A Theoretically Grounded Chronic Illness Model Integrating Medical- and Community-Based Social Service Providers

Traditional medical care accounts for 10% of health outcomes, whereas SDOH account for over 60%. Optimal care of older adults with chronic illnesses requires integration of medical and social service providers. Such partnerships remain uncommon. The authors describe a successful health system/Area Agency on Aging (AAA) integrated team model that meets weekly to discuss challenging community-dwelling older adults and generate care recommendations back to the primary care providers. As part of a quality improvement project, outcomes measured over 6 months during 1 year show a statistically significant decline in the number of important threats to independent living related to the 4Ms (ie, lower fall risk, fewer high-risk medication issues, less behavioral health concerns, and less frequent health care utilization). AAA care managers expressed high satisfaction with the team process and indicated that it helped them address important issues. This model is easily replicated and modifiable to differing local needs. If replicable in rigorously designed research studies, these results would argue for changes in Medicare and Medicaid reimbursement policies to support this interagency integrated model of collaborative care.