The Benefits and Challenges of Aging in Place

Laura N. Gitlin, MD, Professor and Dean of the College of Nursing and Health Professions, Drexel University, Philadelphia, PA and Eric Jutkowitz, PhD, Assistant Professor of Health Services, Policy and Practice, Brown University, Providence, RI, provided a deeper insight into the current challenges and policy issues older adults face that need to be addressed.

Older Adults Prefer to Age in Place
Surveys have shown that the majority of older adults would prefer to age in place, whether that means aging in their long-term residence or the community in which they have spent most of their lives. However, experts have been redefining what it means. Gitlin argues that instead of aging in place, the conversation needs to be shifted to older adults aging in the right place depending on their social, physical, cognitive, and financial needs. “For the majority, it means aging in a place that is familiar to them, where they have created a routine, possess historical knowledge, and carry nostalgic memories of past experiences,” Gitlin said. However, 2 major obstacles currently prevent older adults from comfortably aging in their communities—their poor physical environment and the lack of primary care coordination assistance. 

While many senior citizens are intelligent, assiduous, creative, and do not experience major cognitive impairments, their physical abilities are likely to decrease over time. In 2020, 40% of those aged 65 and older reported having trouble moving around,¹ and Gitlin points out that as they start experiencing mobility difficulties, such issues as going up and down stairs, lack of first-floor bathrooms, or having bathrooms that are too small to accommodate wheelchairs, can severely affect their independence to carry out their activities of daily living. In these instances, the housing itself becomes a huge barrier to aging in place. In fact, 1 out of every 5 falls among seniors cause a serious injury, resulting in more than 32,000 annual avoidable deaths and imposing more than $50 billion in medical costs for public and private healthcare programs.^2,3

Yet it is not just the physical challenge that poses a substantial financial burden for the healthcare system. Untimely and uncoordinated access to primary care visits also negatively affects payers, providers, and patients alike. For example, lack of transportation to and from a healthcare appointment and administrative assistance for those who live in the community can lead to increased need for acute care. In 2016, approximately 11%, (or nearly 2 million of all older adult emergency department visits were associated with ambulatory care-sensitive conditions. These are conditions that could have typically been managed in a primary care setting, thus, substantially lowering the overall costs of a care episode. In fact, the majority of admissions for ambulatory care-sensitive conditions were related to chronic conditions that could be controlled by primary care physicians if addressed in time.⁴ Similarly, minor and relatively inexpensive home improvements and modifications have the potential to significantly reduce risk of falls and subsequently provide significant savings to the healthcare system.

Two major obstacles currently prevent older adults from comfortably aging in their communities—their poor physical environment and the lack of primary care coordination assistance.

Disconnect Between Health and Social Services
Gitlin suggests that an elderly individual’s home and his/her living environment should be seen as part of the health profile. Over the past few decades, researchers have worked on demonstrating the benefits of various technologies and services, (eg, assisted living technologies and patient navigator programs) that would allow for the elderly to age in place and reduce emergency department visits and hospitalizations.⁵ Giltlin’s work has also shown that providing coordinated occupational therapy, nursing, and home repairs to low-income, disabled older adults can result in fewer falls, reduced difficulty to perform activities of daily living, and improved health-related quality of life.^6,7 She explains that the concept of the intervention was very patient-centric: an occupational therapist assessed a patient’s home environment to coordinate necessary home improvements. “We found that the benefit was huge, and that we were able to reduce mortality after just 6 visits. In other words, we were able to slow disability, if you will, and decrease health utilization,” she said.

Currently, traditional fee-for-service Medicare is very limited in the types of long-term care services that the program provides to its beneficiaries. Typically, these services do not extend beyond traditional healthcare. Consequently, when it comes to long-term care for adults who want to age in place, the majority of the social services costs that they encounter must be covered out of pocket. Jutkowitz points out that many people spend down their assets and eventually qualify for Medicaid, the largest payer of long-term care services. “But even in these instances, many individuals still have to organize and coordinate everything themselves, because there is no mechanism for coordinating social or long-term care services,” he explained. Gitlin points out that there are pockets of programs (eg, Program of All-Inclusive Care for the Elderly), but not all older adults will qualify or know about them, and not all medical and health professionals even know to refer their families. This lack of knowledge creates underutilization of programs such as Medicare Wellness and puts many older adults in a disadvantaged position. To improve utilization and access to these services, innovative approaches must be created that can incentivize primary care providers to change the way they evaluate their elderly patients’ health status.

Untimely and uncoordinated access to primary care visits also negatively affects payers, providers, and patients alike.

Primary Care Providers Should Be Incentivized
Both Gitlin and Jutkowitz admit that the current system is overly complicated and fragmented and is not helpful for the patients. Current financial disconnect often hinders further advancement of coordinated care. Developing, implementing, and maintaining a social services program requires continuous funding, but most of the time none of the savings encountered by the healthcare system are redistributed to these programs. “We have data showing that some of these community and social programs save money, reduce healthcare utilization, and decrease nursing home placement,” Gitlin explained. “But while these programs result in societal cost savings and in savings for the healthcare systems, they do not kick back to the programs themselves.” This budgetary and structural disconnect between the 2 systems leaves most social programs in great need for financial support. “Particularly during the COVID-19 pandemic, many of the community-based programs have really been struggling,” she added.

One way to introduce a shift in what providers view as primary care for the elderly is to incentivize changes in the reimbursement models. Alternative payment models and accountable care organizations can be viewed as good value-incentive program model examples. Created over the past decade, these models include a network of healthcare providers that work on delivering coordinated, timely, and high-quality care to the beneficiaries of public and private healthcare plans. Jutkowitz explains that, “these are programs where the healthcare system is responsible for the care and cost of that care for individuals or groups of people. There are set targets and the healthcare system receives a proportion of savings if their spending can be reduced below these targets. As a result, these providers are incentivized to reduce high-cost healthcare services, and as part of the process, they could invest in social care programs or other interventions that help prevent these costly events.” The benchmarks for these models are not only set to create incentives for healthcare spending reduction, but are also established for quality of care and measured outcomes, often accounting for geographic and social risk-factor variation. In January 2021, there were 477 accountable care organizations registered under Medicare Shared Savings Programs with 10.7 million beneficiaries. However, while these programs are a promising step in the right direction, currently they provide care to only about 20% of the overall 65 and older population in the United States, leaving millions of aging adults without adequate care.

Developing, implementing, and maintaining a social services program requires continuous funding, but most of the time none of the savings encountered by the healthcare system are redistributed to these programs.

 
Where Can HEOR Add Its Value?
Since many of the accountable care organizations, programs are still in their early stages, they are continuously being evaluated and improved. One of the major challenges that value incentive program models have encountered so far has been establishing a reliable, small subset of standardized measures that would create benchmarks for quality of care and overall program effectiveness. As a result, interventions and studies that directly measure impact of coordinated long-term care are needed. Jutkowitz emphasizes that the perspective from which an intervention measures its cost-effectiveness (or any other outcome metric) is extremely important. He explains that even when a program shows significant benefits from a societal perspective, if the stakeholders of the project do not receive the results relevant to their objectives, a widespread implementation and funding of such interventions will be a challenge. For example, if we look from the perspective of a provider or an accountable care organization, then reducing emergency department visits and hospitalizations as well as subsequent costs is the desired outcome. Programs that fail to show these exact results, even if they provide other considerable benefits, might not get the deserved support. Therefore, Jutkowitz points out, interventions that account for multiple perspectives are needed to synchronize social service support programs and the healthcare system.

About the Author:
Ilze Abersone, BS, MS, is a research consultant for Vital Statistics Consulting, Maplewood, NJ, USA

References:

1. Administration for Community Living. 2020 Profile of Older Americans. Published May 2021. Accessed June 2021. https://acl.gov/sites/default/files/Aging%20and%20Disability%20in%20America/2020ProfileOlderAmericans.Final.pdf.

2. Centers for Disease Control and Prevention. Keep on Your Feet—Preventing Older Adult Falls. Published December 2020. Accessed June 2021. https://www.cdc.gov/injury/features/older-adult-falls/index.html.

3. Florence SC, Bergen G, Atherly A, Burns E, Stevens J, Drake C. Medical costs of fatal and nonfatal falls in older adults. J Am Geriatr Soc. 2018;66(4):693-698.

4. Lesser A, Israni J, Lo AX, Ko KJ. Older adult visits to the emergency department for ambulatory care sensitive conditions. JACEP Open. 2020;1(5):824-828.

5. Graybill EM, McMeekin P, Wildman J. Can aging in place be cost effective? A systematic review. PLoS One. 2014;9(7):e102705.

6. Szanton SL, Thorpe RJ, Boyd C, et.al. Community aging in place, advancing better living for elders: a bio-behavioral-environmental intervention to improve function and health-related quality of life in disabled older adults. J Am Geriatr Soc. 2019;59(12):2314-2320.

7. Gitlin LN, Winter L, Dennis MP, Corcoran M, Schinfeld S, Hauck WW. A randomized trial of a multicomponent home intervention to reduce functional difficulties in older adults. J Am Geriatr Soc. 2006;54(5):809-816.