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According to the US Census, the number of people in the United States aged 65 and older will nearly double between 2012 and 2050. Today, 46 million Americans are over the age of 65, making up 13% of the total population. With 10,000 people turning 65 every day, there are unique challenges changing the health care environment. Proportionally, there will be more adults living in the oldest ages (age 85+), as well as a shift in the ethnic and racial composition, with an increase in the proportion of Hispanic and nonwhite older adults. Consequently, there is expected to be a 200% rise in the demand for health care services, with an estimated 70% of older adults likely needing long-term care at some point. This changing landscape presents an urgent opportunity to redesign health systems to meet the complex needs affecting patients, families, and society.


A. Individuals

Multimorbidity is common in older patients, with over half of older patients having three or more chronic diseases. Having multiple chronic conditions increases an individual’s risk of disability and health care utilization, which leads to a disproportionate amount of spending for caregiving and higher levels of care like hospitals or nursing homes. Older adults have a lot of heterogeneity in not only disease presentation, but also in risk of harm, prognosis, and care preferences. This heterogeneity includes a diverse range of functional, cognitive, and sensory abilities, including varying degrees of social support or isolation. Older adults may prefer health care in a more assessable setting (like home) or need increased streamlining and simplification of information, medications, or transitions. A health system designed to care for older adults must have the flexibility to account for and adjust to this multiplicity.

B. Health Systems

There are many evidence-based models of care for older adults (eg, Acute Care of the Elderly [ACE] and Program of All-Inclusive Care for the Elderly [PACE]). However, for various reasons, health systems have found it difficult to scale up these models. Therefore, only a small portion of older adults are cared for in this way.

Many health systems do participate in quality assurance tactics to reduce variation in clinical care and to ensure adherence to guidelines. However, given that older adults have more multimorbidity, medications, and unique challenges, as described earlier, it becomes harder to account for patient preferences and cumulative disease burden complexities as a system. Current strategies often promote small changes in cumulative reduction of relative risk of a disease, with less focus on the cumulative risk of harm, which may be more important for older patients.

Although there are some health systems with well-integrated system-wide approaches for care coordination, the majority of care that older adults receive is fragmented and burdensome. ...

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