Transforming Healthcare to Improve the Health and Well-Being of Older Americans

As we round out Older Americans Month, it is crucial that we continue to recognize the significant contributions of older adults and the urgent need to transform and improve their healthcare. Our current system is ill-equipped to meet the complex needs of older adults, who often contend with multiple chronic conditions. This inadequacy leads to fragmented and sub-optimal care, resulting in poor health outcomes, avoidable adverse events, hospitalizations, institutionalization, and increased costs. 

To meet these challenges, AHRQ remains committed to using its research capabilities to build the evidence base and identify solutions ready for action. To do so, the agency has released a Special Emphasis Notice to announce its strong interest in funding health services research to improve care quality for older adults.  Research proposals for enhancing service access, delivery, organization, and equitable distribution are welcome. In particular, AHRQ seeks research to address critical questions related to the development, implementation, evaluation, and scalability of person-centered models of care to optimize older adults’ physical and mental health, functional status, and overall well-being. 

AHRQ recognizes that improving care for older adults is also a health equity issue as minoritized, low-income, and socioeconomically disadvantaged individuals and communities have a higher burden of illness, less access to care, and inadequate resources and supports. The health inequities they experience in care delivery have been well documented.  AHRQ seeks to fund research that will show how to deliver equitable care. Research is also required to strengthen and increase the capacity of primary care to deliver high-quality team-based care for this rapidly growing population.

AHRQ’s recent Special Emphasis Notice builds on the agency’s longstanding commitment to supporting health services research in older adults, especially those with multiple chronic conditions and those from socially disadvantaged communities.

For example, the AHRQ Research Summit on Transforming Care for Persons Living with Multiple Chronic Conditions in 2020 brought together patients and their caregivers with experts in research, clinical care, policymaking, and funding partners to identify research gaps and opportunities, informing AHRQ’s multiple chronic conditions research agenda. Building upon these insights, AHRQ hosted a 2023 Stakeholder Roundtable on Optimizing Health and Function as We Age (PDF, 1.7 MB) with attendees representing diverse community backgrounds and expertise, to help identify promising approaches for health system transformation to improve care.

Older adults benefit from having comprehensive, longitudinal, shared, person-centered care plans that are accessible and used by the whole care team to coordinate care and align it with a person’s goals. AHRQ and the National Institute of Diabetes and Digestive and Kidney Diseases are partners in developing an interoperable e-care plan as a tool to facilitate data sharing and care planning. Clinician-facing and patient/caregiver-facing SMART on FIHR applications aggregate data across multiple electronic health records, including information about health-related social needs, functional status, patient-reported outcomes, and goals. AHRQ has recently launched the Person-Centered Care Planning for Persons with Multiple Chronic Conditions initiative to increase the uptake of and to scale and spread care planning as a component of routine clinical practice.

On May 30, the Department of Health and Human Services released to Congress, “Aging in the United States: A Strategic Framework for a National Plan on Aging,” a report by experts from 16 federal agencies and departments, including AHRQ, who are working together through the Interagency Coordinating Committee on Healthy Aging and Age-Friendly Communities. It is the initial step in developing a national plan to improve the aging experience for older adults and to create age-friendly communities that appreciate their contributions, sustain health and wellbeing at all ages, recognize and support family caregivers, and value and reward the work of the professionals who provide in-home and community-based care. 

AHRQ’s unique federal mission to improve healthcare contributes to achieving this goal.

Addressing the complex medical, behavioral, and social needs of older adults requires coordinated efforts from multiple sectors, including patients, families/caregivers, communities, clinicians, practices, healthcare systems, states, and federal partners. The sustainability of Medicare and Medicaid depends on doing this effectively. 

AHRQ aims to support research, implement evidence, and provide tools and training to transform healthcare for older adults while creating system-level changes that promote health equity. AHRQ is committed to optimizing health, functional status, and well-being for individuals and communities as they age—not just during Older Americans Month, but throughout the year and beyond.

Dr. Bierman is AHRQ’s chief strategy officer. Dr. Dotson is a Federation of American Scientists Health System transformation and active aging impact fellow at AHRQ. Dr. Azar is an advanced fellow in geriatrics at the U.S. Department of Veterans Affairs on detail at AHRQ. Dr. Valdez is AHRQ’s director.

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