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Author ORCID Identifier

https://orcid.org/0009-0006-4245-1354

Date Available

4-26-2023

Year of Publication

2023

Document Type

Capstone

Degree Name

Doctor of Social Work (DSW)

Faculty

Laura Escobar-Ratliff

Abstract

This capstone reviews three scholarly products that examine how chronically ill older adults interact with healthcare systems and senior service delivery systems in the United States. The systematic literature review examines how community-based senior programs that are funded by the Older Americans Act (OAA) positively impact health outcomes and promote health and wellness among the older adult population. The conceptual paper examines how Accountable Care Organizations (ACOs), Managed Care Organizations (MCOs), Area Agencies on Aging (AAA) interact with the patient and with one another using the lens of Systems Theory. The practice application paper examines best practices regarding care coordination among all systems that impact the older adult, uses a case example to discuss how care coordination addresses service gaps, and discusses strategies that organizational leaders can use among all systems to promote care coordination behaviors. Key findings across all papers include identifying the “systems” that impact the care of the older adult, the impact of community-based senior systems on health outcomes in the population, and complex care coordination all as means to address the social determinants of health among the older adult population.

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