and providers.

For residents living with dementia, we work closely with caregivers and families to fine-tune our person-centered approach, with guidance from evidence-based care models. We understand that when all the people who share responsibility for someone’s care work in concert, that individual is more likely to receive the treatments and attention they need to not only stay healthy, but also thrive in their environment. At Brookdale, we are committed to this approach, which we live day after day after day.

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Brookdale provides opportunities for providers to round inside our community to experience firsthand how their patients live. Let us show you what Brookdale life might look like for your patient.

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