Rethinking Care for our Nation’s Seniors

Counsell Steven_11 5x7 Blue April 2014By Steven Counsell, M.D.

One of the greatest challenges facing healthcare today is how to appropriately and effectively serve the nation’s growing Medicare population. This is both a clinical as well as an administrative conundrum as the solution must take into account not only the specific healthcare needs of the patient, but the financial and operational resources of the provider and payer. And it must be viewed at both a micro and macro level, so both the patient individually and society as a whole benefit from the course of action followed.

To frame this issue in perspective, Medicare represents approximately 20 percent, or $572 billion, of all national healthcare spending. Each year about one in five seniors is admitted to a hospital at a collective cost of more than $100 billion. More than half of all Medicare beneficiaries receive treatment annually for five or more chronic conditions such as diabetes, heart failure, depression, and diminished physical and/or mental capacities including falls and dementia. To compound matters further, on average, a Medicare patient is seen by two primary care physicians and five specialists in four practices.

Nowhere is the challenge greater or the issue more pronounced than when it comes to treating low-income seniors. This population represents a particularly complex and high-cost group of older adults who often suffer from socioeconomic stressors and low health literacy. In addition, low-income seniors often have multiple chronic conditions for which they habitually fail to receive or follow the recommended standard of care … and so the cycle of pain, suffering and frequent visits to the emergency room and hospital continues.

Achieving improvements in care for the frail elderly, including low-income seniors, is exceedingly difficult. As the American Geriatrics Society accurately notes, quality care for patients with multiple chronic conditions requires development and implementation of individualized, coordinated plans of care. Such plans often call for further evaluation, treatment, referrals, and patient or caregiver education. In addition, coordination usually involves managing care transitions across settings – including nursing homes, hospitals, rehabilitation centers, home healthcare and other sites – and often depends upon a team of geriatrics healthcare providers, which may include physicians, nurses, pharmacists, psychiatrists, therapists and social workers.

Throughout the country programs are in place – and new ones are being tested – that are attempting to provide a best-practice model so as to make a meaningful impact. Most of these programs have at their core a combination of any or all of the following elements: patient education, reliance on evidence-based treatment guidelines, engagement of the family and caregivers, and a dependence on care coordination as a way to end the fragmentation that only adds to the confusion and already high cost of managing multiple chronic conditions.

To effectively move the needle, true innovation is required. One example of this is taking place at Indiana University (IU) School of Medicine, which has developed GRACE Team Care™, an approach that replaces traditional care coordination with a high-intensity care team expressly designed to improve the patient experience and bring measurable improvement results, particularly for low-income seniors, dual eligible, and others with complex medical and social needs. This program is being implemented through the Medicare Advantage program of IU Health Plans and is being successfully applied at several other health plans, medical groups and VA hospitals in select markets around the country.

At the core of the GRACE (Geriatric Resources for Assessment and Care of Elders) program is a unique and specially trained support team headed by a nurse practitioner and social worker who assist the primary care physician in fully addressing a patient’s health conditions and achieving a patient’s goal from the comfort of their own home. The GRACE team provides patients with expert care for geriatric conditions; healthcare education; medication management; and coordination of care between specialty physicians, the emergency department, hospitals and a broad array of community support services. This approach has been proven to enhance quality of geriatric care in ways that optimize health and functional status, improve quality of life, decrease excess healthcare use, prevent long-term nursing home placement and lower overall healthcare costs. In addition studies have shown that GRACE can generate cash flow and cost savings and produce a 95 percent ROI per year for the sponsoring organization.

With the population of Americans 65 and older expected to nearly double to more than 70 million by 2030, providing high-quality, cost-effective healthcare to older adults is imperative. We urge healthcare leaders throughout the industry – hospitals, health plans, physicians groups, allied health professionals, regulators, legislators and others – to welcome new models of care that build upon today’s knowledge and realities while constructing a better system for everyone.

Steven Counsell, M.D., is executive director of the GRACE Team Care program, Mary Elizabeth Mitchell professor and director of Geriatrics at Indiana University School of Medicine and president-elect of the American Geriatrics Society.

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