In May, the Department of Health and Human Services’ newly formed Interagency Coordinating Committee on Healthy Aging and Age-Friendly Communities released a strategic framework for a national plan on aging. This framework outlines collective goals for supporting the health and well-being of older adults: Age-Friendly Communities, Coordinated Housing and Supportive Services, Increased Access to Long-Term Services and Supports, and Aligned Health Care & Supportive Services. Each of these goals involves multiple sectors and stakeholders, and likely multiple policy levers.
How can we tell if we are moving the needle toward these goals? How can we capture the value of our alignment and interventions? How can we do due diligence when seeking to optimize the impact of our on-the-ground work?
The main ways we can do these things are via data and applied research practices. Applied research focuses on helping us understand how to prevent and solve practical problems that affect real people (as opposed to theoretical or basic research, which contributes to general knowledge). Applied research practices help find and correct problems and inefficiencies by studying how a system is working and help us understand and articulate impact by evaluating the effects a program has had.
To answer the above questions, applied research leverages quantitative and qualitative data from various systems and actions relevant to the program. For example, applied research in healthcare is often referred to as health services research, a field that “studies how social factors, financing systems, organizational structures and processes, health technologies, and personal behaviors affect access to health care, the quality and cost of health care, and ultimately, our health and well-being” (Agency for Healthcare Research and Quality, 2014). This quote recognizes the stakeholders and systems that need to be engaged and leveraged in applied research.
Advancing applied research in aging will ultimately improve older adult health and well-being. Yet, it is hard to carve out time to consider opportunities to engage in applied research in new ways. This issue of Generations Journal was designed to explore a range of issues related to applied research in aging, based on our joint interests as co-editors.
Urgent Need for Data
For me, Claire, a palliative medicine physician and health services researcher, what brings me to the issue of health services research is the urgency with which we need better data to advocate for the needs of older adults with serious illness, given our shifting healthcare systems.
In the past decades we have seen a major transformation of healthcare, particularly that which is delivered through the Medicare program, from fee-for-service to value-based care payment structures. The majority of Medicare is now delivered through private insurance companies, via Medicare Advantage (MA) plans, which are paid capitated amounts to deliver care.
Given the MA plan’s strong profit motive, there is incentive and opportunity for such plans to limit
the delivery of important care.
MA plans are particularly appealing for their lower cost-sharing for some services and expanding benefits, and enrollment in them has grown the fastest in Black and Hispanic communities. MA plans promise innovation and flexibility, including expanded abilities to deliver services not covered by traditional insurance but critical to meeting the needs of older adults, such as transportation, meals, and caregiver supports. These plans offer incredible opportunity to meet the needs of older adults.
Yet, given the strong profit motive baked into the MA plan, there is both incentive and opportunity for MA plans to limit the delivery of important care. For example, we have long known that people are more likely to leave the MA program when they become sicker, likely because of challenges with limited provider networks, service denials, and prior authorization requirements. While supplemental benefits are promising, there is minimal transparency in who receives these benefits, and other advantages of MA, such as closer integration of Medicare and Medicaid benefits for some who are dually eligible, have yet to be proven in evaluations.
This growth of the MA program, coupled with tremendous promise and great opacity, calls for applied research into how new benefits and programs through MA could address social needs and if they are reducing or widening disparities in care for the populations they insure.
Outcomes Evaluations Discern Impact in Social Care
And for me, Bonnie, a health policy professional working in a health system’s social work and community health department, much of my work is focused on implementing, refining, and sustaining efforts to address health-related social needs and mental health concerns. As practitioners, it is incumbent upon us to use whatever information we can to ensure we are having our intended impact, finding ways to optimize, and advocating for what we need to do it better and more sustainably.
In practice, this is hard to do. We often cannot measure or access data on the outcomes we most want to study. Documentation and data systems are complex and not nimble, making it a slow process to refine templates and build reports. It can feel daunting to focus more on documentation, data, and research when you are just keeping up with your caseload or workload. However, by seeking out and leveraging data from diverse internal and external sources, program leaders can identify priority populations, project program reach and impact, monitor progress toward goals, address participant and staff feedback, and design outcomes evaluations to discern impact. For instance, at Rush, outcomes evaluations have helped us to understand areas of impact on patients, families, and healthcare providers, and to advocate for additional funding from our institution, philanthropic funders, and from Medicare itself.
While our evaluations and anecdotal feedback consistently show improved patient and family outcomes after our social work and community health worker interventions, it is challenging to identify what it is about their presence and their interventions that contributes to those outcomes. For more than 10 years, leaders in social care have identified a need to understand “which specific service components yield desired outcomes for specific patient populations,” to address social needs at scale (Shier et al., 2013).
‘It is hard to pinpoint causal impact when there are multiple levers involved.’
Applied research on social care has advanced in the past decade; however, questions remain about how social care intervention components—e.g., resource navigation, care coordination, and emotional support—contribute to improvements in health and in care utilization (Gottlieb et al., 2024). For instance, Rush’s social work after-hospital transitional care intervention trial demonstrated statistically significant increases in primary care appointment attendance compared with the control group. Was that primarily because the social worker reminded the patient and coordinated transportation logistics for the appointment? What role did other aspects of the intervention, such as connection with home-delivered meals, identifying in-home caregiver support options, and building a trusting relationship with the patient and family play in enabling them to recover from the hospitalization and ultimately attend that appointment?
What role did other community influences have, such as an advertisement the patient saw for a medication they had a question about, or their neighbor who is always checking in on them? It is hard to pinpoint causal impact when there are multiple levers involved, but applied research practices and innovations provide guideposts for ways we can try.
Advancing Applied Research in Aging
So, what motivates our shared interests in bringing this issue of Generations Journal forward? We both see a challenge and opportunity in research that addresses social needs, traditionally viewed as not in the purview of the healthcare system but necessary to meet the needs of older adults. This is as important for novel programs within an academic health system as it is for evaluations of supplemental benefits delivered through MA plans.
The article by Teresa Moro, Jeannine M. Rowe, and Victoria M. Rizzo appropriately highlights how interprofessional research collaborations can best advance research on social care. Inherent to addressing the social needs of older adults is a deep consideration of how our current systems and proposed programs influence inequities in healthcare delivery. Addressing inequities through health services research is addressed with nuance by Megan Huisingh-Scheetz et al., and Amy Eisenstein speaks to how equity issues may be incorporated in programmatic evaluation.
We also have selected articles highlighting research that has been effectively translated to directly inform care delivery and policies. The authors in this issue of Generations Journal illustrate that impact can occur at many levels: from pragmatic trials and research-practice partnerships where clinical innovations are designed to be most effective in real-world settings, to community-based aging research, to the use of data at the state level to advance caregiver support. We hope these pieces serve as inspiration for where and how applied research can be most effective, and provide valuable lessons in research funding, design, and dissemination.
The articles in this issue highlight the exciting growth in aging health services research that addresses social needs, health inequities, and that directly translates to programs and policies that improve patient care. We are grateful for the opportunity to have worked with such an outstanding group of authors and hope you enjoy learning from all of them.
Claire Ankuda, MD, is an associate professor in Geriatrics and Palliative Medicine at the Icahn School of Medicine at Mount Sinai and lives in Vermont. Bonnie Ewald, MA, is an assistant professor in the Department of Social Work at Rush University in Chicago.
Photo credit: Shutterstock/Wirestock Creators
References Agency for Healthcare Research and Quality. (2014). An organizational guide to building health services research capacity. United States Department of Health and Human Services. https://www.ahrq.gov/funding/training-grants/hsrguide/hsrguide5.html
Gottlieb, L. M., Hessler, D., Wing, H., Gonzalez-Rocha, A., Cartier, Y., & Fichtenberg, C. (2024). Revising the logic model behind health care's social care investments. The Milbank Quarterly. https://doi.org/10.1111/1468-0009.12690
Shier, G., Ginsburg, M., Howell, J., Volland, P., & Golden, R. (2013). Strong social support services, such as transportation and help for caregivers, can lead to lower health care use and costs. Health Affairs, 32(3), 544–551. https://doi.org/10.1377/hlthaff.2012.0170
