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Care Management White Papers

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As a leader in complex chronic care, SeniorBridge is proud to publish resources for professionals serving older adults developed by our executive leadership team in collaboration with our Professional Advisory Board and  other nationally recognized chronic care and geriatric experts. 

Here you will find our latest white papers.

Best Practices in Managing  Complex Chronic Care  at Home 

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Given that 1 in 5 Americans over the  age of 50 and nearly 70% over the age of 65 will need long-term care (LTC), it is not surprising that eldercare became a top agenda item for federal and state governments, as  well as for individuals, eldercare providers, and employers. Furthermore, the 65 and older population is expected to more  than double between 2010 and 2050, and the number of 85-year-olds is projected to grow five-fold. 

This paper focuses on best practice standards for managing fee for service complex chronic care in  the private sector and provides a brief discussion of LTC trends at the federal  and state level. The 2010 "Patient Protection and Affordable Care Act" includes a provision that allows individuals to purchase  Long Term Care insurance by voluntarily contributing to Medicare. 

This paper explores the following:

  • What is managing complex chronic care?
  • How can we best manage complex chronic care needs at home?
  • Managing a patient’s and family’s ambivalence to care
  • Coordinating care among multiple providers
  • Recognizing the unique clinical needs of this population
  • Providing optimal clinical care
  • Supervising paraprofessional caregivers
  • Recognizing the importance of complex ethical issues
  • Industry recommendations
  • Critical advice for consumers and referral sources when choosing a provider or making a referral


Navigating Caregiving in Uncharted Waters 

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Meeting on the heels of the passage of historic health care reform legislation, SeniorBridge convened a symposium to explore how demographic and socio-economic changes are influencing  the caregiving processes for families.

At the event, Jason Karlawish, MD, of the Institute on Aging at the University of Pennsylvania and a member of the SeniorBridge Professional Advisory Board,  discussed results of a SeniorBridge commissioned survey of 4,400 people who identified themselves as a caregiver about who they were, what they did, and how they felt about caregiving.  While reinforcing previous knowledge, the findings provided a stimulus for symposium discussion at the symposium and served as a bridge to the real-world experiences shared by our guest panelists and audience participants.

This symposium  also drew on the expertise of  other members of the SeniorBridge Professional Advisory Board, the contributions of physicians, nurses, social workers, academic elder care professionals, and the perspectives of three guest panelists who had each authored books about their own caregiving experiences. The anticipated goal of this symposium was to develop this White Paper that would serve as a practical resource to support family caregivers, professionals, healthcare institutions, and community-based services.

A Professional Guide to Managing Complex Chronic Care  in the Community

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Are physicians, particularly primary care physicians (PCPs),  adequately prepared to address the complex care needs of our  aging population? What do they need to know? In our fragmented, acute care-oriented system of healthcare  delivery, those with complex chronic care needs and the frail  elderly can suffer in several ways. People with 5 or more chronic  conditions see an average of 14 different physicians and use an  average of 50 prescriptions per year. While these specialists may  provide excellent care individually, when a patient is seen by  multiple specialists, the chance of a medical error increases  because there is often no integrated plan of care. The patient  leaves the primary care doctor’s office with one plan and then receives a different plan from a specialist he or she is seeing for  a different health problem. Communication among the  physicians is rare.

The goal of this Professional Guide is to help healthcare  professionals in primary care outpatient settings meet the needs of patients requiring complex chronic care — a challenge for even  the most experienced clinicians. We hope these guidelines will serve as a refresher, contribute a few new ideas, and provide a  convenient compendium of some frequently used assessment instruments. Additionally, we hope this guide will lead to greater  awareness of the issues and better patient outcomes and help make working with the frail elderly a more rewarding experience.

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SeniorBridge is a private pay offering of Humana At Home.