How Nurses Enable Health Plans to Support Members Aging in Place

June 27, 2022 - The United States population is aging, with an influx of Baby Boomers set to dramatically increase the population of individuals over age 65 by tens of millions. According to the Federal Interagency Forum on Aging-Related Statistics, this population is projected to increase the total population over 65 by nearly 18 million to 70 million by 2030, more than 20 percent of the US population.

An emerging trend among this aging population is the desire to remain in their homes for the long haul. A 2021 survey by AARP found that 77 percent of adults 50 and older plan to age in place. This is certain to create healthcare challenges, given that 90 percent of adults over 65 have one or more chronic conditions requiring higher levels of medical care and specialized treatments.

A lack of preparation

Responsible for managing utilization and costs for this population, health plans must ready themselves for a surge in demand for services and competition for a limited pool of providers to provide home healthcare.

But a sense of urgency is found wanting, with current planning efforts falling short of where they need to be in order for the healthcare system to serve consumers and meet them where they are.

“The keyword that is missing today is planning. Payers have the ability to significantly influence the evolution of home health, given their role in keeping members as healthy as possible for as long as possible and their ability to invest in the necessary capabilities,” Ed Motherway, President of CareScout, explains.

“The first is providing accessible quality healthcare for each of their members, which for an aging population means moving basic preventive care or interventionist activity out of facilities and into the home. Unfortunately, that’s not something that is prevalent today.”

Consumer frustrations around healthcare represent real problems for health plans serving an aging population. For healthcare consumers, accessibility is the end-all-be-all. That becomes especially important for individuals wishing to age in place for whom the difficulty of interacting with the healthcare system could easily lead to care gaps.

“I find navigating healthcare for my family to be difficult. However, that same level of difficulty as someone ages will push them to ignore preventative healthcare because of the time, energy, and resources needed to navigate it — that will have catastrophic results,” Motherway emphasizes.

“Payers have to focus on helping to make the healthcare system simple, easy, and effective. Generally, that means mimicking in-home clinical care models for fairly basic health education and clinical interaction.”

Another key factor for effective home healthcare is coordination. As health plans expand their offerings more widely, they need to utilize resources they cannot generate organically.

“The marketplace is demanding evolution much faster than organizations can adjust,” Motherway observes. “They have to cobble together services leveraging any number of partnerships to be effective.”

The inability to integrate disparate resources into a streamlined experience will likely lead to consumer dissatisfaction and poor utilization.

“A consumer experiencing uncoordinated care will develop less tolerance for seeking care as time goes on. Proper coordination of care ensures effective outcomes and experiences, both are key to loyalty and therefore retention,” says Motherway.

Scaling home healthcare

Facing increasing demand but lacking the resources to support aging in place, health plans are looking to strategic partnerships to establish, optimize, and scale their home health offerings leveraging the latter’s fulfillment capabilities.

Partners with large networks of registered nurses can provide the means necessary to support high-quality care programs in the member’s home. But health plans must think carefully about their choice of partner, paying particular attention to its history and track record.

“Payers will want to consider how long their partner has been in business and its efforts to perfect their fulfillment capabilities,” Motherway explains. “The right partner is able to bolt on to the health plan, taking, fulfilling, and billing for activities supporting the care model. It’s that simple.”

“It’s very attractive to organizations that are forced to grow and implement these home health programs rapidly but lack the design and organic capability to execute in the timeframes that are required. External resources solve a piece of that puzzle — not all the pieces but a key piece of the puzzle when it comes to registered nurse resources for payer programs.”

For major players actively competing in the Medicare space and working to enhance their care management capabilities, access to additional provider resources allows health plans to be more flexible and shift resources where they are most needed.

“Even if they are providing care management for Medicare patients today and are seasoned at it, the acceleration of demand requires good clinical managers to develop other levers to accommodate for that growth,” Motherway advises. “Because at the end of the day, a health plan relying on one solution such as an organic set of nurses can experience staffing challenges, but the expectation for care remains the same. A solution offering variable capacity allows the plan to respond quickly to excess stress on its resources — the RNs — and maintain its promise to members.”

What’s more, nursing staff delivering home healthcare can also bring to bear a wide array of specializations that can meet the unique health needs of members, which is of increased importance — from those with chronic conditions to those health characteristics of older patient populations.

“Chronic care management firms are supporting health plans. There are provider requirements for post-acute care, and all of those are different dimensions for RNs to participate in. There is a real opportunity for health plans to work with a strategic partner to optimize their in-home models to meet the evolving and changing needs of members,” Motherway concludes.

For payers to their members where they are, they must rethink how they staff, organize, and deploy their care management resources. Those better able to meet the expectations of members are the ones most likely to outpace their competition and increase enrollment.  

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About CareScout

A trusted leader with more than 20 years of experience, CareScout performs objective, accurate, and timely clinical assessments to help payers make informed decisions. CareScout’s nationwide network of 35,000+ registered nurses and licensed social workers can easily and seamlessly supplement your existing clinical assessment services.

Learn more about CareScout here.