Maximizing the Quality of Life for Seniors and Helping Them to Maintain as Much Independence as Possible
THE COMPREHENSIVE SENIOR ADVISOR
Older patients are the most expensive to treat, yet there is relatively little known about how to integrate the diverse elements of their care in ways that maximize benefits and minimize costs. Questions persist as to how to provide older patients with the appropriate mix of services as they age and whether more could be done to improve the management and delivery of their medical care.
We provide coordinated, comprehensive Care Plans for the growing population of Seniors that can be maintained and managed by non-geriatric specialists.
Growth of Aging Populations
Over the last fifty years the number of people over the age of sixty has tripled and is expected to triple again over the the next half century, resulting in a senior population of almost two billion people by 2050. Combined with the skyrocketing costs of healthcare, an increase in chronic diseases and demand for quality care and outcomes, coupled with shortages of trained healthcare personnel and facilities, a search for alternative ways to practice medicine where cost effective solutions can be delivered anytime, anywhere is critical.
New ways of delivering services, allowing patients to remain in their home or communities whlle still being attended to by a provider at a remote location and delivering a broad range of services including the monitoring of vital signs, clinician-patient e-visits and consultations, and patient education is an important development for the those who are often homebound or unable to secure transportation.. Data delivered can be used to .analyze the patient's status and trigger timely intervention by one or more healthcare professionals.
Comprehensive Geriatric Assessment
According to a recent survey by Quest Diagnostics, 40% of older Americans with chronic conditions reported that they do not tell their doctor about loneliness, transportation barriers to seeking care, and other factors that influence health, with many admitting that they "struggle to stay on top of my health issues and need more support." The Comprehensive Geriatric Assessment is a thoroughly researched process that has been used to manage frail and older people ensuring that the right healthcare gets practiced at the right time.
Comprehensive Geriatric Assessment
The CGA is a twenty-year old "interdisciplinary process with inputs from a Care Team consisting of not only multiple doctors and specialists, but also nurses and allied health professionals. It is multi-dimensional taking account not just of medical diagnoses but functional impairments and environmental and social issues which affect patient well-being. A comprehensive assessment involves looking not only at disease states as a standard medical assessment might do, but at a range of domains such as: comorbidities, nutrition, medications, medical device efficacy, cognition, anxiety, mobility, balance, housing, social networks, and poverty. It produces problem lists and develops goal-driven interventions to tackle these. CGA is not a one-off event, it is an iterative systematic approach to the the collection of patient data requiring multi-disciplinary ongoing communication between all members of the team. Ultimately, it provides and coordinates an integrated plan for treatment, rehabilitation, support and long-term care."
Clinical Nurse Specialist, Kimberly McClane, Screening Instruments for Use in a Complete Geriatric Assessment
Sounds Great! What's the Problem?
Most non-geriatricians are unaware of the existence of Comprehensive Geriatric Assessment (CGA). This is compounded by the fact that as of 2020 there were 7,000 geriatricians practicing in the United States, with only about 50% of them practicing full-time. The gap between need and supply is widening as it has been estimated that if one doctor can care for 700 patients with complicated needs, we will require 33,200 geriatricians by 2025 to provide for the wellbeing of seniors.
This shortage of geriatricians is exacerbated by the fact that the CGA, when it is used, is still largely a manual process. There is little, if any, data integration and minimal coordination at best. The absence of an automated, integrated, easy-to-use platform built on the principles of interoperability fails to leverage a process that when well-implemented has been proven to improve the wellbeing and independence of seniors.
Finally, when and if a Care Plan is developed, the fact that it is mostly a paper-based one makes access to and ongoing use of it by patients and caretakers extremely limited. Clearly a better solution is needed.
THE COMPREHENSIVE SENIORADVISOR
As a rule, a well-managed CGA program can help extend the quality of life, functionality, and independence of a growing senior population. Unfortunately, too few non-geriatric specialists are aware of this program. Although it is a well-defined process with proven results, it is a cumbersome, largely manual one that is difficult to implement and maintain. eHealthAnalytics addresses these issues with our highly automated, integrated Comprehensive Senior Advisor, a tool for both geriatricians, non-geriatric medical professionals, and patients that leverages voice data entry and natural language processing that can help deliver:
- Greater diagnostic accuracy
- Improved patient functional ability
- Improved patient cognitive ability and emotional wellbeing
- Reduced patient morbidity and mortality
- Fewer adverse drug and device events
- Decreased use of nursing homes and hospital readmissions
- Increased patient care satisfaction
- Lower costs
- Increased revenue for providers
The Comprehensive Senior Advisor (CSA) provides an accurate, integrated, dynamic, easy-to-use environment that fosters collaboration and will provide an interdisciplinary, holistic approach to the managment of the wellbeing of the vulnerable senior population by both geriatricians and and primary care physicians.
The CSA will leverage voice input of data wherever possible and electronic sources including EMRs, the CGA evaluation process, vital sign readings from remote patient monitoring devices and providers, and interactions with the patient through the telehealth/telemedicine provider.
Data will be generated that has been cleansed, integrated, and engineered for analytic use from a series of automated modules that produce a set of metrics and actionable insights that will be made available to all authorized Care Team members, patients and their caretakers.
Data output will cover all aspects of a patient's physical and mental well being, inform the development and delivery of a Care Plan, and provide input needed to use machine learning to predict the fact that intervention is needed before a condition becomes acute.
THE COMPREHENSIVE SENIORADVISOR COMPONENTS
The roots of Comprehensive Geriatric Assessment go back over seventy years to the core concepts suggested by Dr. Marjory Warren in the United Kingdom. They have changed little since and there is general agreement as to what should be included in an evaluation and ongoing monitoring. The Comprehensive SeniorAdvisor will address the following components.
This crucial component focuses on individual function and disease morbidity. Testing of varous aspects of physical health and wellbeing are included such as:
- Physical Examination
- Medical Devices via Remote Patient Monitoring
- Medication Review
- Medical Device Quality Review
- Nutrition Assessment
- Bone Health Assessment
- Pain Assessment
- Activities of Daily Living
- Instrumental Activities of Daily Living
An estimated 20% of patients sixty-five and older meet the criteria for some sort of mental disorder, a number that according to the Substance Abuse and Mental Health Services Administration (SAMHS) is expected to double, affecting fifteen million patients by 2030. Unaddressed, behavioral health challenges can lead to lower quality of life, isolation, worsening chronic conditions, and a risk of death through suicide or substance abuse. Given that over 20% of seniors have a mental health diagnosis, the prevalence of comorbidities and chronic medical conditions tends to lead to worse outcome and increased costs.(Ontrak, 2021, How to Address the Growing Behavioral Health Crisis Among Seniors)
This module will focus on various aspects of health and wellbeing and their associated metrics including:
- Identification of population at risk
- Differentiation between normal signs of aging and behavioral health problems
- Cognitive Decline
- Substance Abuse
About 28% of older adults (approximately 13.8 million people) live alone. Social loneliness and isolation are associated with numerous physical conditions including high blood pressure and depression. Socially involved individuals suffer less illness, overcome sickness more readily, and experience better health outcomes than persons who are more socially isolated. This module will focus on relationships within family, social groups, and the community. Various aspects of interpersonal relationships and social support along with their associated metrics will be addressed including:
- Living Arrangements
- Social Support
- Caretaker Stress
- Sexual Intimacy
This module focuses on personal and community safety, covering various aspects of safety and wellbeing and associated metrics including:
- Quality of Residence
- Neighborhoood Safety
The patient's ability to provide for daily needs and associated metrics include the ability to pay for:
- A functional residence
- Adequate food supplies
- Needed medications
- Access to personal transportation
This module covers various aspects of spirituality and their associated metrics, focusing on individual beliefs in God, a HIgher Being, and the comfort gained from these values, including:
- Sources of Hope
- Organized Religion
- Spiritual Activities
- Effects on end-of-life care
Proper care planning is crucial for ensuring that both seniors and their family caregivers get the care and support they need. The Comprehensive Senior Advisor will help develop a Care Plan based on an integrated, data-driven, patient-centric model that can be shared and monitored by the entire Care Team as well as the patient. This plan can be modified as needed based on any changes in the status of the patient.
The ability to demonstrate and calculate value for all of a health system’s patients from prevention to diagnosis and treatment of chronic diseases to improve the lifetime health and wellbeing of a specific population requires powerful advanced analytics that rely on the integration of disparate sources of data – especially ‘Real World Data’ – in massive amounts. Our intelligent data lake, containing access to highly curated, comprehensive, integrated data with respect to the physical condition, mental health, environment, treatment, and outcomes for millions of seniors will be available for our advanced analytics and for use by our clients on a subscription basis.
Data Analytics are critical to the success of geriatric assessment and management. At-risk patients must be identified, and services targeted to reduce their use of expensive and low-quality care, including prevention, maintenance, and long-term care. Our Advanced Analytics Module provides tools that support Comprehensive Geriatric Assessment and the development of an appropriate Care Plan for each patient. Additionally, our machine learning-based analytics enable the identification of the potential onset of new conditions or escalation in the severity of current medical and other related issues. All analytic output is made available for inclusion in the patient’s electronic medical record.
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