health outcomes in patients with multimorbidity. Examples of Policy Levers: • Requiring the Secretary of Health and Human Services to make grants to the states to support the establishment and maintenance of interdisciplinary geriatric mental health outreach teams in community settings where older adults reside or receive social services. • Requiring training programs certified by state licensure boards to place a greater emphasis on communication and interpersonal problem-solving skills in order to strengthen caregiving relationships • Incentivizing workforce training focused on unique social, physical, and mental healthcare needs of older adults. Active Organizations: American Holistic Nurses’ Association, Society for Post-Acute and Long-Term Care Medicine, Eldercare Workforce Alliance, Paraprofessional Healthcare Institute Addressing the Health Needs of an Aging America | 20 Focus Area: Community Health Workers In a fragmented health system, older adults—especially those with multiple, complex conditions— could benefit substantially from the support of community health workers who serve as “system navigators.” Navigator roles for aging and chronically ill patients have developed relatively recently, yet they show promise in helping to patients to manage their health, from serving as peer health coaches and assisting with transitions across care settings. Randomized controlled trials have also shown significant reductions in glycemic control for low-income patients with diabetes. Examples of Policy Levers: • Ensure seniors have adequate access to community-based supports and services that keep enable aging-in-place • Using authority of public health agencies to make evidence-based musculoskeletal programs and resources available to public health and healthcare workers Active Organizations: American Association of Service Coordinators, American Public Health Association Coordinating Care to Improve Age-Related Health Outcomes Fragmentation in the healthcare system between settings and even between professional groups has been proven as an indicator for poor quality, higher costs, and lower health outcomes. Lack of coordination can result in the failure to deliver necessary services and overtreatment that exposes patients to unnecessary risks and costly hospital readmissions. Care coordination, in its most basic form, involves deliberately integrating the activities of two or more participants involved in a patient’s care to provide appropriate and timely care. Typically, care coordination activities fall within the clinical domain, but there are many policy levers that can influence how clinicians provide services to improve the patients’ value of care. The study revealed several strong opportunities for evidence-based policy related to care pathways and bundles, disease management programs, specialized units, discharge coordination and patient navigation, and coordinated delivery of primary care. Learning from the evidence base what interventions improve care coordination, including the results of ongoing demonstration programs, will inform which policy levers could be most effective. Addressing the Health Needs of an Aging America | 21 Focus Area: Care Pathways and Bundles Care pathways are detailed, evidence-based, multidisciplinary plans for the treatment of a particular patient over time and in multiple settings towards an anticipated outcome. For geriatric patients, these pathways often emerge from the results of a comprehensive geriatric assessment and can treat a variety of conditions, such as stroke, colorectal surgeries, hip fractures, and ventilator associated pneumonia. One example is the enhanced recovery after surgery (ERAS) pathway, which has been proven a cost effective strategy for treating patients with major colorectal surgeries. Related to care pathways are bundled payments, which define an “episode of care” and provide a global payment to cover the costs for the episode. This transfers the risk of care from the payer to the healthcare provider to provide the highest quality care at the lowest cost. The payments can include one setting or span across multiple healthcare settings, which are jointly at risk for the care. These bundles