Three papers on the role of care coordination and social support strategies in managing health outcomes for aging populations

As the U.S. population continues to age, healthcare systems face increasing challenges in meeting the needs of older adults while managing healthcare costs and reducing avoidable hospital use. This dissertation examines whether care coordination and social support strategies can improve health outcomes for older adults by focusing on three levels of intervention: community, organizational, and interpersonal.

The first study evaluates the implementation of the Accountable Health Communities (AHC) model in Colorado. The results suggest that local implementation context matters, as rural counties served by a managed care organization saw reductions in emergency department (ED) use, while urban counties served by an Area Agency on Aging did not. The second study uses a five-year simulation model to assess the Iowa Return to Community (IRTC) program, which supports older adults transitioning from institutional settings back to the community. The program was associated with significant cost savings and improved outcomes, particularly among individuals with informal caregivers. The third study analyzes national survey data to assess how different caregiving arrangements relate to hospitalization. It finds that individuals receiving support from both family and non-family caregivers had fewer hospitalizations, though results varied by cognitive status and racial or ethnic background.

Together, these studies provide evidence that effective support for older adults requires strategies tailored to individual needs and local context. When health and social systems work together, they can more effectively support older adults in aging safely in their communities while also reducing avoidable healthcare use and spending.