Creating a “Wellness Pathway” between health care providers and community-based organizations to improve the health of older adults

To effectively manage the health of older high-risk patients, health care organizations need to adopt strategies that go beyond the doctor's office and into patients' homes and communities. Community-based organizations (CBOs) are important underutilized partners in activating and providing the resources necessary to deliver coordinated, culturally-tailored services to older individuals. This paper describes the process and preliminary results of creating and implementing a “Wellness Pathway” to improve the health of older individuals by coordinating care between health care providers and CBOs, such as senior centers. The Wellness Pathway provides a mechanism whereby health care providers refer patients to programs at the senior center, and senior center staff members refer patients for urgent or primary care services at the health care provider organization. The aim of the project was to determine whether the creation of the Wellness Pathway through the health care provider and CBO education and engagement is feasible and to identify challenges in scalability. During the 6 month study period, 25 patients were referred through the Wellness Pathway, and six patients acted on the referral. Stakeholders at both organizations were interviewed to obtain detailed information regarding their experiences with, and perceptions of, the Wellness Pathway. Patients and providers who participated in the pilot believe that it has the potential to positively impact the health of older patients and is worth continuing. The primary challenges that arose in the implementation of the Wellness Pathway resulted from inadequate levels of health care provider and staff engagement and from lagging patient recruitment.