Our ability to effectively treat the growing number of individuals who live with multiple chronic diseases will remain compromised unless health systems explore innovative approaches.

The time constraints of the typical primary care practice often do not allow providers to take a comprehensive look at all of their patients’ needs. Enabling office staff to assist in this work, presents a tremendous opportunity to create patient-centered and comprehensive care plans.

Caroline Morgan Berchuck, MD, describes a promising new complex care hospitalist model that aims to address this fragmentation and support people with complex needs in realizing better health outcomes.

Dr. Neglia and The Holston Medical Group have established a unique program that cares for acutely ill patients in an ambulatory setting even though their illnesses would qualify for an inpatient hospitalization.

A new care delivery model of providing hospital-level services in the home (sometimes referred to as “home hospitalization” or “hospital at home”) has been launching with pilots at a number of health systems nationally.

Four key interventions are essential to create an age-friendly system of care. If care providers consistently do these four things for every older adult, every time, across care settings, we believe we will save lives and avoid harm.