Health AGEnda

Report from the Brain Trust

This month some of the best thinkers in geriatrics (most of whom Hartford is privileged to support as grantees) have an important paper in Health Affairs on the preparation of the physician workforce for care of older adults with chronic conditions.

They start by drawing out the service need implications of the demographic shifts we face (20% of the population >65 by 2030) and noting the poor quality and high costs of providing care to older adults with our current methods. Reasoning from the skills needed to implement effective models of care, such as IMPACT, Guided Care, and GRACE,  they deduce the skills that physicians need in order to successfully participate in these care models. (Already this line of reasoning is a significant departure of the more conventional world view that casts the physician as the alpha and the omega of patient service, regardless of what specific skills he or she may have.)

Finally, from this portrait of the workforce and its needed competencies, the authors get down to business in discussing the human capital infrastructure (i.e. teachers) needed to inculcate these competencies in physicians. They address an ongoing discussion within the geriatrics field: should geriatrics be a clinical specialty, or an academic/educational specialty that provides leadership in teaching, researching, and designing services for high quality care of older adults?  If the latter, it improves care through its impact on other physicians and health professionals, rather than through its own direct care.

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Making the Best Case (Management)

The Guided Care Team at Kaiser Permanente Mid-Atlantic (from left): Cecilia Daub, Kay Lewis, Carol Groves, Lya Karm, Eileen Erbengi, Melanie Lanier

We take great delight in congratulating Kaiser Permanente Mid-Atlantic States Region for winning the 2010 Case In Point Platinum Award in the case management provider program category. Kaiser received the award on April 20 at the National Press Club, in Washington, DC.

The award recognized Kaiser Permanente for their implementation of Guided Care, a proven approach to care management developed by Chad Boult at Johns Hopkins University, with support from the John A. Hartford Foundation and the Jacob and Valeria Langeloth Foundation in partnership with the NIA and AHRQ.

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Irresponsibly Responsible or Responsibly Irresponsible?

I was recently at a site visit for federal policymakers to Baltimore to learn about the Foundation-sponsored Guided Care project directed by Chad Boult.  I’ve already blogged about the trip, highlighting stories of some of the Guided Care patients we met. This time, I want to add some observations inspired by the comments of the physicians working with the Guided Care nurses.

istock_team-leader2colorxsmallIn speaking about their experiences with Guided Care, the three physicians we interviewed were in a quandary. Although they said they enjoyed having a Guided Care nurse and admitted their work now went more smoothly, they could not quite bring themselves to say that patient care was better than before.  One doctor started out with a story of how the nurse working with him had brought him the news of a contraindicated prescription in one of his patients.  At first he said that it couldn’t be true because he knew he didn’t do things like that.  But when confronted with the evidence, he had to admit that he had made a mistake.

Unfortunately, the physicians weren’t willing to make the same admission about Guided Care. They saw the evidence but balked at drawing the logical conclusion: their care was not as high quality before they received a Guided Care nurse.  Several of the physicians said that without the nurse they would have done everything the same, but would just have taken longer.

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Connecting Patients to Policymakers

Recently, we were able to achieve that pinnacle of foundation aspirations–cross-project synergy–when one of our grantees, The National Health Policy Forum at George Washington University, brought its audience of policymaking experts from the major federal agencies to visit another grantee, Guided Care at Johns Hopkins University.

guided-care-logoIt was a timely visit. As health reform is writhing its way through Congress, policymakers are considering how to provide better care more efficiently–especially to the “frequent flying” chronically ill older adults that Guided Care was designed to serve.  Yet it can be difficult to translate knowledge from researchers to a policymaker audience. That’s why the visit included the personal stories of three older adult beneficiaries and a family caregiver.

One of the beneficiaries, Mr. Altman, was the perfect spokesperson to fill the gap between the Guided Care experts and the policymakers.  A WWII veteran of the army air force and subsequently an attorney and long-time member of office of the general counsel in the department of health and human services, Mr. Altman WAS a member of the policymaker audience with his personal clock dialed forty years forward. A powerful speaker despite his serious heart disease and recent bout of thyroid cancer, among other health concerns, he reminisced briefly about his work in the 1960s with the Social Security Administration at the time of the founding of Medicare.

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Guided Care Featured

We were delighted to see Guided Care featured in Anne Underwood’s March 31 post to the New Old Age blog, on the New York Times Web site ( We’re proud of the support the John A. Hartford Foundation has been able to give to Guided Care and encouraged to see the model gaining notable media attention.

guided-care-logoDeveloped by Chad Boult, MD, and his colleagues at Johns Hopkins in Baltimore, Guided Care represents a new kind of health care delivery model that, like another of our programs, Care Management Plus, represents our deep interest in discovering new ways to bring higher quality primary care to older adults in a more cost effective way. Developing and implementing these new models is critical to the future sustainability of Medicare, which is quickly becoming overburdened with the costs of care.

Building off of positive pilot study results, Guided Care is currently being tested at eight primary care sites in the Baltimore-Washington D.C. area in a randomized trial involving more than 900 patients, 300 caregivers, and 48 primary care physicians. So far, results are encouraging.

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