GENERATIONS – Journal of the American Society on Aging

receives a prescription for medication, the sen- sor would note that the person may be less likely to adhere to their medication schedule. Then provider(s) can be informed of this in real time. The sensor may encompass multiple data col- lection methods, such as specific fields in the electronic health record and-or specific informa- tion from administrative and claims databases. It is important that the sensor can collect data on social determinants of health, as well as infor- mation related to a person’s physical and cogni- tive functioning. Additionally, the sensor should collect healthcare use and cost data as a way to track care and provide feedback regarding the model’s effectiveness. As mentioned, in addition to collecting these data, the sensor would identify when certain combinations of values indicate that a popula- tion member has experienced a significant event or has an increased risk for an adverse outcome. Although the data need to be accessible to pro- viders and those coordinating care, it is crucial that the data also are secure and confidential. Finally, the data require a specialty unit of qualified individuals to oversee the entire accountable healthcare system and provide a centralized mechanism to coordinate care, which we refer to as the Mission Care Coor- dination Center, or MC3. This specialty unit of individuals involved in running the MC3 includes an interdisciplinary team involving, at a minimum, a nurse, a social worker, an ana- lyst, and a healthcare administrator to carry out necessary tasks. The MC3 dynamically cat- egorizes and triages the biopsychosocial needs of the population and optimally dispatches the diverse workforce accordingly, while provid- ing timely feedback to that workforce at both the individual case management and population levels. The MC3 is supported by patient-, clini- cian-, and dual-facing technologies that collect and visualize information and support better decision-making. The MC3 model reflects recommendations made by the American College of Physicians to

routinely screen for and respond to social deter- minants of health, and account for complexity and variation in how social determinants link to outcomes in different conditions (Daniel, Born- stein, and Kane, 2018). The advanced track of the Accountable Health Communities model includes a “back- bone” organization to “facilitate data collec- The team-based approach involves providers and community partners outside the healthcare system. tion and sharing among all partners to enhance service capacity” (Alley et al., 2016). As speci- fied in the Accountable Health Communities model, the organization would operate indepen- dently from the accountable health community and may not have the ability to determine where the resources are needed the most, or have the authority to get them to the right people, at the right time. The MC3, in contrast, is an integrated, cen- tralized unit. We believe such a centralized method of care coordination is not only more efficient, but also leads to greater equity within populations, as well as more support for the healthcare providers who care for the most socially complex individuals. How the Model Functions To provide an example of how these four pro- posed elements of a population health model function in practice, consider the fictional case of Mr. Smith, a 72-year-old man who lives with his wife. Mr. Smith presents to the emergency department with a chronic obstructive pulmo- nary disease (COPD) exacerbation after running out of his scheduled inhalers. He is known to the SECBCI and the larger accountable health com- munity through previous encounters. In addition to cognitive impairment, his past medical his- tory includes Type 2 diabetes, with retinopathy and major depressive disorder.

70 | Spring 2019

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