It's Time for Senior Living to Go Beyond the Amenities to Support Value-Based Care

At Brookdale, we’re already seeing that the greater the clinical capabilities at a senior living community, the greater the opportunities to partner with the providers, payers and accountable care organizations driving value — to improve outcomes for everyone. The clinical expertise Brookdale has on-site tackles the social determinants, care coordination challenges, and stressors families and individuals face every day trying to manage care for themselves and their loved ones, usually at the cost of prevention. We achieve this by taking a purposeful and team-based approach to primary care for our residents, which 1) addresses the daily preventive habits that can affect outcomes; and 2) coordinates care as a part of a larger care team. This creates value for our partners — and their patients — by helping to reduce acute care episodes and readmissions from our communities to hospitals.

Our approach to valuable, preventive care starts and ends with tackling social determinants. When a resident comes to live with us, everything Brookdale provides helps overcome social determinants to establish a healthy environment for our residents. This allows primary care providers to focus on managing chronic conditions in partnership with us. When they prescribe an intervention, such as new medication or diet, providers have peace of mind that the care plan can be followed at Brookdale without social determinants like transportation to the pharmacy or grocery store getting in the way.

Residents and families can also leave their doctor’s appointments knowing that Brookdale will help coordinate the provider’s clinical recommendations and next steps. We can schedule follow-up visits and transportation, manage medication and involve our pharmacy partners to assist in avoiding polypharmacy or medication-interaction issues. Brookdale also opens its doors to rounding physicians, which makes even the most intimate value-based care alignment and partnerships possible. The care providers we partner with to help reduce costs and improve outcomes have routine access to their patients’ living environments, where those daily preventive steps are taken to help keep them at home — and away from the hospital.

The Brookdale HealthPlus® program has allowed us to expand these clinical capabilities and care coordination within certain communities in Ohio. It establishes an RN as a Care Manager in each community who helps bridge the communication gap between the family and the physician. These nurses know each resident’s health status and have demonstrated exactly how we can achieve value-based outcomes in assisted living — by actively participating in residents’ healthcare needs alongside the family. With any changes in status, our PointClickCare® technology enables Care Managers’ responsiveness by prompting them with the next steps in a care pathway. We created these evidence-based practice protocols with a medical advisory group, so Brookdale HealthPlus® Care Managers know what to monitor, what to do next, how to address it if it’s manageable in the community and when to call the doctor. It’s making a positive difference in outcomes. We’re not providing acute care, but we are there to react in a clinically appropriate manner — and to triage the next steps in the care continuum.

At its most basic structure, value-based care emphasizes that high-risk individuals — such as older adults living with chronic conditions — have access to preventive care and care management that will identify changes in condition and allow response before more expensive interventions may be necessary. That extra push to help seniors navigate the care they need is essential to helping them stay healthier, longer. Outside of a senior living community like Brookdale, most of that care coordination can fall on the family or the individuals themselves, even when they’re in facility-based care. Families have a tough time navigating the complex healthcare system. So, unfortunately, for most seniors that means they don’t receive the preventive care they need. We’re proud of the outcomes we’re seeing at Brookdale by simply stepping in to be responsive when conditions change — or, through our lifestyle interventions, helping to prevent them entirely.

The Centers for Medicare and Medicaid Services has added flexibility to value-based care partnerships by allowing payers to reimburse for benefits that address social or behavioral factors. At Brookdale, we look beyond the disease and treat the whole person — body, mind and spirit. That’s the guiding force behind our Optimum Life® program, an evidence-based and holistic approach to population health that’s based on six dimensions of wellness. This helps us manage our residents’ chronic conditions and helps residents maximize their health and well-being with a real emphasis on value and prevention.

We aim for residents to stay as healthy as they can, for as long as they can, and avoid moving to a higher level of care, such as a skilled nursing facility. Our ability to manage their conditions well also means that they’ll be able to enjoy more time at home with their friends and community at Brookdale, with the goal of fewer acute care episodes. Simply put, we’re aiming for a higher quality of life and better health. At Brookdale, we know that delivering effective healthcare to seniors means supporting them every day to help reduce the risk of serious illness. That’s why high-quality assisted living is essential to a value-based continuum of care.

Kim Elliott joined Brookdale in July 2014 and has served as our Senior Vice President and Chief Nursing Officer since August 2021. Elliott has more than 27 years of experience in senior living and has developed a care philosophy based on the importance of individualized care, personal choice and resident independence. Elliott received a BSN in nursing from the University of Kentucky and a master’s degree in nursing with a nursing executive specialty from Chamberlain University.

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