I don’t think we do a great job articulating why we do the things we do at the Hartford Foundation. Given the problems of the un- and under-insured among younger Americans and the many issues in aging beyond health (including basic needs like food, housing, and transportation), why do we think aging AND health is an area that is worth our while?
Our answer is fairly simple: We believe that the aging of our society is just the kind of profound social change that calls for philanthropic intervention. While the health care implications of this social transformation are only part of its consequences, they are as serious as any. Plenty of other foundations have shown how health care in the US is not the high reliability, high quality enterprise that we would all like it to be. However, what many of our health funder colleagues don’t focus upon is the tremendous impact that these quality defects have specifically on older adults (e.g., here and here).
Not only did the new SCAN Foundation sponsored series, “Caring for the Aging Patient: From Evidence to Action” start late last month in The Journal of the American Medical Association, but on Tuesday January 5, 2010, the SCAN-sponsored special issue of Health Affairs, “Advancing Long-Term Services and Supports” was released at a special briefing session at the National Press Club in Washington DC.
SCAN President and CEO, Bruce Chernof, MD kicked off the event with observations about the importance of thinking through the full continuum of long-term care needs of older adults (and the disabled) and the willingness of the policy-analytic community represented by Health Affairs to address the issue.
In the beginning of November, I spoke about nurse-led change at the American Academy of Nursing’s annual meeting. If we are going to reform the health care system, I said, nurses must be at the forefront of change. Nurses have the most contact with patients; they are the most highly respected profession in America, according to the Gallup Poll; and they are 2.3 million strong. They are in the trenches, making health care happen every day, one patient at a time.
In order to create change, nurses need to identify the deficiencies in our health care system, understand what strategies are available to fix them, and make possibly uncomfortable choices in favor of change. Here are a few inconvenient truths that nurses must confront:
Health care reform = better care for older adults. Caring for older adults is nursing’s core business. Although older adults represent only 13 percent of the population, they are 46 percent of patients in critical care; 50 percent of hospital days; 70 percent of home health services; and 90 percent of residents in nursing facilities. Whether or not nurses are geriatric specialists, they still need to know how to provide appropriate care for older adults. Nursing education must address this issue.
Hospital quality = nursing quality. No one has more impact on the quality of care that hospitals provide than nurses. Together with social workers, nurses play a critical role in patient and family education at discharge; in addition, the success or failure of the discharge process directly affects hospital readmission rates. Nursing procedures also directly impact the prevalence of “never” events such as pressure ulcers and hospital acquired infections.
Team care = better care for older adults. Effective teams have a common purpose, specialization of function, defined roles, and processes for coordination in place. Unfortunately, creating them is difficult. Chris Langston, in an earlier post entitled “Team or Mob,” details the factors that work against teamwork in the health care system. Nurses—as well as physicians and social workers–need to put aside desires for autonomy in recognition that teamwork among health care professionals yields the best results for patients.
Nursing must embrace all nurses. Fights over turf, the nursing competence of one degree holder over another, and entry requirements are counterproductive. Nurses need to unite behind change. In fact, nurses must be leaders for change, even if lacking in resources. They cannot wait for others—politicians, bureaucrats, or academic colleagues—to “allow” or “invite them” to join the debate. Nurses have the skills and knowledge we need now to revitalize and reshape the health care system to deliver better care to older adults.
Imagine being on a precarious rocky pinnacle with sheer cliffs plunging all around you. Yet, off in the distance is a much taller mountain range dwarfing the height where you stand. I think this is a metaphor for the journey towards improved health care quality, in general and especially for older adults. As a country we have climbed up a peak of high tech fragmentation, super specialized workforce, and fee-for-service payments that incent procedures rather than outcomes. And while we are not on top of the world, it sure is a long way down if we take the smallest wrong step.
We are living in a system where the quality of care is not adequate, particularly for those with complex chronic conditions who need coordination, education, behavior change, and caring. Worse the pinnacle where we stand is actually falling apart and bits and pieces are sliding into the abyss around us – the failures of quality and value that will only become worse as the population ages and the burden of complex chronic disease becomes more acute. Our pinnacle is crumbling, but we are almost paralyzed by the fear of losing what we still have if we try to make it to those distant heights.
The theme of the Foundation’s annual report this year was leadership–leadership to change the way the US health system prepares health professionals to care for older adults and the resulting quality of care they receive. These are big changes because of the size of the industry involved (16% of GDP and growing) and the counter-cultural nature of the issues–aging of the population, problems in everyday quality of care, and the need for an enhanced workforce–none of which are “sexy” issues.
This week we are very proud of the leadership shown by Lewis A. Lipsitz, MD of Harvard Medical School, Hebrew Senior Life, and the Beth Israel Deaconess Medical Center in Boston. Dr. Lipsitz, Director of the Hartford Center of Excellence in Geriatric Medicine and Training at Harvard University, is a long-time Foundation grantee and advisor. Recently he issued a clarion call for change in an op-ed in the Boston Globe talking about the need to strengthen geriatric medicine, improve care of older adults, and ensure that all physicians have basic competence in their care.