Care Coordination for the Sandwich Generation

Eesha Chakravartty, MD

Senior Advantage, a recently launched Cedars-Sinaiprogram, is partnering with "sandwich generation" families to better prepare them and walk them through the aging journey and to protect older adults through outstanding primary care.

"Senior Advantage is especially beneficial for, and is primarily focused on, patients who have chosen Medicare Advantage as their insurance option. The team can leverage those benefits and resources to provide truly comprehensive care," said Cynthia Litt-Deculus, vice president and chief population health officer at Cedars-Sinai.

Read: Medicare Open Enrollment: Learn More About Insurance Coverage for Medicare Participants

A Coalition of Caregivers

Cedars-Sinai's Senior Advantage offers a comprehensive approach to caring for medically complex patients age 65 and older who are enrolled in Medicare Advantage plans. At its core is a designated:

• Primary care physician, focused on older adults
• Pharmacist
• Nurse
• Case manager
• Patient service representative, who assists with scheduling, insurance matters, answering questions, and providing support to patients and their care teams

Care team members meet weekly to discuss patients' issues. They also carefully coordinate with Cedars-Sinaispecialists, collaborating with cardiologists, endocrinologists, neurologists, nephrologists, urologists and surgeons. For example, to treat debilitating arthritis flares, they bring in orthopedists, pain management specialists and physical therapists.

Case managers bridge these connections and steer people in the right direction when multiple, overlapping illnesses make navigation unclear. They oversee patients' overall health, checking in with them and watching for serious, subtle symptoms that can slip through the cracks, such as swollen legs or shortness of breath. If a patient is hospitalized, liaisons smooth those transitions.

"It takes a village to care for an aging patient," Chakravartty said. "Making sure that all care team members are involved at the right time is critical."

From the beginning, the partnership tackles polypharmacy-the use of multiple medications. Aging adults often take a dizzying assortment of 10 to 15 medications across different regimens. Pharmacists closely assess patients' prescription drugs and supplements, with an eye toward dosing, potential drug interactions, medication risks and unnecessary duplications. They also consider everyone's treatment goals. Then, the team whittles down treatments, streamlining them into a more manageable, effective medication plan.

A consistently healthy, balanced diet is another type of medicine for the heart, gut and brain. A missed meal could be dangerous for a diabetic patient over 65. To reinforce its importance, Senior Advantage has a nutrition program. Registered dietitians guide patients on healthy eating habits and weight.

"In all of our interactions, we try to educate families on normal aging, disease processes and treatments, so they're not caught by surprise or frustrated," Chakravartty said. "The hope is that we can arm them with information to not only be aware of what is happening now, but also predict what might happen and plan for the patient's future needs."

Read: How to Manage Multiple Medications

Safety in Numbers

The sandwich generation, patients and doctors are often up against the same enemy: the clock.

A collaborative network affords more time for "head-to-toe" triaging to prevent avoidable complications, illnesses and hospitalizations, said Senior Advantage physician Mary Norman, MD, in Culver City. Visits are typically twice as long as a regular primary care appointment: one hour for new patients, with 40-minute follow-ups.

Physicians give vaccines and screen for cancer, hearing loss, balance and low bone density in an effort to stave off deadly falls and fractures. Dementia is another priority: Each patient is tested for cognitive changes and advised on a personalized brain health plan.

At home, the team provides devices to measure blood pressure and sugar (glucometers) that enable stronger, continuous monitoring. If glucose levels spike after a new steroid medication for back pain, you can sound the alarm before it leads to a trip to the Emergency Department.

Mary A. Norman, MD

"It facilitates an active dialogue," said Leslie Ramirez, MD, a Cedars-SinaiSenior Advantage physician in Beverly Hills.

With caregivers stretched so thin, Cedars-Sinaisocial workers are another key safety net. In tandem with the California Department of Social Services In-Home Supportive Services, the team secures tools to help patients age safely in place, such as transportation to appointments, catheters and durable medical equipment. Patients can also access advanced care planning in primary care, providing an opportunity to clarify their end-of-life care wishes.

These resources provide families with much-needed peace of mind, according to Norman, and an "environment where your loved one has control over their health and is free to find true purpose."

Read: Meeting Older Adults Where They Are

Leslie M. Ramirez, MD

Team Building

Relatives are updated through My CS-Link, and caregivers can join medical appointments virtually from wherever they are. Don't be afraid to speak up for your loved one at every stage or ask questions, experts encourage.

The process starts with choosing a primary care doctor to play quarterback.

"The most important thing that you can do for your aging parent is make sure you have a medical team that you trust," Norman said.

For some, a Spanish-speaking practice such as Ramirez's ensures everyone is on the same page.

"It's not just patient-centered care," Chakravartty added. "It's really family centered."

To make an appointment with Senior Advantage, schedule an appointment directly with Eesha Chakravartty, MD, Mary Norman, MD, or Leslie Ramirez, MD. For any questions, call Cedars-SinaiMedical Network Patient and Provider Services at 800-700-6424 or 310-385-3555, 8 a.m.-5:30 p.m., Monday-Friday.