In health care for older adults (and for everyone really), we know where we want to end up.
It gets articulated in different ways, but generally speaking I think we can all agree we want care for our older loved ones that is coordinated, comprehensive, continuous, and geriatrically expert.
But the path that gets us to that destination is often unclear. To help guide us—the John A. Hartford Foundation and all other stakeholders in the business of health care—we have just funded three grant projects that we hope will shine a light on the way forward.
Two of the grants fall under our new Policy and Communications funding area. First, as a way of helping the nation understand the important lessons to be drawn from the innovation that is so rapidly occurring in health care, we will support Health Affairs, the nation’s leading health policy journal, to publish and widely disseminate research, analysis, and commentary on new health care models that improve health for older adults.
With federal demonstration projects, Health Care Innovation Awards, and other investments from the Centers for Medicare and Medicaid Innovation, along with investments made by foundations like ours and health systems themselves, we have both a tremendous opportunity and a challenge.
How do we learn from what is working as we test new models of payment and care delivery? How do we learn from what isn’t working and avoid duplication of effort and wasted time and energy?
We believe that one way to aid in this effort is to put a spotlight on health care innovations in Health Affairs, a journal that has tremendous influence among policy makers and other health care decision makers (it was cited 91 times in Congressional testimony and the Federal Register last year). We look forward to partnering with Health Affairs and our fellow colleague funders such as the SCAN Foundation in supporting coverage of aging and health policy issues that can have an impact on practice.
Secondly, and also under the Policy and Communications portfolio, we have made a grant to the Dartmouth Institute for Health Care Policy and Clinical Practice.
This project is meant to address a conundrum and impediment for moving forward: For the most part we know who the most complex, highest utilizing, highest cost, and poorly served patients are within our system—mostly older adults with multiple chronic conditions and functional limitations. But we really know relatively little about how this population actually receives their care and from which providers and what types of hospitals and health systems.
We are investing a great deal in primary care as the answer to many health care woes, but how stable and continuous is primary care for complex patients seeing not only their family physician, but also a cardiologist, an endocrinologist, and three other “ologists” focused on different diseases and conditions? How much of a difference in overall costs does it make when states invest more in home and community-based, long-term services compared to institutional nursing home care?
We don’t know.
We hope to learn more about how care is organized—or disorganized—for these vulnerable people through the expertise of Dartmouth and long-time Hartford grantee and geriatrician Julie Bynum MD, MPH, who will take a deep dive into big data (namely Medicare, Medicaid, and nursing home data sets), to reveal heretofore unknown information about older adults with complex care needs—many of whom are so-called “dual-eligible” Medicare and Medicaid beneficiaries—as well as the providers who care for them, the systems in which they receive care, and how this all relates to utilization and costs across Medicare and Medicaid.
This should help us craft better policies and target them more efficiently to change practice, improve care, and reduce costs for this high-need, high-cost population. A publicly available and geographically specific Dartmouth Atlas report will help us understand the variation in cost and utilization across the country and provide a potential avenue for practice change within specific physician-hospital networks.
Finally, under the new Developing and Disseminating Models of Care portfolio, we have funded an exciting 18-month planning grant led by Mary Tinetti MD at Yale University.
In this project, we will strive to find a way forward in true care coordination and patient-centered care for the patients described above who are very complex and seeing several health care providers (all those “ologists”).
Too often, the care received by older adults is not driven by their own goals. Too often, the “team” of health care providers has no sense of those personal health goals and doesn’t communicate with each other effectively, when they should all be working together to align their care around what the patient wants.
By engaging a broad group of stakeholders, including providers, payers, and patients/families, this planning process will identify a set of modifiable problems that influence quality, health outcomes, and health care costs for the most complex older adults. Then the stakeholders and project leaders will aim to develop a new health care delivery approach that better aligns care around patient goals.
If a seemingly feasible and sustainable model can be developed, we will test that approach in real-world health systems as a second phase to the initiative. This will be a multi-phase project aimed at improving care of complex elders through primary care/specialty care redesign and alignment and we know it will be a huge challenge.
But we also believe that by bringing the right stakeholder groups together, we can identify a path forward that leads us to the place where we want to be—better health and health care for older adults.