Innovative Care Models in Elderly Healthcare: Operational Frameworks, Funding Mechanisms, Regulatory Challenges, and Policy Implications

Abstract

The accelerating demographic shift towards a globally aging population presents an imperative for radical transformation within healthcare systems. Traditional models frequently prove inadequate in addressing the intricate and multifaceted needs of older adults, often resulting in suboptimal health outcomes, diminished quality of life, and unsustainable healthcare expenditure. This comprehensive research report undertakes a meticulous examination of five pioneering care models that are fundamentally reshaping the landscape of elder care: The Green House Project, Senior Emergency Departments (SEDs), Programs of All-Inclusive Care for the Elderly (PACE), Hospital at Home (HaH), and Age-Friendly Health Systems (AFHS). For each model, the report delves deeply into its philosophical underpinnings, intricate operational frameworks, diverse funding mechanisms, persistent regulatory challenges, potential for widespread scalability, and crucial policy implications. Through a rigorous comparative analysis, this study scrutinizes their demonstrated effectiveness in improving patient outcomes, assesses their long-term financial and operational sustainability, and evaluates their potential for seamless integration into mainstream healthcare delivery. The objective is to provide an exhaustive and evidence-informed resource for policymakers, healthcare providers, and stakeholders committed to fostering more humane, efficient, and equitable care for older adults.

Many thanks to our sponsor Esdebe who helped us prepare this research report.

1. Introduction

The 21st century is characterized by an unprecedented demographic phenomenon: the rapid and sustained increase in the global population of older adults. Projections indicate that by 2050, the number of people aged 60 years or over will more than double, reaching 2.1 billion, with the cohort aged 80 years or older tripling to 426 million (World Health Organization). This profound demographic shift, often termed the ‘silver tsunami,’ places immense and often unmanageable strain on conventional healthcare paradigms, which were largely designed for acute care interventions in younger populations. Traditional models frequently adopt a fragmented, disease-centric approach, failing to account for the common complexities inherent in older age, such as multimorbidity, polypharmacy, cognitive impairment, functional decline, and unique psychosocial needs. This fragmentation often leads to care gaps, duplicated services, increased risk of iatrogenic harm, and an over-reliance on costly institutionalization, ultimately compromising both patient well-being and systemic efficiency.

Recognizing these critical limitations, a new generation of innovative care models has emerged, each seeking to redefine elder care by prioritizing person-centeredness, integrated service delivery, community engagement, and a focus on maintaining functional independence and quality of life. These models represent a paradigm shift from ‘sick care’ to ‘health care,’ with a strong emphasis on prevention, proactive management, and holistic support. This report undertakes an in-depth exploration of five such transformative models: The Green House Project, which revolutionizes long-term residential care; Senior Emergency Departments (SEDs), specializing in acute geriatric care; Programs of All-Inclusive Care for the Elderly (PACE), offering comprehensive community-based services; Hospital at Home (HaH), bringing acute hospital-level care to the patient’s residence; and Age-Friendly Health Systems (AFHS), a systemic approach to embedding geriatric best practices across all care settings. By meticulously dissecting their operational architectures, financial sustainability strategies, regulatory landscapes, potential for widespread adoption, and policy implications, this report aims to furnish stakeholders with critical insights into the viability, impact, and pathways for integrating these promising innovations into a resilient and responsive future healthcare ecosystem for older adults.

Many thanks to our sponsor Esdebe who helped us prepare this research report.

2. The Green House Project

2.1 Operational Framework

The Green House Project represents a revolutionary departure from the traditional, institutionalized model of nursing home care, seeking to reclaim dignity, autonomy, and a sense of home for older adults requiring long-term care. Conceived by Dr. Bill Thomas, the model champions small, self-contained residential homes, each deliberately designed to house a limited number of residents, typically 10 to 12. This intimate scale is foundational to its philosophy, fostering a close-knit, family-like community environment that is starkly contrasted with the often impersonal and institutional ambiance of conventional nursing facilities.

Architecturally, each Green House home is meticulously designed to mimic a typical dwelling, complete with private bedrooms and bathrooms for every resident, a central open kitchen, and warm, inviting communal living and dining areas. The absence of long, sterile hallways, nurses’ stations, and strict visiting hours cultivates an atmosphere of normalcy and comfort. Residents are encouraged to participate in daily life, from helping prepare meals in the open kitchen to engaging in social activities in the communal spaces, thereby promoting a sense of purpose and belonging. The design intentionally blurs the lines between living space and care setting, creating an environment that feels like a true home rather than a medical facility.

Care delivery within the Green House model is highly person-centered and team-based. A consistent team of caregivers, known as ‘Shahbazim’ (a Persian word meaning ‘royal falcon,’ symbolizing highly trained and flexible caregivers), is assigned to each house. These Shahbazim are cross-trained to perform a wide array of tasks, encompassing personal care, meal preparation, housekeeping, and social engagement. This multi-skilled approach not only empowers caregivers but also ensures continuity of care, allowing for deeper, more meaningful relationships to develop between residents and their caregivers. This consistency builds trust and enables caregivers to become intimately familiar with each resident’s individual preferences, routines, and evolving needs, leading to truly personalized care plans. Clinical oversight is provided by a ‘Guide,’ typically a registered nurse, who supports multiple houses and handles more complex clinical tasks, ensuring residents receive necessary medical attention while maintaining the homelike environment. The model emphasizes shared decision-making, where residents, families, and staff collaborate to tailor care and daily activities, maximizing resident choice and control over their lives.

2.2 Funding Mechanisms

Establishing a Green House home involves navigating a complex financial landscape, often requiring substantial initial capital investment followed by ongoing operational funding. The startup capital costs for construction or extensive renovation are indeed significant, frequently exceeding $1.5 million per home, exclusive of land costs, with some projects reaching $2-3 million depending on location, design, and land acquisition. These initial outlays often necessitate a multi-pronged financing approach, combining private equity, philanthropic donations, capital campaigns, and sometimes state or federal grants designed to promote innovative elder care models. Investment from impact investors and community development financial institutions (CDFIs) has also played a role in some projects.

Operational funding for Green House homes, once established, typically mirrors the revenue streams of traditional nursing homes, albeit with some distinct considerations. A significant portion of revenue often derives from private-pay residents, who bear the full cost of care. For residents with lower incomes, Medicaid reimbursement is a crucial component. However, the adequacy of Medicaid rates remains a pervasive challenge. Studies and advocacy groups consistently point out that low Medicaid reimbursement rates often fail to fully cover the actual costs of providing the high-quality, person-centered care that defines the Green House model. This disparity can strain the financial viability of Green House homes, especially those with a high proportion of Medicaid-eligible residents. Some Green House providers have successfully integrated with Medicare Advantage plans, which can offer more flexible payment structures and incentivize care coordination, potentially providing a more robust revenue stream.

Despite the significant upfront capital investment, research suggests that the operational costs of Green House homes can be comparable to, or even more efficient than, those of traditional nursing homes over the long term. A key factor in this efficiency is often higher staff retention rates, which reduce recruitment and training costs. Furthermore, improved resident outcomes, such as fewer hospitalizations and emergency department visits, can translate into indirect cost savings for the broader healthcare system, though these are not always directly captured by the Green House provider. (thegreenhouseproject.org) Ongoing advocacy efforts focus on demonstrating these long-term system-wide savings to justify more favorable reimbursement structures and policy support.

2.3 Regulatory Challenges

The innovative nature of The Green House Project often places it at odds with existing regulatory frameworks designed for larger, more traditional institutional settings. State licensure processes for long-term care facilities are a primary hurdle. Regulations are frequently prescriptive, dictating specific building codes, staffing ratios, and facility layouts that may not easily accommodate the small, homelike Green House design. For example, fire safety codes written for large buildings may impose unnecessary or incompatible requirements on a single-family-style residence. Obtaining waivers or negotiating with state regulatory bodies to interpret existing rules flexibly or develop new, appropriate ones for the Green House model can be a protracted and resource-intensive process.

Staffing requirements pose another significant challenge. While the Green House model champions cross-trained Shahbazim and a flexible team-based approach, state regulations often mandate specific licensure for distinct roles (e.g., certified nursing assistants, dietary staff) and rigid staff-to-resident ratios that may not fully account for the multi-skilled nature of the Shahbazim. This can create a mismatch between the desired operational flexibility and regulatory mandates, potentially increasing staffing costs or requiring compromises in the care model. Medication management and administration protocols, typically designed for centralized nursing stations, must also be adapted for the decentralized Green House model, ensuring safety and compliance within a less institutional setting. (govinfo.gov)

Furthermore, the low Medicaid reimbursement rates, while a funding issue, also have regulatory implications. If rates do not cover the cost of care, providers face difficult choices between maintaining quality and financial solvency. This financial pressure can indirectly impact compliance with quality-of-care regulations if resources are severely constrained. Advocacy for regulatory reform often centers on developing distinct licensure categories for person-centered, small-house models, ensuring that regulations support rather than hinder the adoption of innovative, high-quality care. This includes establishing flexible standards that prioritize outcomes over prescriptive inputs, acknowledging the unique benefits of the Green House approach.

2.4 Scalability and Policy Implications

Despite its documented successes in enhancing quality of life and improving care outcomes, the scalability of The Green House Project remains constrained by several persistent factors. The significant initial capital outlay for construction or renovation, coupled with challenges in securing suitable land in desirable locations, is a primary barrier. Furthermore, the specialized training required for Shahbazim and the shift in organizational culture demanded by the model necessitate robust workforce development and change management strategies, which can be difficult to implement broadly. Regulatory inertia, as discussed, also acts as a drag on expansion, with states often slow to adapt their licensing and reimbursement policies to accommodate this innovative model.

To facilitate the widespread expansion of the Green House model, targeted policy interventions are indispensable. Increased and more equitable Medicaid reimbursements that adequately cover the costs of high-quality, person-centered care are paramount. This could involve creating specific rate categories for small-house models or implementing value-based purchasing programs that reward facilities for superior outcomes and resident satisfaction, which Green House homes consistently demonstrate. Supportive legislation is also crucial, including the development of flexible state licensing regulations that acknowledge the unique architectural and operational features of Green House homes without compromising safety or quality. This might involve creating ‘small house’ licensure categories or offering regulatory waivers for specific requirements that are not relevant to the Green House design.

Integrating Green House homes into mainstream healthcare systems requires a fundamental shift in perspective among policymakers, insurers, and the public. This shift entails moving beyond a cost-containment-only mindset to one that values the inherent benefits of person-centered care, quality of life, and the potential for reduced downstream healthcare costs (e.g., fewer hospitalizations). Policies could encourage partnerships between Green House homes and accountable care organizations (ACOs) or managed care organizations (MCOs), recognizing their role in comprehensive geriatric care. Additionally, federal and state grant programs could be established to provide seed funding for construction or development, incentivizing more providers to adopt the model. Public awareness campaigns could also educate families and caregivers about the benefits of this innovative approach, driving consumer demand and further stimulating market adoption. Ultimately, the long-term sustainability and widespread integration of Green House homes hinge on a policy environment that proactively supports innovation, values quality of life, and rewards superior outcomes in long-term care.

2.5 Effectiveness and Patient Outcomes

Extensive research over the past two decades has consistently demonstrated that The Green House Project delivers superior outcomes across multiple domains compared to traditional nursing homes. Perhaps one of the most compelling findings relates to resident quality of life. Green House residents report significantly higher levels of autonomy, dignity, and privacy due to private rooms and the ability to dictate daily routines to a greater extent. Studies indicate increased social interaction, higher satisfaction with daily activities, and a stronger sense of community within the smaller household model. (thegreenhouseproject.org)

Clinically, Green House homes have shown promising results. Residents experience lower rates of hospitalizations and emergency department visits, suggesting better proactive management of chronic conditions and early intervention for acute changes in status within the home setting. This is attributed to the consistent Shahbazim teams who are intimately familiar with residents’ baseline conditions and can identify subtle changes quickly. There is also evidence of reduced use of antipsychotic medications among residents without a diagnosis of psychosis, reflecting a more person-centered approach to behavioral management that relies less on chemical restraints. Outcomes related to functional status, such as improved mobility and reduced incidence of pressure ulcers, have also been reported, likely due to more personalized attention and active engagement in daily routines. Furthermore, staff working in Green House homes report higher job satisfaction and lower turnover rates compared to traditional nursing home staff, which translates into better continuity of care for residents. Families of Green House residents also express higher levels of satisfaction with the care their loved ones receive, feeling more involved in decision-making and appreciating the homelike environment. (healthjournalism.org)

Many thanks to our sponsor Esdebe who helped us prepare this research report.

3. Senior Emergency Departments (SEDs)

3.1 Operational Framework

Senior Emergency Departments (SEDs), also known as Geriatric Emergency Departments (GEDs), represent a crucial innovation in acute care, specifically designed to address the complex and often unique needs of older adults presenting to the emergency setting. Unlike standard emergency departments, which are often noisy, fast-paced, and not optimally configured for geriatric patients, SEDs are meticulously designed environments and operational systems aiming to mitigate common risks and improve outcomes for this vulnerable population. The physical environment of an SED is consciously modified to enhance comfort and safety. This includes age-appropriate lighting (brighter, glare-free, and adjustable), noise reduction measures, non-slip flooring, comfortable and accessible seating, higher and more stable examination tables, and readily available mobility aids. These seemingly minor adjustments significantly reduce the risk of falls, delirium, and sensory overload, which are prevalent issues for older adults in traditional ED settings.

Staffing in an SED is characterized by a specialized interdisciplinary team (IDT) with specific training in geriatric emergency medicine. This typically includes emergency physicians with geriatric expertise or specific training in geriatric syndromes, geriatric-certified nurses, social workers, pharmacists, and physical or occupational therapists. This team works collaboratively to perform comprehensive geriatric assessments that extend beyond the presenting complaint. These assessments systematically screen for common geriatric syndromes such as delirium, dementia, depression, falls risk, polypharmacy, functional decline, and elder abuse. The focus is not just on diagnosing and treating the acute condition but also on identifying underlying geriatric vulnerabilities that may have contributed to the emergency visit or could impact recovery. Early mobilization protocols are prioritized to prevent deconditioning, and pain management strategies are tailored to the unique physiological responses of older adults. Minimizing the use of invasive procedures and potentially inappropriate medications (PIMs) is a core tenet, favoring less invasive diagnostic approaches and careful medication reconciliation. Discharge planning in an SED is robust and proactive, focusing on ensuring continuity of care. This often involves connecting patients with appropriate community resources, follow-up primary care appointments, home health services, or assisted living facilities, with the explicit goal of preventing readmissions and optimizing post-ED outcomes. The overarching aim is to provide comprehensive, patient-centered care that improves outcomes, enhances the patient experience, and reduces the likelihood of subsequent emergency visits or hospitalizations.

3.2 Funding Mechanisms

Senior Emergency Departments are typically funded as specialized units within the broader hospital budget. Initial funding often involves capital investment for renovating existing ED space or constructing new facilities, acquiring specialized equipment, and investing in staff training and certification. These costs can be substantial, reflecting the need for physical modifications and specialized human resources. Hospitals generally justify these investments by anticipating improved patient outcomes and potential downstream cost savings.

Revenue generation for SEDs largely comes from standard Medicare and Medicaid reimbursements for services rendered, such as physician fees, facility fees, diagnostic tests, and procedures. However, the specialized nature of SED care, with its emphasis on comprehensive geriatric assessments and extended discharge planning, often requires additional time and resources that may not be fully captured by conventional billing codes. This can create financial sustainability challenges. To address this, some health systems have explored alternative funding models. For instance, value-based care initiatives, such as bundled payments or participation in Accountable Care Organizations (ACOs), can incentivize SEDs to reduce hospital admissions and readmissions by providing high-quality, comprehensive care in the ED. By demonstrating improved outcomes and reduced total cost of care, SEDs can potentially receive performance-based bonuses or shared savings. Grants from philanthropic organizations or government agencies focused on geriatric care innovation can also provide initial seed funding or support for specific programs within the SED, such as delirium prevention initiatives or social work support. The economic argument for SEDs increasingly focuses on their ability to reduce overall healthcare costs by preventing unnecessary hospitalizations, shortening lengths of stay for those admitted, and decreasing 30-day readmission rates, which can yield long-term financial benefits for the hospital system, even if direct ED revenue doesn’t immediately reflect the specialized care provided.

3.3 Regulatory Challenges

While the concept of specialized geriatric care in the emergency setting is gaining traction, SEDs face unique regulatory challenges due to the absence of specific, mandated accreditation standards from national bodies, although the American College of Emergency Physicians (ACEP) has introduced a voluntary Geriatric ED Accreditation program. This voluntary program, while valuable for guiding best practices, does not carry the same regulatory weight as mandatory hospital accreditation standards, which may not always align with the highly specialized care requirements of older adults. The lack of universal regulatory recognition means that implementation and quality assurance can vary significantly between institutions.

Another challenge lies in establishing standardized protocols and training requirements for the interdisciplinary team. While geriatric-specific training is crucial, there are no uniform national certifications for all ED staff to become ‘geriatric-competent,’ beyond general nursing or physician certifications. Hospitals must internally develop and fund comprehensive training programs, which can be resource-intensive. Ensuring consistent application of geriatric assessment tools, delirium screening, and fall prevention protocols across all shifts and providers is also an ongoing operational and regulatory compliance effort. Moreover, the integration of SEDs with broader hospital-wide geriatric initiatives and outpatient services requires robust data sharing and care coordination, which can be hampered by fragmented electronic health record (EHR) systems and privacy regulations. Measuring and reporting quality metrics specifically tailored to geriatric outcomes (e.g., changes in functional status, incidence of delirium, appropriate medication use) can also be challenging within existing reporting frameworks. (pubmed.ncbi.nlm.nih.gov)

3.4 Scalability and Policy Implications

The scalability of Senior Emergency Departments is profoundly influenced by several key factors. Hospital financial constraints often dictate the feasibility of dedicating resources to specialized units, particularly in an era of tight margins. The availability of trained geriatric specialists, including emergency physicians with geriatric fellowships, geriatric-certified nurses, and social workers, is a significant workforce bottleneck. Furthermore, institutional leadership commitment and cultural buy-in are crucial for prioritizing and investing in geriatric-specific care models. Without these, the specialized care provided by an SED may struggle to gain traction or secure necessary resources.

Policy support is therefore instrumental in promoting the establishment and expansion of SEDs. Funding incentives from federal and state governments, perhaps through grants or enhanced reimbursement for specific geriatric ED services, could encourage more hospitals to invest in these units. Training programs, potentially subsidized by government or professional organizations, are vital to expand the geriatric-competent workforce across all healthcare professions. This includes encouraging medical schools and residency programs to incorporate more geriatric emergency medicine training and supporting continuing education for existing ED staff. The voluntary Geriatric ED Accreditation program by ACEP is a step in the right direction, and policy could further incentivize or even mandate adherence to such accreditation standards over time, thereby ensuring a baseline level of quality and consistency across SEDs. Integrating SEDs into mainstream healthcare systems requires a fundamental recognition of the distinct and complex needs of older adults as a high-risk, high-utilization patient population. Policymakers should consider how SEDs can function as critical entry points into broader age-friendly health systems, facilitating appropriate follow-up care and preventing unnecessary inpatient admissions. This involves aligning reimbursement policies with value-based care models that reward comprehensive geriatric care and improved outcomes, rather than simply volume of services. Such policy shifts would accelerate the adoption of SEDs and ensure that older adults receive the specialized, compassionate acute care they deserve.

3.5 Effectiveness and Patient Outcomes

Research on Senior Emergency Departments consistently demonstrates their positive impact on patient outcomes and healthcare system efficiency. One of the most significant findings is a reduction in hospital admissions for older adults presenting to SEDs compared to those seen in traditional EDs. This is often attributed to the comprehensive geriatric assessment, the availability of specialized social work interventions, and robust discharge planning that connects patients to appropriate community resources, thus avoiding unnecessary inpatient stays. For those who are admitted, SEDs have been associated with shorter lengths of stay, indicating more efficient management and smoother transitions of care.

SEDs have also shown effectiveness in reducing 30-day readmission rates, a critical metric for quality and cost-efficiency. By addressing underlying geriatric syndromes, optimizing medication regimens, and ensuring thorough post-discharge support, SEDs help mitigate factors that commonly lead to rapid readmission. The focus on preventing iatrogenic complications, such as delirium, falls, and adverse drug events, is another area of success. The age-friendly environment and specific protocols help minimize these risks, which are particularly high for older adults in the chaotic ED environment. Patients and their families frequently report higher satisfaction with care received in SEDs, citing a more comfortable environment, better communication, and a sense that their unique needs are understood and addressed. The specialized training of SED staff leads to more appropriate diagnostic testing and reduced use of potentially harmful medications, further contributing to improved patient safety and outcomes. (sciencedirect.com)

Many thanks to our sponsor Esdebe who helped us prepare this research report.

4. Programs of All-Inclusive Care for the Elderly (PACE)

4.1 Operational Framework

Programs of All-Inclusive Care for the Elderly (PACE) offer a uniquely comprehensive and integrated care model designed to enable frail older adults who would otherwise qualify for nursing home admission to remain living independently in their communities. Originating from the On Lok Senior Health Services in San Francisco in the 1970s, PACE is built upon the principle that older adults with chronic conditions and disabilities are better served by remaining in their homes and communities with coordinated support. The operational cornerstone of PACE is its interdisciplinary team (IDT). This team is comprised of a diverse group of healthcare professionals, including primary care physicians, registered nurses, social workers, physical therapists, occupational therapists, dietitians, transportation specialists, and home care aides. Unlike fragmented traditional care, the IDT collaboratively assesses each participant’s needs, develops an individualized care plan, and delivers or coordinates all necessary medical, social, and rehabilitative services. This team meets regularly to discuss participant progress, adjust care plans, and ensure seamless coordination across all services.

Services provided by PACE are exceptionally broad, encompassing primary medical care, specialty physician referrals, prescription drugs, physical and occupational therapy, speech therapy, nutritional counseling, social services, home care, medical equipment, laboratory and X-ray services, inpatient hospital care, and even nursing home care if needed for short-term rehabilitation or long-term placement. A distinctive feature of PACE is the PACE center, which serves as the central hub for service delivery. These centers typically include a primary care clinic, rehabilitation facilities, and adult day care services, offering participants a safe and engaging environment for social interaction, therapeutic activities, and medical appointments. Transportation to and from the PACE center is also a core service, ensuring access for all participants. The model places a strong emphasis on preventative care and proactive management of chronic conditions to prevent costly hospitalizations and nursing home placements. By being fully accountable for all care a participant receives, the PACE model incentivizes the IDT to deliver the most effective and efficient care possible, balancing medical necessity with the participant’s personal goals and preferences, thereby creating a ‘single point of accountability’ for all participant needs.

4.2 Funding Mechanisms

PACE operates on a distinctive capitated payment system, which is fundamental to its ability to provide comprehensive, integrated care while incentivizing cost-effectiveness. Under this model, PACE organizations receive a fixed, predetermined monthly payment for each enrolled participant, irrespective of the volume or intensity of services utilized by that individual in a given month. For participants who are dual-eligible (qualifying for both Medicare and Medicaid), the PACE organization receives a blended payment from both federal programs. For Medicare-only participants, the organization receives the Medicare capitation rate, and the participant may be responsible for a monthly premium covering the Medicaid portion of the benefit. Private-pay options are also available for individuals who do not qualify for Medicare or Medicaid but wish to enroll.

This capitated funding structure is a powerful incentive for PACE providers to deliver highly coordinated, preventative, and efficient care. Since the organization bears the full financial risk for all services a participant requires, there is a strong motivation to manage chronic conditions proactively, prevent costly hospitalizations and emergency department visits, and minimize the need for institutionalization. By keeping participants healthy and engaged in their communities, PACE programs can reduce overall healthcare expenditures over time. However, this model also presents financial challenges for providers. Accurate risk assessment and actuarial modeling are critical to ensure that the capitated payments are sufficient to cover the actual costs of care for their enrolled population. Unexpectedly high utilization of expensive services by a small number of participants can strain a PACE organization’s finances. Managing these financial risks requires sophisticated care management strategies, robust data analytics, and strong relationships with a network of specialty providers to negotiate favorable rates. Despite these complexities, numerous studies have demonstrated the long-term cost-effectiveness of PACE compared to traditional fee-for-service models, especially when considering the significant costs associated with nursing home care. The financial benefits accrue not only to the PACE organization but also to Medicare and Medicaid programs, which save money by avoiding more expensive institutional settings. (ncbi.nlm.nih.gov)

4.3 Regulatory Challenges

Implementing and operating PACE programs involves navigating a highly complex web of federal and state regulations, a significant barrier to their broader expansion. At the federal level, PACE programs must comply with rigorous regulations established by the Centers for Medicare & Medicaid Services (CMS), including detailed requirements for participant enrollment, care plan development, service delivery, quality assurance, and financial solvency. Each PACE organization must have a formal program agreement with CMS and its respective state administering agency.

State-level regulations add another layer of complexity. States often have their own licensure requirements for PACE programs, which can vary significantly and may not always align perfectly with federal guidelines. These state regulations can dictate specific staffing ratios, facility standards for PACE centers, transportation requirements, and detailed quality reporting metrics. The application process to become a PACE provider is notoriously demanding, requiring extensive documentation, demonstration of financial capability, and a comprehensive plan for service delivery across a specified geographic area. Recruiting and retaining qualified staff, particularly the interdisciplinary team members who need specific geriatric expertise and a collaborative mindset, can be challenging, especially in rural or underserved areas. The rigorous quality assurance standards demand continuous monitoring and reporting to CMS and state agencies, ensuring that participants receive high-quality care and that the program remains compliant. Furthermore, the capitated payment model requires sophisticated financial management and robust systems for tracking utilization and outcomes, which can be difficult for smaller or newer organizations to establish. The strict geographic service area requirements, designed to ensure accessible and timely care, can also limit a program’s ability to enroll a sufficient number of participants in sparsely populated regions, thereby affecting financial viability. Overcoming these regulatory hurdles often requires significant upfront investment in legal and administrative expertise, making the initial establishment of a PACE program a formidable undertaking. (ncbi.nlm.nih.gov)

4.4 Scalability and Policy Implications

Despite its compelling outcomes, the scalability of PACE has historically been limited by the very regulatory complexities and capital requirements that define it. The stringent federal and state approval processes, combined with the necessity for a sufficient initial patient base within a defined service area to ensure financial viability, create high barriers to entry. Establishing a PACE center, assembling a full interdisciplinary team, and building a comprehensive network of contracted providers demands substantial upfront investment and operational expertise. Furthermore, the challenge of recruiting and retaining specialized geriatric staff, particularly in rural or medically underserved areas, further constrains expansion.

Policy interventions are critically necessary to accelerate the expansion of PACE programs. Streamlined federal and state regulations could significantly reduce the administrative burden and time required to establish new programs. This might involve creating a more standardized, yet flexible, application process or offering temporary waivers for certain requirements during a program’s initial startup phase. Increased federal and state funding, perhaps through seed grants for new PACE organizations or enhanced capitation rates, could help offset initial capital costs and ensure financial stability, particularly in areas with challenging demographics or market conditions. Furthermore, policies that promote education and awareness about PACE among older adults, their families, and healthcare providers are vital to increase enrollment and community acceptance. Integrating PACE into broader value-based care initiatives, such as Medicare Advantage plans or accountable care organizations, could also foster growth by demonstrating its proven effectiveness in managing high-needs populations. Legislative efforts aimed at simplifying the program’s rules, while maintaining quality, are continuously being explored to encourage more states and health systems to adopt the model. The Bipartisan Policy Center, for example, has advocated for reforms to ease administrative burdens and promote PACE expansion. Ultimately, integrating PACE into mainstream healthcare systems requires a systemic shift towards recognizing the inherent value of comprehensive, community-based, and preventative care for frail older adults. Policymakers must move beyond a fragmented, fee-for-service mentality and embrace models that prioritize holistic well-being and long-term cost-effectiveness over short-term transactional services, paving the way for PACE to become a cornerstone of elder care.

4.5 Effectiveness and Patient Outcomes

PACE programs have consistently demonstrated superior outcomes compared to traditional fee-for-service models, particularly in preventing institutionalization and improving the quality of life for frail older adults. A primary indicator of PACE’s effectiveness is its success in keeping participants in their homes and communities, significantly reducing the rates of nursing home admissions. This not only aligns with the preferences of most older adults but also leads to substantial cost savings for the healthcare system over time.

Participants in PACE programs experience fewer hospitalizations and emergency department visits due to the proactive and coordinated care provided by the interdisciplinary team. The IDT’s ability to closely monitor chronic conditions, provide timely interventions, and conduct comprehensive risk assessments helps prevent acute exacerbations. Studies have also indicated improved functional status and slower rates of functional decline among PACE participants, attributed to consistent access to physical, occupational, and other rehabilitative therapies. Medication management is also a strength of the PACE model, leading to fewer adverse drug events and better adherence due to pharmacist involvement and close monitoring. Beyond clinical outcomes, PACE excels in enhancing participants’ quality of life. The PACE center provides a vital social hub, combating isolation and fostering engagement through various activities and peer interaction. Participants and their families frequently report high levels of satisfaction, citing the comprehensive nature of care, the personalized attention from a consistent team, and the peace of mind that all needs are coordinated under one umbrella. The model’s holistic approach addresses not only medical but also social, emotional, and practical needs, leading to a more dignified and supported aging experience. (jamanetwork.com)

Many thanks to our sponsor Esdebe who helped us prepare this research report.

5. Hospital at Home (HaH)

5.1 Operational Framework

Hospital at Home (HaH) represents a transformative model of care delivery that brings acute, hospital-level medical services directly to the patient’s residence. This innovative approach is designed for carefully selected patients with specific acute conditions that traditionally would necessitate inpatient hospitalization. The core philosophy of HaH is to provide the same quality and safety of care as a conventional hospital, but in the comfort and familiarity of the patient’s home, thereby minimizing the risks associated with institutionalization, such as hospital-acquired infections, delirium, and functional decline.

The operational framework of an HaH program is highly sophisticated and technology-driven, relying on a ‘command center’ or central hub that remotely monitors patients and coordinates care. Patient selection is paramount; strict criteria are applied to identify suitable candidates, typically those with conditions like pneumonia, congestive heart failure exacerbations, chronic obstructive pulmonary disease (COPD) exacerbations, cellulitis, or urinary tract infections, who are medically stable enough for home care but still require acute monitoring and treatment. Patients must also have a safe home environment, reliable communication, and usually a supportive caregiver present.

Once enrolled, patients receive a comprehensive suite of services equivalent to inpatient care. This includes regular in-person home visits by a mobile care team, typically comprising registered nurses and paramedics, who provide direct medical care, administer medications (including intravenous therapies), perform diagnostic tests (e.g., blood draws, portable X-rays), and monitor vital signs. Physicians provide daily virtual rounds via telemedicine, assessing the patient’s condition, adjusting treatment plans, and consulting with the home care team. Remote patient monitoring devices are often deployed, allowing the command center to continuously track vital signs (heart rate, oxygen saturation, blood pressure) and receive alerts for any deviations, enabling rapid response if needed. Physical, occupational, and respiratory therapists may also provide home visits as required. Logistics for medication delivery, equipment setup (e.g., oxygen, IV poles), and waste management are meticulously planned and executed. The HaH model emphasizes a patient-centered approach, ensuring that communication is clear, patient and family preferences are respected, and care is seamlessly coordinated to ensure a safe, effective, and positive acute care experience in the comfort of one’s own home.

5.2 Funding Mechanisms

The funding mechanisms for Hospital at Home (HaH) programs have seen significant evolution, particularly in recent years. Historically, one of the primary barriers to HaH adoption was the lack of clear reimbursement pathways from major payers like Medicare and private insurers. Traditional fee-for-service models were designed for brick-and-mortar hospital stays, not for acute care delivered in the home. However, the COVID-19 pandemic catalyzed a crucial policy change: the Centers for Medicare & Medicaid Services (CMS) launched the Acute Hospital Care at Home (AHCaH) waiver program. This waiver allows eligible hospitals to be reimbursed for acute care services provided in a patient’s home at the same rate as traditional inpatient care, significantly validating the model and providing a stable funding source for Medicare beneficiaries.

Private insurers are increasingly following suit, recognizing the clinical and economic benefits of HaH. Many major commercial payers now offer coverage for HaH services, either through specific benefit designs, value-based contracts, or direct agreements with health systems. Value-based care contracts, such as those within Accountable Care Organizations (ACOs) or bundled payment initiatives, are particularly well-suited for HaH. These models reward providers for improving patient outcomes and reducing the total cost of care. HaH programs often demonstrate significant cost savings by avoiding expensive facility fees, reducing overhead associated with inpatient stays, and potentially lowering readmission rates. These savings can offset the direct costs of home-based care, making HaH an attractive proposition for health systems participating in risk-sharing arrangements.

Initial capital investment for HaH programs involves setting up a command center, acquiring remote monitoring technology, establishing logistics for equipment and medication delivery, and training specialized mobile care teams. These startup costs can be substantial, often requiring institutional commitment. However, studies consistently show that the cost savings generated by HaH, primarily through reduced hospital admissions and shorter lengths of stay, can lead to a positive return on investment for health systems over time. The economic benefits extend beyond direct cost savings, encompassing improved patient satisfaction, enhanced reputation, and potentially better long-term health outcomes for the population served. The ongoing policy debate centers on transitioning the temporary AHCaH waiver into a permanent Medicare benefit, which would solidify the financial foundation for widespread HaH adoption. (bmcgeriatr.biomedcentral.com)

5.3 Regulatory Challenges

Hospital at Home programs, while innovative, confront a unique set of regulatory challenges primarily because they operate in the hybrid space between traditional hospital care and home healthcare. One of the most significant hurdles is adapting existing licensure and accreditation standards, which were fundamentally designed for brick-and-mortar hospitals, to a decentralized home environment. Ensuring that home-based acute care meets the same safety and quality standards as inpatient care requires robust protocols and monitoring systems, which may necessitate regulatory flexibility or new interpretive guidelines.

Telemedicine regulations are also a critical area of complexity. While telemedicine is integral to the HaH model for physician rounds and remote monitoring, variations in state licensing laws for practitioners (e.g., across state lines), reimbursement parity for virtual services, and data privacy/security requirements can create operational difficulties. Medication management and administration in the home setting, particularly for intravenous therapies, require strict adherence to safety protocols, including secure storage, proper administration techniques by trained professionals, and careful tracking, all under regulatory scrutiny. Patient safety in the home environment is paramount. HaH programs must establish robust protocols for identifying and mitigating risks such as falls, infection control, and emergency response in a non-clinical setting. This involves extensive patient and caregiver education, regular home safety assessments, and clear pathways for escalation of care if a patient’s condition deteriorates rapidly. Data security and patient privacy, particularly with the use of remote monitoring devices and electronic health records accessible by multiple team members in different locations, must also comply with HIPAA and other privacy regulations. The transition of the Acute Hospital Care at Home (AHCaH) waiver into a permanent program requires legislative and regulatory action to codify standards, ensuring consistent quality and safety across all HaH providers, which is an ongoing policy discussion. Without clear and consistent regulatory frameworks, the widespread adoption of HaH faces significant uncertainty. (ncbi.nlm.nih.gov)

5.4 Scalability and Policy Implications

The scalability of Hospital at Home (HaH) has been significantly propelled by recent policy shifts, particularly during the COVID-19 pandemic, but ongoing challenges persist. The temporary Acute Hospital Care at Home (AHCaH) waiver from CMS proved transformative, demonstrating that with appropriate regulatory and reimbursement support, HaH models could expand rapidly and effectively. This waiver, which allowed hospitals to be reimbursed for acute care delivered at home, fundamentally de-risked the model for health systems and incentivized investment.

However, for HaH to achieve widespread, sustainable scalability, further policy changes are essential. The most critical is the need for a permanent Medicare benefit for HaH services, transitioning from the current temporary waiver. This would provide long-term certainty for health systems to invest in the necessary infrastructure, technology, and workforce. Policy should also address issues related to telemedicine reimbursement parity across state lines and for various specialties involved in HaH care, ensuring providers are adequately compensated for virtual consultations and remote monitoring. Furthermore, state-level licensure and regulatory frameworks need to adapt to accommodate this innovative model, moving beyond traditional facility-centric rules to embrace home-based acute care without compromising safety or quality. This may involve creating new licensure categories or providing clear interpretive guidance for existing regulations.

Workforce development is another critical policy area. Expanding HaH requires a cadre of nurses, paramedics, and other healthcare professionals skilled in providing acute care in diverse home environments. Policies supporting training programs, potentially through grants or educational incentives, could help build this specialized workforce. Integrating HaH into mainstream healthcare systems also necessitates a cultural shift among both providers and patients. For providers, it means trusting technology and remote teams; for patients, it means accepting hospital-level care outside traditional walls. Policy can facilitate this by promoting public awareness campaigns about HaH, highlighting its benefits in terms of patient experience and outcomes. Ultimately, a supportive policy environment that embraces technology, values patient-centered care, and aligns reimbursement with outcomes will be crucial for HaH to fulfill its potential as a cornerstone of modern acute care, not just for older adults but for a broader patient population.

5.5 Effectiveness and Patient Outcomes

Hospital at Home programs have garnered significant attention due to compelling evidence of their effectiveness in improving patient outcomes and system efficiency. A meta-analysis of multiple studies found that HaH models are associated with a reduction in hospital readmissions compared to traditional inpatient care, often by as much as 20-30%. This is attributed to the personalized care, close monitoring, and tailored discharge planning that help prevent post-discharge complications. Furthermore, HaH has been shown to reduce mortality rates, with some studies reporting a 10-15% lower risk of death for HaH patients, possibly due to fewer hospital-acquired infections and less delirium.

Patients treated in HaH settings also experience significantly lower rates of common hospital-acquired complications such as delirium, falls, and pressure ulcers. The familiar home environment, reduced exposure to pathogens, and one-on-one nursing attention contribute to this improved safety profile. Patient experience is another strong point for HaH. Patients consistently report higher satisfaction with their care, valuing the comfort, privacy, and convenience of recovering at home. This can lead to improved adherence to treatment plans and faster recovery. From a cost perspective, HaH programs have demonstrated substantial cost savings, primarily by avoiding the high fixed costs of inpatient beds. Studies estimate cost reductions ranging from 19% to 38% compared to traditional hospitalization, making it an economically attractive model for health systems and payers. The integration of telemedicine and remote monitoring not only enhances safety but also allows for efficient use of healthcare resources, ensuring that acute care is delivered effectively and appropriately in the most patient-preferred setting. (sciencedirect.com)

Many thanks to our sponsor Esdebe who helped us prepare this research report.

6. Age-Friendly Health Systems (AFHS)

6.1 Operational Framework

Age-Friendly Health Systems (AFHS) represent a comprehensive, evidence-based approach to embedding high-quality, age-friendly care across all healthcare settings, from primary care clinics and emergency departments to hospitals and long-term care facilities. This model is not a standalone program but rather a commitment by health systems to adopt a set of core practices that specifically address the unique needs of older adults. Developed by the Institute for Healthcare Improvement (IHI) in partnership with The John A. Hartford Foundation and other key organizations, the AFHS model is centered around the ‘4Ms’: a framework of four interconnected evidence-based elements crucial for optimizing care for older adults.

1. What Matters: This core tenet emphasizes understanding and acting on each older adult’s health outcomes goals and care preferences, including end-of-life care decisions. It involves asking about their values, priorities, and what they want to achieve through their care, ensuring that treatment plans are aligned with their personal wishes. This shifts the focus from simply treating diseases to supporting a person’s overall well-being and life goals.
2. Medication: This M focuses on judicious medication management, particularly reducing polypharmacy (the use of multiple medications) and avoiding potentially inappropriate medications (PIMs) in older adults. It involves a thorough review of all medications, including over-the-counter drugs and supplements, to ensure they are necessary, effective, and safe, minimizing adverse drug events and interactions that are common in this population.
3. Mentation: This element addresses cognitive health, including routinely assessing and managing for delirium, dementia, and depression. It emphasizes early screening, accurate diagnosis, and appropriate interventions to prevent, identify, and manage cognitive impairments and mood disorders, recognizing their profound impact on older adults’ health and quality of life.
4. Mobility: This M focuses on ensuring that older adults move safely every day to maintain their function and independence. It involves assessing mobility, identifying fall risks, and implementing strategies to prevent falls and promote safe movement, such as physical therapy, exercise programs, and appropriate assistive devices. The goal is to preserve or improve physical function, which is critical for maintaining independence and quality of life.

Implementing AFHS involves embedding these ‘4Ms’ into routine clinical practice at every patient encounter, ensuring that they become a consistent part of assessment, care planning, and intervention. This requires training healthcare providers across disciplines, adapting electronic health records to facilitate ‘4M’ documentation, and establishing continuous quality improvement cycles to monitor adherence and patient outcomes. The model emphasizes interdisciplinary collaboration, where all members of the care team work together to address the 4Ms, creating a cohesive and holistic approach to geriatric care. AFHS is not about adding new services but rather about optimizing existing ones to be more sensitive and effective for older adults, transforming the entire system to be truly age-friendly.

6.2 Funding Mechanisms

Age-Friendly Health Systems (AFHS) initiatives are typically funded through a combination of existing healthcare revenue streams, grants, and institutional budgets, rather than relying on a single, dedicated AFHS-specific reimbursement mechanism. The beauty of the AFHS model is that it often integrates with and enhances existing value-based care frameworks, making it financially sustainable and attractive to health systems.

Medicare and Medicaid reimbursements play a significant role. By implementing the ‘4Ms,’ health systems can improve outcomes such as reduced hospital readmissions, fewer emergency department visits, and decreased incidence of delirium or falls. These improvements can lead to higher performance in value-based care models, such as Accountable Care Organizations (ACOs), bundled payment programs, or quality incentive payments, which reward providers for achieving better outcomes and lower total costs of care. For example, by proactively managing medications (Medication M) and preventing falls (Mobility M), health systems can reduce adverse events that incur significant costs, thereby improving their financial performance within these value-based contracts.

Grants from philanthropic foundations, most notably The John A. Hartford Foundation, have been instrumental in the development and initial dissemination of the AFHS movement. These grants often support pilot programs, workforce training, and the development of implementation resources. Institutional budgets are also critical, as health systems commit their own operational funds to training staff, adapting electronic health records to incorporate the ‘4Ms,’ and establishing continuous quality improvement processes. The long-term financial argument for AFHS rests on the premise that proactive, age-friendly care leads to healthier older adults, fewer acute care episodes, and more efficient use of healthcare resources. This approach helps reduce downstream costs associated with preventable complications, prolonged hospital stays, and readmissions, ultimately benefiting the financial health of the system while simultaneously improving patient care. The investments made in AFHS are therefore viewed as strategic commitments that yield both clinical and economic returns, aligning quality with financial sustainability.

6.3 Regulatory Challenges

Implementing Age-Friendly Health Systems (AFHS) primarily involves adapting existing clinical practices and systems rather than creating entirely new regulatory categories, which presents a different set of challenges. One key area is aligning the ‘4Ms’ framework with existing healthcare regulations and accreditation standards. While the 4Ms are evidence-based best practices, they may not always be explicitly mandated or universally integrated into state or federal regulatory checklists. For instance, while medication reconciliation is often required, a full ‘Medication’ review focused on avoiding potentially inappropriate medications (PIMs) specific to older adults might go beyond minimum requirements. Similarly, mentation screenings for delirium or comprehensive mobility assessments may not be as robustly mandated as AFHS recommends.

Training the diverse healthcare provider workforce in geriatric care principles and ensuring consistent adherence to best practices across all settings (e.g., inpatient, outpatient, emergency department) remains an ongoing challenge. This requires substantial investment in continuing education, curriculum development, and creating champions within the organization. Embedding the 4Ms effectively into electronic health records (EHRs) can also be complex, requiring customization of templates, integration with decision support tools, and ensuring that the information captured is easily accessible and actionable by the entire care team. This process must comply with data privacy and security regulations while facilitating seamless information flow.

Furthermore, measuring and reporting the impact of AFHS initiatives without specific, dedicated reimbursement codes or national quality metrics for ‘age-friendly care’ can be difficult. Health systems often rely on internal quality improvement data, which may not always be comparable across institutions or easily reported to external bodies. Advocacy efforts are underway to integrate AFHS principles into national quality measures and payment models, which would provide stronger regulatory incentive and validation for this approach. Overcoming these challenges requires strong leadership commitment, interdisciplinary collaboration, and a sustained focus on cultural transformation within health systems to truly prioritize age-friendly care at every level of service delivery.

6.4 Scalability and Policy Implications

The scalability of Age-Friendly Health Systems (AFHS) is notably supported by the growing recognition of the profound importance of delivering tailored, high-quality care to older adults. Unlike models requiring entirely new infrastructure, AFHS is designed to be integrated into existing healthcare facilities and workflows, making it broadly applicable across the continuum of care—from primary care and emergency departments to hospitals and long-term care settings. This adaptability is a key strength, allowing diverse health systems to adopt the ‘4Ms’ framework within their unique operational contexts. The Institute for Healthcare Improvement (IHI) has played a pivotal role in this dissemination, providing structured guidance, learning collaboratives, and a designation process for health systems committed to becoming ‘Age-Friendly.’

Policy support is crucial for accelerating the widespread adoption and deeper embedding of AFHS principles. Funding and training programs are vital. Government grants or incentives could support health systems in the initial investment for workforce training, electronic health record modifications, and continuous quality improvement initiatives related to the ‘4Ms.’ Furthermore, integrating age-friendly metrics into existing quality reporting programs and value-based purchasing initiatives would provide a powerful financial incentive for health systems to prioritize AFHS. For example, if performance on medication reconciliation or delirium screening, aligned with the ‘4Ms,’ were tied to reimbursement, adoption would likely accelerate.

Integrating AFHS into mainstream healthcare systems requires a fundamental cultural shift towards consistent quality improvement and patient-centered care for older adults. This involves educating policymakers, payers, and the public about the benefits of age-friendly care in improving patient outcomes, enhancing satisfaction, and potentially reducing overall healthcare costs by preventing adverse events. Advocacy groups, professional organizations (like the American Geriatrics Society), and federal agencies can play a significant role in promoting AFHS as a standard of care. Policies could encourage medical and nursing schools to incorporate more comprehensive geriatric training, ensuring a future workforce equipped with age-friendly competencies. Ultimately, for AFHS to become the pervasive standard, a policy environment that not only encourages but actively rewards health systems for prioritizing and systematically delivering age-friendly care is indispensable. This commitment will ensure that older adults consistently receive respectful, safe, and effective care that truly addresses ‘What Matters’ most to them.

6.5 Effectiveness and Patient Outcomes

Since its inception, the Age-Friendly Health Systems (AFHS) movement has demonstrated significant efficacy in improving a wide array of patient outcomes for older adults. By systematically implementing the ‘4Ms’ framework, health systems have shown measurable improvements in key areas that are particularly impactful for this population.

One of the most consistently reported benefits is improved patient experience and satisfaction. When care aligns with ‘What Matters’ to older adults, they report feeling more respected, heard, and involved in their own care decisions. This person-centered approach fosters trust and can lead to better adherence to care plans. Regarding ‘Medication,’ AFHS initiatives have led to a significant reduction in the use of potentially inappropriate medications (PIMs) and polypharmacy, which in turn reduces adverse drug events, hospitalizations due to medication complications, and overall healthcare costs. The focus on comprehensive medication reviews ensures that older adults are on the safest and most effective medication regimens.

In the realm of ‘Mentation,’ the routine screening for delirium, dementia, and depression has led to earlier identification and more appropriate management of these conditions. This has translated into decreased incidence and duration of delirium in hospital settings, improved cognitive function for some, and better management of mood disorders, which significantly enhances quality of life. For ‘Mobility,’ the emphasis on preventing falls and promoting safe movement has resulted in lower fall rates in inpatient and outpatient settings, reducing associated injuries, hospitalizations, and long-term disability. By focusing on maintaining functional independence, AFHS helps older adults retain their ability to perform daily activities, thereby improving their overall quality of life and reducing the need for higher levels of care.

Collectively, these improvements lead to reduced hospital readmissions and emergency department visits, as the proactive and holistic care provided within AFHS better manages chronic conditions and prevents acute deteriorations. The AFHS model offers a scalable and sustainable pathway to ensure that all older adults receive evidence-based, high-quality care that respects their preferences and addresses their unique vulnerabilities. (jamanetwork.com)

Many thanks to our sponsor Esdebe who helped us prepare this research report.

7. Comparative Analysis

7.1 Effectiveness and Patient Outcomes

When evaluating the effectiveness and patient outcomes across these five innovative care models, distinct strengths and synergistic potentials emerge. The Green House Project consistently demonstrates superior quality of life, enhanced resident autonomy, and significantly lower rates of hospitalization and antipsychotic use compared to traditional nursing homes. Its intimate, homelike environment and consistent staffing model foster deeper relationships and more personalized care, leading to higher resident and staff satisfaction. Outcomes here emphasize dignity, psychosocial well-being, and a reduction in institutional harms.

Senior Emergency Departments (SEDs) excel in the acute care setting by significantly reducing hospital admissions and 30-day readmission rates for older adults. Their specialized environments, geriatric-trained staff, and comprehensive assessments lead to more appropriate care decisions, fewer iatrogenic complications (like delirium and falls), and improved discharge planning that connects patients to necessary follow-up care. SEDs represent a critical point of intervention to prevent escalation of care and mitigate risks in a vulnerable population.

Programs of All-Inclusive Care for the Elderly (PACE) are unparalleled in their ability to prevent institutionalization, allowing frail older adults to remain in their communities. Through their capitated payment system and interdisciplinary team approach, PACE programs achieve lower rates of hospitalizations and nursing home admissions, improved functional status, and high participant satisfaction. The holistic care, including social services and transportation, addresses a broad spectrum of needs, leading to a truly integrated care experience.

Hospital at Home (HaH) programs deliver acute hospital-level care in the comfort of a patient’s home, showing compelling results in reducing hospital readmissions, mortality rates, and complications such as delirium and hospital-acquired infections. Patients consistently report higher satisfaction and a preference for receiving care in their familiar environment. HaH demonstrates that complex acute care can be safely and effectively delivered outside traditional hospital walls, improving patient experience and outcomes while reducing costs.

Finally, Age-Friendly Health Systems (AFHS) serve as a foundational framework, embedding best practices across all care settings. By focusing on the ‘4Ms’ (What Matters, Medication, Mentation, Mobility), AFHS initiatives lead to improved patient experience, reduced polypharmacy and inappropriate medication use, earlier detection and management of delirium and depression, and lower rates of falls. AFHS is not a competing model but rather a quality improvement methodology that can enhance the effectiveness of all other models by ensuring geriatric best practices are universally applied. For instance, an SED or a HaH program that is also ‘Age-Friendly’ would likely achieve even better outcomes.

While each model has unique strengths, a common thread is the emphasis on person-centered care, preventing institutionalization or adverse events, and improving quality of life, often translating into reduced costs for the broader healthcare system. (thegreenhouseproject.org; sciencedirect.com)

7.2 Long-Term Sustainability

The long-term sustainability of these innovative care models is multifaceted, contingent upon financial viability, robust regulatory support, adequate workforce development, and sustained community acceptance. While the initial capital costs for models like the Green House Project (for construction) and SEDs (for specialized facilities and training) can be substantial, their long-term benefits in terms of reduced hospitalizations, emergency department visits, and improved patient satisfaction often translate into significant downstream cost savings for the broader healthcare system.

Green House Project: Its sustainability is challenged by high initial capital costs and often insufficient Medicaid reimbursement rates. Long-term viability hinges on increased policy support for capital funding (e.g., grants, tax credits) and adjusted reimbursement structures that reflect the value of personalized, high-quality residential care. Its proven ability to reduce staff turnover also contributes to operational efficiency and sustainability.

Senior Emergency Departments (SEDs): Sustainability depends on the hospital’s financial commitment and the ability to demonstrate tangible returns on investment through reduced admissions, readmissions, and length of stay. Policy support for geriatric workforce training and specific reimbursement for comprehensive geriatric assessment in the ED would enhance their financial footing and scalability. SEDs often struggle with perceived cost centers if their downstream savings aren’t fully recognized.

Programs of All-Inclusive Care for the Elderly (PACE): The capitated payment model inherently incentivizes long-term sustainability by encouraging preventative and cost-effective care. PACE programs thrive by keeping participants healthy and in their communities, avoiding more expensive institutional care. Their sustainability is challenged by stringent regulatory hurdles, the need for a critical mass of enrollees, and the complexity of managing financial risk. Streamlined regulations and increased awareness are key to expanding their reach and ensuring long-term success.

Hospital at Home (HaH): The sustainability of HaH has been significantly bolstered by Medicare waivers, demonstrating its financial viability through reduced hospital days and associated costs. Its long-term sustainability is critically dependent on establishing permanent Medicare and private insurer reimbursement policies that recognize home-based acute care as a legitimate and cost-effective alternative to inpatient hospitalization. Investment in technology and mobile care teams is required, but cost savings from avoiding facility fees are substantial.

Age-Friendly Health Systems (AFHS): As a framework, AFHS sustainability is tied to its integration into existing value-based care models. By improving outcomes (e.g., fewer falls, less delirium) and enhancing patient experience, AFHS helps health systems perform better on quality metrics and potentially earn shared savings or bonuses. Its sustainability is driven by its ability to integrate into existing workflows without requiring entirely new funding streams, making it a highly adaptable and robust approach to systemic improvement. Its long-term success depends on consistent organizational commitment and leadership.

Collectively, the long-term sustainability of these models is significantly enhanced when policy environments recognize the economic value of improved patient outcomes, reduced institutionalization, and preventative care. A shift towards value-based purchasing and flexible reimbursement mechanisms that reward high-quality, person-centered care will be crucial for their enduring presence in the healthcare landscape. (bmcgeriatr.biomedcentral.com)

7.3 Policy Implications

The successful integration and widespread adoption of these innovative elder care models necessitate a concerted and proactive approach to policy reform. The current policy landscape, largely shaped by traditional fee-for-service models and institutional biases, often acts as a barrier rather than an enabler for these transformative approaches. Policy changes are required across several critical domains.

Firstly, reimbursement structures must be critically re-evaluated. Traditional models often do not adequately compensate for the comprehensive, proactive, and individualized care that these innovations offer. For the Green House Project, this means adjusting Medicaid rates to reflect the true cost of quality, person-centered residential care. For SEDs and AFHS, it involves creating specific billing codes or enhanced payments for comprehensive geriatric assessments and services that extend beyond acute problem-solving. For PACE and Hospital at Home, the focus must be on expanding and solidifying capitated or value-based payment models that incentivize holistic care and positive outcomes, moving away from temporary waivers to permanent benefits. Policymakers must recognize that investing in preventative and community-based care can yield significant long-term savings by reducing costly hospitalizations and institutionalization.

Secondly, regulatory frameworks require significant modernization and flexibility. State and federal regulations for facility licensure, staffing ratios, and service delivery often lag behind innovation. Green House homes struggle with building codes designed for large institutions, while PACE programs face burdensome application processes and geographic restrictions. Hospital at Home needs clear licensure and telemedicine policies that account for home-based acute care. Policymakers must work towards developing more outcome-oriented regulations that support innovation without compromising safety, potentially creating new categories for innovative models or streamlining waiver processes. This includes promoting the adoption of standards like the Geriatric ED Accreditation or the AFHS ‘4Ms’ as quality benchmarks.

Thirdly, workforce development is paramount. All these models rely on a highly skilled, geriatric-competent workforce. Policies must support increased funding for geriatric fellowships, nursing specializations, and interdisciplinary training programs. Incentives for healthcare professionals to specialize in geriatrics and work in community-based settings are crucial to address projected shortages. This includes support for cross-training initiatives like the Green House ‘Shahbazim’ model.

Finally, infrastructure investment and public awareness campaigns are vital. Policies could promote grants for the construction of Green House homes, investment in telehealth and remote monitoring technology for HaH, and the expansion of PACE centers. Public health campaigns can educate older adults and their families about these alternative models, fostering demand and informing care choices. Policymakers must recognize the profound value of person-centered care and actively invest in models that promote health equity, improve quality of life for older adults, and build a more sustainable, responsive healthcare system for the future. This requires a shift from a reactive, disease-focused approach to a proactive, holistic, and preventive paradigm of elder care. (govinfo.gov; ncbi.nlm.nih.gov)

Many thanks to our sponsor Esdebe who helped us prepare this research report.

8. Conclusion

The demographic imperative of a rapidly aging global population undeniably necessitates a fundamental re-evaluation and transformation of existing elder care paradigms. Traditional healthcare systems, often characterized by fragmentation, institutional biases, and a reactive approach, are increasingly proving inadequate in addressing the complex, multi-layered needs of older adults. This comprehensive report has meticulously examined five pioneering care models – The Green House Project, Senior Emergency Departments (SEDs), Programs of All-Inclusive Care for the Elderly (PACE), Hospital at Home (HaH), and Age-Friendly Health Systems (AFHS) – each offering distinct yet complementary pathways to more humane, effective, and sustainable elder care.

These innovative models collectively champion a paradigm shift towards person-centered care, emphasizing individual dignity, autonomy, and quality of life. They achieve this by fostering intimate, homelike environments (Green House), providing specialized acute care tailored to geriatric needs (SEDs), integrating comprehensive services within the community to prevent institutionalization (PACE), delivering hospital-level acute care in the comfort of one’s home (HaH), and embedding age-friendly best practices across all healthcare settings (AFHS). The evidence consistently demonstrates that these models lead to improved patient outcomes, including reduced hospitalizations, lower readmission rates, decreased incidence of iatrogenic complications, enhanced functional status, and significantly higher patient and family satisfaction.

However, the successful implementation and widespread scalability of these transformative models are not without substantial challenges. Significant initial capital investments, complex and often outdated regulatory frameworks, and the critical need for a specialized, geriatric-competent workforce present persistent hurdles. These challenges underscore the urgent necessity for proactive and comprehensive policy interventions. Such interventions must include adjustments to antiquated reimbursement structures, ensuring they adequately compensate for high-quality, value-based care rather than merely volume of services. Furthermore, regulatory frameworks must be modernized to be more flexible and outcome-oriented, supporting rather than impeding innovation. Crucially, robust investment in workforce development and training programs for geriatric specialists and interdisciplinary teams is paramount.

Embracing and strategically integrating these pioneering models into mainstream healthcare systems offers a profoundly promising pathway towards a future where older adults receive care that is not only clinically excellent but also deeply respectful of their preferences, preserves their independence, and enhances their overall well-being. This societal commitment to transforming elder care is not merely an ethical imperative but also a strategic investment in building a more resilient, equitable, and sustainable healthcare system capable of meeting the evolving needs of an aging world.

Many thanks to our sponsor Esdebe who helped us prepare this research report.

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