TY - JOUR
AU - J. Drost
AU - S. Fosnight
AU - M. Hughes
AU - S. Hazelett
AU - B. Chrzanowski
AU - J. Marchiano
AU - M. Gareri
AU - D. Kropp
AU - K. Baughman
AU - M. Sanders
A1 - 
AB - Traditional medical care accounts for 10% of health outcomes, whereas SDOH account for over 60%. Optimal care of older adults with chronic illnesses requires integration of medical and social service providers. Such partnerships remain uncommon. The authors describe a successful health system/Area Agency on Aging (AAA) integrated team model that meets weekly to discuss challenging community-dwelling older adults and generate care recommendations back to the primary care providers. As part of a quality improvement project, outcomes measured over 6 months during 1 year show a statistically significant decline in the number of important threats to independent living related to the 4Ms (ie, lower fall risk, fewer high-risk medication issues, less behavioral health concerns, and less frequent health care utilization). AAA care managers expressed high satisfaction with the team process and indicated that it helped them address important issues. This model is easily replicated and modifiable to differing local needs. If replicable in rigorously designed research studies, these results would argue for changes in Medicare and Medicaid reimbursement policies to support this interagency integrated model of collaborative care.
AD - Summa Health, Akron, Ohio, USA.; Direction Home Akron Canton Area Agency on Aging and Disabilities, Uniontown, Ohio, USA.; Northeast Ohio Medical University, Rootstown, Ohio, USA.
AN - 41968720
BT - Popul Health Manag
C5 - Education & Workforce; Healthcare Disparities
CP - 4
DA - 08/2026
DO - 10.1177/19427891261437468
DP - NLM
ET - 20260412
IS - 4
JF - Popul Health Manag
LA - eng
N2 - Traditional medical care accounts for 10% of health outcomes, whereas SDOH account for over 60%. Optimal care of older adults with chronic illnesses requires integration of medical and social service providers. Such partnerships remain uncommon. The authors describe a successful health system/Area Agency on Aging (AAA) integrated team model that meets weekly to discuss challenging community-dwelling older adults and generate care recommendations back to the primary care providers. As part of a quality improvement project, outcomes measured over 6 months during 1 year show a statistically significant decline in the number of important threats to independent living related to the 4Ms (ie, lower fall risk, fewer high-risk medication issues, less behavioral health concerns, and less frequent health care utilization). AAA care managers expressed high satisfaction with the team process and indicated that it helped them address important issues. This model is easily replicated and modifiable to differing local needs. If replicable in rigorously designed research studies, these results would argue for changes in Medicare and Medicaid reimbursement policies to support this interagency integrated model of collaborative care.
PY - 2026
SN - 1942-7891
SP - 223
EP - 232+
ST - A Theoretically Grounded Chronic Illness Model Integrating Medical- and Community-Based Social Service Providers
T1 - A Theoretically Grounded Chronic Illness Model Integrating Medical- and Community-Based Social Service Providers
T2 - Popul Health Manag
TI - A Theoretically Grounded Chronic Illness Model Integrating Medical- and Community-Based Social Service Providers
U1 - Education & Workforce; Healthcare Disparities
U3 - 10.1177/19427891261437468
VL - 29
VO - 1942-7891
Y1 - 2026
ER -