GENERATIONS – Journal of the American Society on Aging

Effective care transitions are key to achieving health systems’ population health management approaches. sitions Program (CCTP), which provided a framework for CBOs to partner with hospitals in addressing the needs of high-risk Medicare patients. An evaluation of CCTP concluded that most successful care transitions programs effec- tively linked patients with community-based services (Econometrica, Inc., and Mathematica Policy Research, 2017). While care transition partnerships have con- nected acute- and post-acute-care settings with CBOs, the lack of sufficient malnutrition iden- tification and treatment across care settings means that patients may be at an increased risk for developing chronic health conditions and frailty, and be more susceptible to falls and loss of independence (Agarwal et al., 2010). System- atically screening for and addressing the social determinants of health for malnutrition across the care continuum, as standard practice in care transition programs, could lessen adverse health outcomes. hospital readmissions, but also to implementing health systems’ population health management approaches, including risk-based care contracts, Accountable Care Organizations, and bundled payment models. As incentives drive care out of acute care settings, healthcare providers are partnering with CBOs to transition older adults from acute- and post-acute-care settings to home. Across the country, CBOs are using evidence-based care transition models, such as the Care Transitions Intervention and the Tran- sitional Care Model, to support those who are at risk for otherwise avoidable readmissions. Many of these care transitions programs originated in the Community-based Care Tran- Partnerships and screening, educating across the care continuum

Another important focus in the current healthcare environment is on both disease pre- vention and health promotion. As noted by the Administration for Community Living, evidence- based disease prevention and health promotion programs have been shown to reduce the need for costly medical interventions and are associ- ated with older adults’ improved health. Because of this, risk-bearing healthcare organizations are increasingly looking to partner with CBOs to deliver these programs to improve patient care and to lower costs. The National Council on Aging’s National Falls Prevention Resource Center reports that one in four older adults falls every year, and that falls are the leading cause of fatal and non-fatal injuries among elders. Loss of muscle mass and dizziness from malnutrition can increase older adults’ risk of falling. Evidence-based fall pre- vention programs, such as A Matter of Balance, can reduce fall risk, promote physical activ- ity, and improve fall self-management (Haynes, League, and Neault, 2015). Delivering education about malnutrition to older adult participants in fall prevention pro- grams and incorporating malnutrition screening into workshop programming could be effective for increasing awareness about malnutrition and advancing comprehensive malnutrition care in the community. Embedding malnutrition- specific modules into existing programs could also provide an opportunity to partner with healthcare organizations that are employing population health strategies to improve health outcomes and reduce costly medical care. There is a similar opportunity to embed mal- nutrition care components into existing chronic disease self-management programs, particularly given that an estimated 95 percent of health- care costs for older Americans can be attrib- uted to chronic diseases (Centers for Disease Control and Prevention, 2013). Chronic disease self-management programs encourage older adults with chronic conditions to better manage their conditions. For example, the Chronic Dis-

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