Making the decision to move into a senior living community is stressful. It’s really the first transition for a lot of older adults and their families, and one I often compare with sending your kids off to school for the first time.

We all try our best to make the move as easy as possible. But helping residents adjust to their new lives is just the first step. Then the focus must turn to providing proactive, personalized whole-person care to help them stay in their new communities longer and avoid unnecessary further transitions.

Many programs and partnerships are available to help your residents age in place, but not all are created equal. At Optum, we believe programs should engage the resident, the family and the communities. Doing so ensures that issues are detected and addressed before they lead to more serious issues, such as unnecessary hospitalizations or transfers to higher levels of care.

When partnering with a care model, the program should include these five components:

Preventing decline

Helping residents maintain activities of daily living should be a top priority, because ADL decline is one of the main drivers for moving people out of their homes and into the next level of care.

Falls prevention and social determinants of health are key parts of that effort. Hip fractures, for example, often can lead residents to a skilled nursing stay. And research demonstrates that it is difficult to regain their previous level of functioning after that type of fracture. A good care model should focus on helping them maintain their independence and safety.

Advanced care planning

Advanced care planning is another critical piece of the puzzle. It’s important to have in-depth, empathetic conversations with residents and their families about where they are, what they value, what their wishes are, where they think they’re going and what their likely disease trajectory looks like.

It can be a difficult conversation, and one that takes several meetings to get through, but it’s necessary to ensure that our treatment plans are aligned with their goals of care. Those conversations often serve as a catalyst to alleviate some of the unknowns for the resident and their family so that they can adequately prepare — both mentally and physically — for what the future might bring.

Care coordination

Making sure residents are getting all the help they need — both from their providers and other external resources — is crucial. Look for a partner that closely monitors all aspects of their care and knows how to tap into all of the services available, whether that’s transportation to off-site appointments, prescription delivery or in-home therapy.

A good partner also knows the local landscape and can direct residents to Medicaid or community resources for assistance with things they might not otherwise be able to afford, such as cleaning and laundry.

Oftentimes, it’s those seemingly small extras that make the difference between whether a resident can stay in their home or must be transferred to the next level of care.

Chronic conditions support

Management of and support for chronic illness is a critical component of all senior care.

We know that chronic illnesses cause decline over time. That’s why it’s so important that residents get proactive care from providers who not only oversee the management of their chronic conditions, but also educate them about their disease trajectory and develop the best plan of care to fit their lifestyle and long-term care goals.

Multi-disciplinary teams to meet residents where ‘they are’

Senior care is changing along with resident demands. This means we must provide more than a “peanut butter spread-approach” to care.

A good partner offers multi-disciplinary care teams that make regular visits to really get to know your residents and who can flex to meet their unique needs. That’s crucial to helping identify changes early and preventing unnecessary and unwanted transfers for care outside of their homes.

Because ultimately, helping residents age in place gracefully, and on their own terms, is all about transitions, whether it’s easing or preventing them.

Jamie Babcock is vice president of clinical operations for senior community care at Optum.

The Optum care model and UnitedHealthcare Assisted Living Plan brings specialized health plan benefits, clinical support and expertise to residents in assisted living communities. The model is led by an advanced practice clinician who works one-on-one with residents to coordinate and support their physical and behavioral health care needs. For more information, visit

The opinions expressed in each McKnight’s Senior Living marketplace column are those of the author and are not necessarily those of McKnight’s Senior Living.

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