Conversations about the changing health care system in America tend to focus on tools and obstacles: technology, tele-health, universal insurance, finances, politics, medicine and advanced specialized education for nurses and home health aides, but hidden behind all the noise is a serious effort to design “real life” health care models that deliver on some “real people” needs. Key among these needs are safety, independence, aging at home and less time in emergency rooms and hospitals.

There are currently about 50 million Americans over age 65 on Medicare, and two-thirds of these individuals are dealing with multiple chronic medical conditions. The physical and financial well-being of our nation rests on our ability to find new ways to help this population “age in place” in a safe and healthy fashion.

Interestingly, the most successful innovations in this regard involve taking a fresh look at the delivery of basic healthcare services, including new approaches to managed care and other health plans that are based on one of the traditional cornerstones of good health: community based, patient-centered care. By doing a better job of coordinating the various elements of an elderly person’s care — access to their doctors; home care services provided by visiting nurses, therapists and home health aides; the support of family caregivers and social workers; and the self-care practiced by patients themselves — we are finding that even the sickest elderly patients can be stabilized at home to a remarkable degree.

Seventy-two-year-old Mrs. Green is a perfect example of this. Diagnosed with congestive heart failure–the leading cause of hospitalization in the U.S., and a major cause of unplanned readmissions among older Americans — she found herself caught in a cycle of weight gain and fatigue that resulted in repeated emergency admissions to her Brooklyn, NY hospital. She was a statistic–the kind of “frequent flyer,” as the medical community terms it, who drives up health care costs dramatically without ever improving her underlying condition.

Today, although Mrs. Green still has congestive heart failure (along with arthritis and mild dementia), she hasn’t made a trip to the hospital in years. That’s because she now has a care coordinator, supplied by her managed long term care health plan, who helped her transition from the hospital to home and has been on a mission to keep her there ever since. Her care coordinator checks in on a regular basis to monitor Mrs. Green’s symptoms closely, make sure that she takes her medications faithfully, and connects her promptly with her doctor if her symptoms show any signs of worsening. She has also helped educate Mrs. Green and her family about how to care for her condition.

Up in Harlem, diabetes had its grasp on Catherine, who also suffered from severe hearing loss and edema. With blood sugar levels regularly spiking above 300 into the danger zone, Catherine preferred to think she was a victim of faulty blood sugar monitors rather than an aging woman with chronic and speedily worsening diabetes. When the nurse care manager and home health aide, who were part of Catherine’s interdisciplinary care coordination team, presented her with undeniable evidence displayed on a working blood sugar monitor–three days in a row — she finally relented and the team was able to sit down and talk about how to get Catherine back on track, and keep her there.

The persistent inquiry and patient engagement that Catherine’s nurse care manager and home health aide (who was trained as a health coach) focused on their patient is more the norm than the exception in many populations. Stubbornness is a common defense for many diabetes patients who can’t bear the thought of giving up a favorite sweet drink or pastry. But Catherine’s care team knew to move slowly and work to earn her trust. They charted progress with monitoring technology and made helpful signs, posters and notes to help Catherine remember the effect that those blood sugar spikes had on her eyes, her feet and her kidneys.

Eventually — one step at a time — Catherine warmed to the realization that some bread, a small apple and a bit of cheese could actually be enjoyable, and made for much healthier snacking options. Even when she occasionally goes off course and has a bite or three of one of her favorite cinnamon buns, she knows she can get back on track again quickly. Today, Catherine’s blood sugar levels fall consistently in the “safe zone.” She’s proud of her progress and eager to tell her neighbors and friends how they can “beat the sugar spikes” too.

Success stories like that of Catherine and Mrs. Green demonstrate how personalized, proactive care plans can help keep even chronically ill patients healthier and happier. A patient-centered approach isn’t new to health care–but the growing use of technology, regular medical reassessments and sophisticated care coordination by managed care plans like VNSNY CHOICE, which is a part of the not-for-profit Visiting Nurse Service of New York, have raised the concept of patient-centric care to a new level.

Nurses and care coordinators now utilize laptops and state-of-the-art software to maintain accurate health records, communicate with other medical systems, and educate patients about necessary lifestyle changes. At the same time, changes in care management approaches are leading hospitals to team much more closely with community health providers to track the progress of patients and connect them swiftly with a doctor as needed.

Health plans and care providers are also employing tele-health technology, in which a patient’s daily weight or blood glucose measurements are sent directly to a central computer that can raise an alarm automatically. This kind of continuity of care in turn helps medical teams proactively manage at-risk patients with chronic conditions such as diabetes, high blood pressure and congestive heart failure. Used consistently, such personalized care innovations can keep an emerging symptom from becoming a serious or potentially life-threatening situation.

As we continue to address unmet needs in this area of the healthcare landscape through thoughtful advances in personalized care, it’s my belief that we’ll see an increasingly positive impact on the daily lives of America’s seniors. The business community appears to agree with this assessment. In mid-September, for example, Google/Alphabet announced they are making a major investment in Oscar, an insurance plan startup that combines technology and a patient-centered approach to shape affordable health care options. While the challenges of healthy aging are great, the promise is even greater–for in this age of innovation, the only limit is our own imagination.

Note: Patients’ names have been changed for privacy

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