July 24, 2026
As large numbers of baby boomers become eligible for Medicare, the U.S. is experiencing a demographic surge that is reshaping labor markets, housing and healthcare. At the same time, value-based care models are rewarding better health outcomes, challenging providers in rural and lower-resourced communities to meet the changing needs of their aging patients. It also creates opportunities to connect and transform the delivery of quality care that supports both medical and nonmedical needs.
Over 11% of the OCHIN network’s active patients are 65 or older, and that share is expected to increase as nearly 400,000 additional patients become eligible for Medicare by 2030. Older patients naturally experience greater medical complexity because the risk of chronic diseases such as hypertension, diabetes and heart disease increases with age. They also have more needs outside the doctor’s office, such as transportation, placing additional strain on caregivers.
Another challenge is that many people feel they must transition to larger or more distant health systems to receive the specialty care and services they need as they age. This perception creates challenges for patients and can disrupt longstanding relationships with their care teams, weakening the local care networks that help communities thrive and undermining the stability of community-based care that supports residents’ long-term health.
Fortunately, Medicare often improves access to care through broader coverage, especially for those who were previously uninsured or covered by Medicaid. This allows patients to continue seeing their provider of choice locally. Medicare also reimburses providers at more sustainable rates, helping ensure reliable access to high-quality local care.
Through their partnership with OCHIN, community healthcare teams across the network are well positioned to deliver highly coordinated, person-centered care as the needs of older adults become more complex. This creates opportunities for improved patient engagement and retention, better clinical outcomes, and a more sustainable community-based care system. That advantage begins with the relationships community-based providers have built over time.
How older adults benefit from a connected care network
Community providers understand their patients and their needs best. In many cases, they have been a person’s primary, trusted source of care for years — or even decades.
Many are also deeply connected to the communities they serve, sometimes having been born and raised there. As a result, they are naturally familiar with the challenges their patients face, such as long distances to specialists or a lack of stable housing.
These factors make providers well positioned to continue caring for patients as they age and transition to Medicare. For older adults and their caregivers, staying with the same trusted care team not only helps simplify navigation of complex healthcare systems but also helps ensure that care decisions are informed by longstanding relationships and a deep understanding of patients’ needs. This continuity supports better clinical outcomes and aligns with value-based care models that emphasize coordination, prevention and trust.
OCHIN members are uniquely positioned to care for older adults in this environment, in part because of the highly interoperable OCHIN Epic electronic health record system they use, which can securely and seamlessly share patient information. This platform provides a shared record for each patient, enabling connected, whole-person care across the services a patient may need and the many ways they receive care, from in-person primary care visits to electronic consultations with specialists for complex conditions. OCHIN Epic is tailored to the needs of community health organizations and their patients, with integrations that support older adults in ambulatory and acute care settings throughout the aging journey, including Medicare screening tools, advance care planning tools and risk score calculations.
These tools are designed for community health providers and paired with OCHIN-led initiatives, such as a statewide Medicare readiness assessment. Together, they help providers achieve better outcomes through clinical excellence, stronger day-to-day operations and collaboration across the OCHIN network.
Helping members navigate Medicare for financial sustainability
Delivering high-quality patient care is just the beginning. OCHIN members also receive extensive support to help newly eligible patients transition from Medicaid to Medicare, supporting patient retention and long-term financial stability. This requires not only clinical excellence but also the ability to understand and manage Medicare requirements and value-based care models, including differences in billing, coding and federal reporting regulations.
That is why OCHIN supports providers through hands-on consulting, workforce development programs and strategic partnerships that address the people, processes and technology together. For example, OCHIN works with providers to identify opportunities for growth and improvement through programs such as OCHIN RISES and Own Your OCHIN. Own Your OCHIN helps organizations identify areas for improvement, while OCHIN RISES provides the structure to act on those opportunities, connecting strategy to execution.
The OCHIN+ workforce development portfolio helps expand providers’ capacity to care for more patients by preparing the future workforce, including through training in medical billing and coding. OCHIN also developed a Medicare educational series that includes two introductory resources focused on Medicare fundamentals and the Medicare Shared Savings Program, one of Medicare’s value-based programs. These resources help health centers and provider organizations build the knowledge, readiness and action plans needed to evaluate and succeed in Medicare and value-based care opportunities.
In addition, OCHIN’s Medicare accountable care organization partnership with C3 is designed to support member organizations serving a growing number of Medicare-eligible patients. The partnership combines insights, data and technology from the OCHIN Epic electronic health record with C3’s expertise in Medicare and value-based care to support care management and reduce costs.
Building evidence for healthier aging in community settings
In addition to helping members improve care delivery today, OCHIN also participates in research that can inform how community-based providers support healthy aging over time. Many of OCHIN’s ongoing and completed research studies focus on promoting healthy aging across the network.
For example, an OCHIN-partnered Annual Wellness Visit and Age-Friendly Health Systems project assessed quality improvement approaches used by outpatient clinics to increase the percentage of patients completing a Medicare Annual Wellness Visit (AWV). The research found that dedicating a team member to integrate the 4Ms — mentation, medication, mobility and what matters — can significantly improve AWV completion rates.
Another OCHIN-partnered study focuses on developing an artificial intelligence tool to predict heart disease more accurately, a condition for which older adults are at higher risk. The tool incorporates factors outside the healthcare system that affect health, alongside clinical data, to improve prediction.
Collectively, these efforts build evidence that can help inform how trusted providers deliver sustainable, high-quality care for people with Medicare in their local communities while improving outcomes and supporting performance on Medicare quality measures.
Advancing toward a more resilient future
Shifting U.S. demographics, as baby boomers age into Medicare, present an opportunity for community healthcare providers to strengthen revenue streams and improve long-term financial stability in an era of value-based care. As the trusted knowledge solutions partner to more than 300 community health organizations, OCHIN will continue to help members adapt and evolve their payment models so they can deliver high-quality care to the communities that depend on them.
“OCHIN harnesses shared commitment among members so that together, we are better positioned to deliver more coordinated, high-quality care to even more patients while simultaneously advancing the mission of each health center and achieving greater health outcomes for our most vulnerable patients,” said Michelle D. Gonzalez, president and CEO of TrueCare, an OCHIN member in California.
For more information, visit OCHIN.org.
