if you are a healthcare payer or provider to impact the social determinants of health and improve health outcomes for your patients.  


Impacting Patient Outcomes – Factors That Clinicians Cannot Control


Are Physicians more effective treating aging patients that are not struggling with the issues of isolation, purpose and independence?  Of course, as these are the people that are happy to be alive and want to stay alive.


If we lived in villages like our ancestors where people knew their neighbors and isolation, purpose, and independence were not the issues of aging… Could the long term success rate of clinical procedures be better?  Could the 30 day readmission rate go down to virtually 0% from about 18%?


As reimbursement model moves from fee-for-service medicine to value-based reimbursement, providers will get paid on whether their patients achieve better health outcomes.  With these changes, factors not in control of clinicians can negatively impact providers.


Successful research has been conducted to show that isolation and purpose can impact health.  Landmark study from Archives of General Psychiatry 2012 found that having a strong sense of purpose can actually reduce the detrimental effects of Alzheimer’s disease.  AARP Research in 2010 proved that loneliness was a significant predictor of poor health.


A half-century ago, JFK said, “It is not enough for a great nation merely to have added new years to life. Our objective must also be to add new life to those years.


With 10,000 people a day turning 65 in USA alone, the world is about to experience a Silver Tsunami.   On the other hand, the possible family care givers are dwindling to unsustainable levels, due to smaller families, divorces and relocations.


A proven way to address this crisis is to bring together neighbors for both support and play, in a new local “Village” model.  Enhancing what had worked for centuries for today’s society.


Modern day “Village” movement started in 2002 in Beacon Hill, MS.  Where some seniors pooled money and hired an executive director with a mission of providing services that would enable them to successfully age in their own homes, and prevent need of moving into a retirement community.  This concept has resonated with a lot of seniors in many communities around the country. Thirteen years later there are about 300 communities that are all trying their version of a “Village” and are in various stages of existence.  The ultimate goal of each of these “Villages” is to help people age in their own homes.


Can we transform the Silver Tsunami into a Silver Reservoir, and redefine the way we age?  So what do we mean by “redefining aging”? Aging with Purpose, Independence and Health while socially connected with neighbors who care.


In a California based Village a 90 year old retired florist felt useful, needed and accomplished, when she created flower arrangements for a holiday party that were auctioned off to make money for the Village.  She was in return paid in points, which she used to get help with chores she could not do.


Also, a group of ladies that call themselves the “Knit and Nosh” group, are giving their hands great exercise to keep arthritis in check, while donating blankets to the VA hospital.


An informal survey of a California based Village members, after Village being in operation for about 4 years, revealed that the members rate of 30 day readmission was 0%.  This was not because Village Leaders and staff were trying to impact the metric, but rather there was a care team that was focused on helping people when they had a chronic or acute medical condition.  As an example, when needed a care team member would visit a member in the hospital during a discharge meeting, where they would make a list of needs to transition home.  Care team would then find resources (other members, non-profits, specialized companies etc.) in the community to meet those needs.


Some of the other Villages across the country are developing specific programs to work actively with providers and hospitals to help patients as they are discharged after a procedure or hospital stay.


VillageCore provides a way for communities to transform into Villages that socially engage and connect their seenagers with each other and necessary resources.  These consistent and sustainable Villages will make the medical community more effective by addressing the factors that are out of direct control of clinicians, but yet directly impact patient outcomes.