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.
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.
A workgroup convened by the Alzheimer’s Association has come up with a useful tool to help clinicians detect cognitive impairment during the Medicare Annual Wellness Visit.
This is a great example of one of our new mottos at the John A. Hartford Foundation: “Putting geriatrics expertise to work.”
We’ve spent decades supporting the education, training, and development of experts in the care of older adults. Because of their work through the years, we know so much more about what good care should look like. Now, it’s time to put that knowledge into practice.
If we want to improve primary care for older adults, we need to know something about their primary care experiences. To find out, we commissioned our first poll, with help from Strategic Communications & Planning, called “How Does It Feel? The Older Adult Health Care Experience.” Between February 29 and March 3, 2012, Lake Research Partners surveyed 1,028 adults age 65 and older about their satisfaction with their primary care provider and whether or not their care included recommended services for older adults.
It turns out that the vast majority of older adults are at least somewhat satisfied with their care. But when you ask them specific questions about the care their doctors are providing, it becomes apparent that this satisfaction may be based on a lack of knowledge about what constitutes good care. We asked respondents about whether or not they had received seven recommended medical services that are typically part of a geriatric assessment (see below).
Last week, I wrote about serendipitously discovering the work of Primary Care Progress, a grassroots physician advocacy group trying to strengthen primary care. The serendipity continued shortly after I saw their work in cyberspace, when I got a chance to meet some of its leaders in the real world (in Philadelphia). Because of the Foundation’s belief that enhanced primary care is one of the essential pillars for improving the health of older Americans, last Monday I attended a meeting sponsored by the American Board of Internal Medicine Foundation. The topic: returning joy to primary care.
You might wonder how returning joy to physicians and other people working in primary care (although most meeting attendees were MDs) would relate to the Foundation’s mission of improving the health of older Americans. But I think the evidence is clear that people who enjoy their work do it better, stay in their careers, and make the work seem more attractive to others. And, if we are to provide the kind of comprehensive and proactive primary care that older adults need, we certainly need more primary care providers (of all professions) who really want to do it.
At the Foundation, we have invested significantly in research and training to try to discover how primary care can better support healthy aging. Projects like IMPACT, Care Management Plus, Guided Care, and the Practicing Physician Education initiative have all tried to make that happen. Other projects such as Indiana University’s GRACE and the Atlantic Philanthropies-funded ACOVE Prime have also offered important lessons on how to make primary care more aging-friendly. We continue to be very interested in how reinvestment in primary care careers, improved payment, and systems redesign can make this critical part of the health care system better able to serve the older adult population. And, of course, we are very aware of the defects and frustrations of primary care as it often very ineffectively tries to serve older people, as I’ve written about here and here. (In a few weeks the Foundation will be releasing the results of its first-ever poll of the experience of primary care by older adults that we hope will shed some additional light on this topic.)
As a way to keep in touch with developments in health care for older adults and feed the raging “Jhartfound” social media beast (joke), I have a series of Google searches running that send me an e-mail digest every night of new online content that uses terms like geriatric, long-term care, gerontology, etc. (You wouldn’t believe how much material is online about “geriatric” pets.)
Recently I got a hit about a presentation (see below) that Helen Kao, a UCSF geriatric medicine faculty member (and GeriPal blogger), made to a group called Primary Care Progress. Curious, I followed the link. Helen’s presentation on GeriTraCCC, (Geriatrics Transitions, Consultation, and Comprehensive Care — descended I think from a Foundation grant) was part of TOM Talks: Transforming Outpatient Medicine.
Consider this: a woman is hospitalized for pneumonia and her admission chest x-ray shows an “incidental pulmonary nodule,” or a growth in the lungs. Should she receive serial follow-up imaging to determine the presence of cancer?
Of course! She may have cancer, and who wouldn’t want to know for sure and start treating it?
What if the woman is 85 years old with congestive heart failure, chronic kidney disease, chronic malnutrition, and needs help from others to bathe and dress?
At least once a week for the last 10 years, I have probably said or written that our fragmented and myopic, episodically focused system of care doesn’t meet the needs of older adults with complex, chronic health problems. And if there is one growing aging issue that throws even more sand in the gears of what little systematic care we have, it’s dementia. In this week’s Journal of the American Medical Association, Elizabeth Phelan, a Beeson Scholar alumna, offers powerful evidence about the consequences of this misfit between the capacities of our primary care system and the needs of older adults with dementia, even in one of the best primary care systems in the country, Group Health Cooperative in Seattle, Washington.
Dr. Phelan, along with her colleagues and mentors at the University of Washington/Group Health Cooperative, used an epidemiological study of dementia incidence among senior members of Group Health in Seattle to assess rates of hospitalization for patients with and without dementia. Controlling for age, sex, and rates of co-morbid illness, she found that all-cause hospitalization was 41% higher for patients with dementia. The raw admission rates were 200 admissions per 1,000 patients per year for those without dementia versus 419 admissions per 1,000 patients per year after the onset of dementia.
To make matters worse, when you look at admissions for potentially preventable, ambulatory-care- sensitive conditions–things like urinary tract infections and congestive heart failure that should respond to careful outpatient management–the differential between non-demented and demented was even greater. Raw rates of admissions were 37 per 1,000 patients per year for the non-demented versus 106 per 1,000 patients per year for the demented. Fully adjusted for other, concurrent medical conditions, ambulatory-care-sensitive admissions were 78% higher among the demented than non-demented patients. Now, we don’t know how many of these admissions might actually be preventable, but some surely were. The size of difference is absolutely terrifying.