Finding (Re)Balance in Healthcare’s Changing landscape: Tilting Care Toward the Community

By Robyn Golden and Bonnie Ewald

In recent years, significant progress has been made in identifying and scaling best practices to support a population having increasing rates of chronic conditions and frailty. The widespread focus on care coordination and collaborations between healthcare and social services, fueled by Medicare and Medicaid finance reforms, is driving reductions in hospitalization rates in many target populations. The continuation—for now, at least—of the Affordable Care Act (ACA) presents a significant opportunity for continued progress in our shared national goal of strengthening communities and improving health outcomes.

Progress in Service Delivery Reform

While there remain many systemic barriers to delivery system reform and cross-sector collaboration, much progress has been made—as highlighted in several sessions at ASA’s 2017 Aging in America Conference. Community-based organizations (CBOs) are uniquely positioned to improve health systems’ ability to provide comprehensive and coordinated care to community-dwelling older adults. Critically, CBOs have expertise in helping individuals and families navigate systems and connect with resources to prevent functional decline that can come with aging and chronic conditions (e.g., Older Americans Act [OAA] services; Medicaid home- and community-based services waivers; other grant-funded programs).

The integration of supportive services into healthcare settings is essential for preventing the exacerbation of health conditions and, after a hospitalization, for enabling recovery. The Health and Aging department (RHA) at Rush University Medical Center in Chicago provides a number of services and programs that aim to integrate mental and physical healthcare, identify patient goals and treatment preferences, and help reach population health goals of increased primary care visits and reduced acute care use. While this department is within the larger academic medical center, RHA’s services mirror those provided by CBOs across the country; like many CBOs, RHA continually advocates for the value of its services to hospital leadership.

The Bridge Model of Transitional Care

RHA provides a number of interventions after a hospitalization, in primary and specialty outpatient care and in community-based settings. One is the Bridge Model of transitional care, in which a social worker works with Medicare beneficiaries, their families and appropriate health and social service providers to address both medical and non-medical barriers to well-being after a hospital stay. In addition to helping the hospital with its value-based purchasing scores and with reducing hospital readmissions, RHA’s Bridge team also is a key part of Rush’s bundled payment efforts and Transitional Care Management program to improve primary care follow-up rates after a hospitalization.

To do this work effectively, RHA works closely with several internal and external partners, meeting regularly with home health agencies, skilled nursing facilities and primary care clinics to identify shared goals, improve communication mechanisms and troubleshoot specific cases. RHA also works with the City of Chicago’s Department of Family and Support Services to connect individuals with critical OAA and Medicaid waiver services. However, coordinating care alone is not enough to promote health and well-being, so RHA offers nationally replicated evidence-based programs, support groups and other programming to help individuals better manage their chronic conditions, live safely in community and stay out of the hospital.

To make participation easier for patients and community members, RHA offers programming at Rush and in Chicago’s west and southwest communities. This would not be possible without CBO engagement across the city; in the past year, RHA has offered group programming at several churches, senior independent living communities, a homeless services organization and the City of Chicago’s senior centers.

Partnering for New Wellness Initiatives

In addition to providing such health promotions programming and connecting with OAA services, RHA is working with Rush leadership to pilot efforts to address housing, food and transportation insecurity among Rush patients and community members. To make it easier for individuals to get to medical appointments, RHA is piloting the use of Lyft’s ridesharing services through a mix of grant and Rush’s community benefit funding, and Rush is exploring grant opportunities to provide a prescription for fresh foods from the Greater Chicago Food Depository for individuals who identify as food insecure. Also, RHA is partnering with the Chicago-based Center for Housing and Health to provide housing and intensive case management to chronically homeless individuals who frequently visit Rush’s emergency department. While there is significant work to be done to create conditions that enable health and well-being in low-resource communities, these initiatives are an important start.

Throughout RHA’s history of developing programs to integrate social work and public health perspectives into healthcare, it has intentionally partnered with CBOs to foster the adoption of programs in their communities with their local hospitals and clinics. Aging Care Connections (ACC), an aging network service provider in suburban Cook County that been RHA’s long-standing partner, is a prime example of a CBO that has expanded on its core OAA and Medicaid waiver services to engage in care coordination initiatives with several hospitals, primary care clinics and skilled nursing facilities. ACC’s efforts to team with healthcare entities have been critical to their success in the changing healthcare and political landscape. Not only is a majority of Illinois’s Medicaid population being shifted to managed care (changing the workflow and demand for CBO services), but the state government is also in a budget stalemate that has led to severely delayed payments, causing dozens of CBOs to reduce services, lay off workers or shut their doors.

While CBOs like ACC and departments like RHA continually face challenges with sustaining their programs, new Medicare fee-for-service reimbursement opportunities indicate a promising route to sustaining this important work. Opportunities and resources from ASA, such as the Aging in America Conference and the Aging and Disability Business Institute, provide crucial platforms for sharing such insights and opportunities with others around the country who are similarly working to rebalance healthcare toward the community—no matter how much damage may be done to healthcare and safety net services over the coming years.

Robyn Golden is director, Health and Aging, at Rush University Medical Center in Chicago. Bonnie Ewald is project coordinator, Health and Aging. To learn more about the Bridge Model or any other initiatives mentioned above, contact Bonnie Ewald at

Editor’s Note: This article appears in the May/June, 2017, issue of Aging Today, ASA’s bi-monthly newspaper covering issues in aging research, practice and policy nationwide. ASA members receive Aging Today as a member benefit; non-members may purchase subscriptions at our online store.