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Supporting Aging Populations through Integrated Communities of Care

Integrating social and medical care is essential for meeting the health-related social needs (HRSNs) of older and vulnerable populations. By bringing together Primary Care First practices, Rural Health Clinics, and community-based organizations, we can ensure that older adults with complex care needs receive comprehensive, patient-centered support that transcends traditional medical services and fragmented social assistance.

The Need for Integrated Care

Older adults with multiple chronic conditions often experience poor health outcomes, leading to increased disability and avoidable deaths. A comprehensive approach that integrates both medical and social care is essential to mitigate these adverse outcomes. By developing a Community of Care (CoC), the goal is to stabilize the health of seniors with multiple chronic conditions, ensuring they receive the right care, in the right setting, at the right time.

CoC Value Expectations

The integration of social and medical care aims to achieve several key goals:

  • Stabilized Health for Seniors: Addressing the complex needs of seniors to significantly improve health outcomes.

  • Right Care, Right Setting, Right Time: Ensuring timely and appropriate care to reduce hospitalizations and ED visits while increasing primary care utilization.

  • Reduced Cost of Care: Effective integration leads to overall cost reduction in healthcare by decreasing hospital and ED visits.

  • Increased Caregiver and Social Support: Providing robust support systems for caregivers and connecting patients to essential community-based services.

  • Sustainability through Payment Models: Establishing sustainable payment models through executed contracts ensures the long-term viability of integrated care systems.

Aligned Objectives

Integrating social care into healthcare delivery aligns with several critical objectives:

  • Better Health Outcomes: Reducing ED and inpatient utilization by driving care to the right setting and increasing primary care utilization.

  • Improved Patient Experience: Enhancing patient experiences through comprehensive, patient-centered care plans.

  • Connectivity to Community Services: Ensuring patients have access to community-based resources that support their overall well-being.

  • Maintenance of Independence: Supporting seniors in living independently in their preferred settings.

  • Support for Caregivers: Providing essential resources and support for caregivers.

Addressing Social Determinants of Health (SDoH)

Three primary SDoH barriers for CoC patients include:

  1. Mental Health: Addressing mental health needs through integrated care models.

  2. Home Environment: Improving home environments to support health and independence.

  3. Food/Nutrition Education: Ensuring access to proper nutrition and education to support healthy living.


Integrating social and medical care within community-based organizations generates significant value for patients, caregivers, and care teams.

This model fosters a comprehensive understanding of patient goals and challenges, enhancing care plans and improving outcomes while reducing costs.


As we advance, continued integration and data sharing at the community level will be crucial in creating a supportive, efficient, and patient-centered healthcare system for older adults with complex needs. Investing in infrastructure at the AAA and community-based organization level to support service fulfillment and coordination is critical for the future.

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