If our work at the John A. Hartford Foundation has taught us one thing, it’s this: In the quest to transform primary care for older adults, a huge part of the answer is deploying more geriatrically expert primary care teams that can coordinate and deliver care designed around the patient’s needs. You could call this the low-hanging fruit of health care reform, because, if there is a population in which we have the biggest opportunity to see improvements in both cost and quality of care outcomes, it is older Americans.
The debate on how best to deliver effective primary care has gone on a long time, sometimes frustratingly so, but it has almost never included a crucial constituency: older adults. Today we are pleased to help change that.
We believe that listening to older adults is essential if we are ever going to transform our primary care system so it can and does deliver well-coordinated, comprehensive, accessible care centered on their needs and goals. This belief has already led the Hartford Foundation to conduct two previous public opinion polls, focused exclusively on adults 65 and older, examining serious gaps in geriatric primary care and mental health care.
Once again I want to call the Hartford community (all of the grantees, fellows, scholars, alums, and friends) to respond to an opportunity to put geriatrics expertise to work.
The Centers for Medicare and Medicaid Services (CMS), the 900-pound gorilla with a checkbook whose actions shape so much of health care for older adults, and its relatively new transformation arm the Center for Medicare and Medicaid Innovation (CMMI), are requesting input from the public on how to achieve large scale transformation of clinician practices. This input will help guide CMS’s policy considerations and potentially lead to the testing of new payment and service delivery models.
Sometime early in March (I almost missed it), CMMI issued a Request for Information (RFI) on Transforming Clinical Practice in which they ask for advice on the processes needed to make truly radical change in health care. The deadline for submitting comments is April 8.
This week, a RAND research team published a report in the Journal of the American Medical Association (JAMA) on a three-year evaluation of Patient-Centered Medical Homes in Pennsylvania, funded by the Commonwealth Fund and Aetna. Since, like almost everyone else, we believe in the potential benefits of enhanced primary care, this is an important paper.
However, its implications are very complicated. I believe the results confirm concerns I had from the beginning that this kind of project wouldn’t work. Why? Because it wasn’t focused enough on the complexly ill and it didn’t incorporate enough special expertise in their care.
The evaluation was led by Mark Friedberg, MD, and used a pre-post, matched practice/patient design where 32 practices worked to become medical homes. The outcomes of the practices and the patients were tracked over three years. A non-random comparison group was created by looking at other practices and patients followed over the same time period to serve as a contrast group not implementing medical home elements.
This month’s issue of The Gerontologist includes a supplement on culture change and transforming nursing homes. The issue features the work of long-time friends of the John A. Hartford Foundation and experts in the field like Deb Saliba, Phil Sloane, Claudia Beverly, Cornelia Beck, and Robyn Stone.
Because nursing homes are an important part of the continuum of care for older adults and not something likely to disappear, we at the Foundation think getting this part of long-term care right is very important (and why we support grantees like PHI—see Amy Berman’s post last week). The papers in the supplement grew out of a conference funded by the Office of the Assistant Secretary for Planning and Evaluation (ASPE) in the U.S. Department of Health and Human Services and convened by RAND to understand what is known and where the gaps are in our understanding of culture change.
Culture change requires modification in both the training and deployment of the health care workforce. It calls for more skillful workers in more effective teams focused on the unique needs and preferences of the individual resident/patient. This long-term care population is necessarily frail and uses a great deal of medical services, along with the supportive services provided by the facilities. .
Over the weekend, Gina Kolata, a New York Times health reporter, wrote a piece on the work of the new Center for Medicare and Medicaid Innovation (CMMI) that was created as part of health reform to test potential improvements in health care organization and delivery.
Interestingly, the slant on the story was on the lack of rigor in the work of CMMI in its failure to use true experimental research designs, those in which participants are randomized to experimental conditions. Using these designs, often referred to as randomized control trials in bio-medicine, yields results that can be interpreted most authoritatively as something about the treatment causing something about the outcome. (Causal inferences.)
Now, I have been critical of the work of CMMI ( See Groundhog Day and Good Judgment Comes from Experience) and of the Centers for Medicare and Medicaid Services (CMS ) more generally in its efforts to answer critical questions about improving health care in America and particularly for the older adult Medicare beneficiaries for whom they are uniquely responsible.
In the world of philanthropy, there are only a handful of foundations focusing on aging and even fewer on aging and health issues.
Five years ago, The SCAN Foundation—an independent private foundation created by, but independent of, The SCAN Health Plan in Long Beach, Calif.,—was born. Over the years, they have been excellent colleagues, co-leaders in Grantmakers in Aging (GIA) and occasional partners on projects. In 2013, the John A. Hartford Foundation and The SCAN Foundation together cofunded an $800,000 grant to the National Committee for Quality Assurance (NCQA) to take on a major challenge: to help develop measures of quality of care for frail and disadvantaged elders that would be based on personalized goals of care and preferences.
In December 2013, Bruce Chernof, MD, president and CEO of The SCAN Foundation, spoke to the Hartford Foundation board about SCAN’s new five-year strategic plan, long-term care reform, and our deepening partnership. We look forward to working with Dr. Chernof and our other colleagues at SCAN over the next five years and beyond.
While we can all see problems in the care of older adults all around us in both our personal and professional lives, figuring out how to deliver better care at a lower cost is not easy.
The John A. Hartford Foundation has been working on demonstration programs for many years and while some are great successes, it is not uncommon for even well-designed interventions to increase costs due to the added services being delivered and the discovery of unmet needs.
Even worse, it is also possible for an intervention designed with all the expertise and good will in the world to fail to change health outcomes or even patient satisfaction with care.
Happy Boxing Day! This holiday season we got an unexpected gift in geriatric medicine.
One of the most easily counted indicators of the success of geriatrics in medical education is the number of graduating resident physicians choosing additional training in geriatric fellowship programs. Each year, the Journal of the American Medical Association compiles the number of trainees in residency and fellowship programs, and the past two years, I’ve graphed the trends and stirred the tea leaves to try to divine the future of the field. (Read Decline in geriatric fellows defies pay boost: +10% = -10% from 2012 and Falling Leaves, Falling Numbers from 2011.)
Last year, I was concerned and puzzled by what looked like continuing and consistent declines in first-year geriatric fellows in Internal Medicine (IM) and Family Medicine (FM) based programs, despite improving financial incentives. This year, there is an abrupt improvement, with first-year fellows in IM and FM rising by almost 20 percent.
While still shrouded in mist, the path to transforming our health care system is becoming more clear.
While the view is still hazy, last week the Centers for Medicare and Medicaid Services (CMS) took a major step to clarify how it will address the major challenge facing Medicare (and therefore our health care system): transforming an episodic, acute-care dominated, fee-for-service system into one that can meet the challenge of complex chronic care, improving the health of older people while reducing spending.
This is the challenge our new “downstream” grantmaking strategy is designed to address, making CMS’s proposal both very welcome and a high-stakes opportunity to advance our hopes.