CMOs, Are You Doing Enough for Older Adults with Complex Health Needs?

“Millennium will be able to see everything that happened in the hospital, and the connection between the two organizations will help coordinate follow-up visits,” Spencer says. “For example, a patient may need a follow-up visit with a Lee Health cardiologist a week after hospital discharge but also need a follow-up visit with a primary care physician sooner.”

The partnership will also coordinate care for older adults who were previously only served by one of the organizations.

“That creates practical mechanisms for seamless care transitions, workflows that connect patients to the resources of both organizations, and escalation pathways for high-risk seniors,” says Iahn Gonsenhauser, MD, MBA, CMO of Lee Health.

Improving preventive care is another priority for both organizations.

“We are going to have more robust efforts and access to services such as screening diagnostics, wellness visits, vaccination uptake, fall-risk assessment, and early detection programs for chronic diseases,” Gonsenhauser says.

Ensuring that older adults who are served by Lee Health and Millennium get annual wellness visits is essential to provide preventative care, according to Spencer.

“It is important to do an annual wellness exam that includes looking at the healthcare needs of patients and establishing care plans,” Spencer says. “These annual wellness visits are the time when we look at all preventive services such as vaccinations, conducting necessary lab work, and screening such as depression and dementia screening.”

Managing chronic conditions

The partnership features tools and infrastructure to help older adults in a broader patient population manage multiple chronic conditions.

“This includes home health services and hospital at home, which help maintain independence for seniors,” Gonsenhauser says. “Extending these kinds of services to older adult patients is going to give them tools to maintain their independence that they may not have had previously.”

For example, Lee Health has infrastructure in place to help older adults navigate polypharmacy and manage polypharmacy.

“A common reason for seniors running into trouble in managing chronic conditions or jeopardizing their independence is the number of medications they balance on a day-to-day basis,” Gonsenhauser says. “It is common for seniors to have more than a dozen medications that they take every day, and just adhering to their medication regimen is a challenge.”

To manage the care of older adults with multiple chronic conditions, the partnership includes data sharing and data analytics to identify patients who are at risk of deterioration and hospitalization, according to Spencer.

“For example, we will have a better ability to predict problems with heart disease, respiratory disease, diabetes, and hypertension,” Spencer says. “These are conditions that many of our seniors have, and we are going to be able to better predict the progression of these illnesses.”

Helping patients with complex health needs

One of the hardest aspects of serving older adults with complex health needs is getting them the right care, at the right place, at the right time. The partnership is designed to address these challenges and to simplify complex care.

Once older adults with complex health needs are identified with capabilities such as data analytics, the partnership is designed to meet those needs.

“This includes determining which clinicians at Lee Health and Millennium are best suited to treat a patient, coordinating care with specialists at Lee Health, and wraparound services such as end-of-life care, dementia care, and home-visit programs,” Spencer says.

Lee Health and Millennium leaders are determined to succeed in efforts to serve older adults with complex health needs and avoid the failures of other healthcare organizations, Spencer explains.

“Many organizations have tried to provide a range of services for seniors with complex health conditions, but you must provide services in a targeted and coordinated fashion with consistency,” Spencer says. “Unless you take that kind of approach, you can create confusion and fail to get patients what they need.”

The partnership is designed to reduce fragmentation in care for older adults with complex health needs, according to Gonsenhauser.

“In the past, Lee Health may not have known what Millennium was doing to provide immediate access to care in the ambulatory setting, or Millennium may not have known what Lee Health was doing in remote patient monitoring or hospital at home,” Gonsenhauser says. “Now, we are orienting the organizations as formal partners. We will be talking about our programs on a formal basis and functioning as one management team to offer services as a network.”