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Getting Paid for Healthier Patients, Not More Tests

This will help more older adults stay at home longer, an Influencer in Aging says

By Sarah Szanton

(Next Avenue invited all our 2016 Influencers in Aging to write essays about the one thing they would like to change about aging. This is one of the essays.)

As a nurse practitioner providing house calls throughout Baltimore, I've seen patients who had to crawl to the front door to let me in. Others had to throw me the keys from an upper window because they couldn't come down the stairs to the first floor. A 101-year-old had to get off a wheelchair to her knees to get to her own refrigerator.

Did you know that 10,000 people turn 65 each day in the U.S.? While many of those over 65 are healthy and contribute to their communities by tutoring in the schools or volunteering to plant trees, others are like the patients I just mentioned — frail and essentially stuck, getting weaker from a combination of constraints.

The vast majority of older adults want to age in their current communities. This makes sense, since they have many ties there that make life rich. What can we do to help all older adults be as healthy as possible so they can maintain these connections and be active parts of their families and communities?

We are actually at the perfect time in history to consider this.

New Incentives for Health Providers

We are in a period of rapid transformation of health care that started well before The Affordable Care Act. In this transformation, we are going from a time in which medical providers have been paid for procedures and visits to a system in which providers are paid for the actual intended outcome of the system: the health of a large group of people.


Moving from covered procedures to covered lives gives us the perfect chance to change things for my patients. For centuries, we have known that poverty, poor housing conditions and poor education affect health; we are finally in a position to do something systematic about it.

When the medical system starts to be paid for health, forward-thinking providers will start thinking more broadly about all of the factors that affect health. For older adults, these can be simple things in their houses — shaky banisters, unlit stairs, holes in the floor. They can also be issues with their medical care, such as being prescribed 26 medications a day from four specialists. Or issues with their own bodies, such as sitting still all day due to weakness.

Intervention Where It Counts

The combination of these factors — environment, health care and person — can lead to disability or an inability to do daily activities. When someone is unable to do these activities, he or she is three times more likely to be extremely costly to the health care system than people who have diseases but no physical limitations. Fixing items like banisters, lighting and flooring are straightforward, provide benefit to all who live in the house. And these changes last much longer than a medication refill.

Grandma Moses didn’t start painting until she was 78. Eubie Blake performed into his 90s. With changes like the ones I’ve discussed, we may be able to unleash that creativity in scores of older adults.


Sarah Szanton In her position at Johns Hopkins’ nursing school, Sarah Szanton, Ph.D., explores how older adults’ environment and stress can affect their health and well-being. The direction of her work was forged from insights she gained early in her career while making house calls to low-income Baltimore elders as a nurse practitioner. She has since developed CAPABLE, an innovative program providing handyman and nursing services to older adults aging in place that has increased mobility, lowered rates of depression and reduced disability by half. Szanton, who earned her Ph.D. in nursing, is actively sharing her model, and her work has sparked keen interest in state and national policy circles. Read More
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