Primary care tailored to older adults: The Oak Street Health way

Routine primary care is key to proactive health management. In fact, it is the only part of the health care system where an increased availability of providers is associated with better outcomes. Adults in the U.S. who have a primary care provider have 19% lower odds of premature death than those who only see specialists for their care. And as adults age, they need primary care that is tailored toward their changing needs. 

Older adults often have layered health needs that benefit from an integrated approach. For example, 95% of adults aged 60 and older are managing at least one chronic condition. Additionally, an estimated 15-25% of older adults have a behavioral health disorder, and nearly 60% of them do not receive treatment. Older adults are also at a higher risk for loneliness and social isolation related to changes in their health and social situations. 

Oak Street Health^®, part of CVS Health^®, developed a primary care model specifically designed for older adults, integrating physical, behavioral and social care to help patients stay happy, healthy and out of the hospital.

Our value-based care model encourages better patient outcomes, emphasizes strong relationships between patients and providers, and delivers personalized support and services based on patients’ needs. 

• While typical providers manage a panel of 2,500 patients, ours see about 500, allowing them to spend more time with patients.

• Monitoring changes to behavioral health, including providing universal depression screenings, helps identify patients who may benefit from behavioral health support.

• Medical social workers and community health workers help patients access resources, serving as advocates and navigators, to support their health and well-being. 

Hear from Joy, an Oak Street Health patient, about how we help her manage her health through our integrated, personalized approach to care. Watch Joy’s video.

We also assess patients’ risk for acute health events. By categorizing patients into four risk levels, we can appropriately allocate care resources, make sure patients get the level of support they need, and prevent unnecessary emergency department visits and inpatient admissions. Leveraging our clinical data and patient engagement, providers routinely refresh patients’ risk categories based on changes to their risk factors and health status. 

This approach allows for a more in-depth picture of our patients and more timely updates than a claims-based system. For the top 5% of our highest-risk patients, we successfully project 30% of acute events that occur in the next 30 days. And for patients who do need care in the hospital setting, we provide transition care, assist with safe discharges and help them avoid readmissions. 

By focusing on preventive care, screening and diagnosis; chronic condition management; coordination with specialty providers; and ongoing patient engagement and social activities, we aim to empower older adults to take control of their health.  

Learn more about Oak Street Health’s approach (PDF) to helping older adults stay healthy, and how Medicare Advantage enables our unique care model, in our white paper.