May 222012

By Joanne Lynn, M.D.

Readers of this blog are familiar with—and mostly supportive of—these two claims: (1) that social and environmental factors are stronger than health care services in shaping the population’s health, but (2) those factors are weaker than health care services in securing funding and public attention. Most of us are convinced that sending more funds and public support toward healthy food and exercise would do more to improve health than sending those funds toward high-cost medications or surgeries.

My question here is whether we can usefully apply the same perspective to the care needed for frail and disabled elders. Some will want to stop and contend that prevention of disability would still be the priority, and that argument has merit, of course. But “prevention” of disability associated with aging is really mostly delay, and most of us will have a period of serious disability before dying, no matter how well we eat and exercise.

As we age and accumulate illnesses and disabilities, we ordinarily need more and more support to get through the day, and we become less and less able to travel to get what we need. Furthermore, what we most need has to be local—no one travels to a referral medical center for spoon feeding or bed baths! So, we come to be tied to our communities, and to the housing, transportation, service supply and service coordination that our local system offers.

A community that has encouraged substantial new building with universal design and substantial retro-fitting of old buildings will have more elders able to stay at home longer, in comparison with one that is inattentive to making its housing stock elder-friendly. Some communities provide substantial non-medical services such as counseling for personal and financial planning, in-home nutrition and caregiver support, and keeping caregivers and elders in relationship with others. Those communities will have less reliance on nursing homes and hospitals, which is generally what aging persons strongly prefer. Senior-friendly housing and transportation are absolutely essential to the well-being of frail elders.

These claims appear to me to parallel the arguments for attention to social and environmental determinants of health generally. Indeed, the call for an “integrator” function to set priorities and manage systems to achieve population health locally seems also to be the right direction for elder care. If anything, elder care even more urgently needs integration across social services, housing, long-term-care services and health care services. A great deal of public and private funding goes into the uncoordinated cacophony of programs that aim to provide support and health care to frail elders, using probably about half of our lifetime expenditures on illness and disability and yielding remarkable waste, gaps, inefficiency and frustration. We need that integrator—and the integrator needs tools and authority.

In some other countries, care of the disabled and elderly is part of the public health system, alongside maternal-infant health and infectious disease. In the United States, however, services for the disabled and elderly have been outside of the scope of public health practitioners, who generally seem to lose interest when primary prevention fails (as it must). Indeed, at least for the elderly, the U.S. has mostly split the medical services into a quite separate category from the social supports. We fund health care with an open checkbook and we measure quality mostly as if each person faced at most one health challenge. In contrast, we primarily fund social services as poverty programs and rarely measure their quality at all.

From my perspective, engendering a way to manage the local system for elder care across medical and social issues is key to achieving “Triple Aim” goals. Can those advocating for attention to social and environmental determinants of health come to include frail elders and disabled persons in their scope? Well-being while living with serious and even fatal disabling conditions counts. Most of us will live for multiple years in this state—and some of us for much longer. Can’t we come to count improved well-being while ill as part of population health, and employ the tools, perspectives and personnel that now advocate for healthy built environments?

About this post:

This week (May 2012),  Joanne Lynn, M.D., Director for the Altarum Center for Eldercare and Advanced Illness, blogs on Improving Population Health. A few months ago (February 2012), David Kindig asked readers, “Where Would You Put the Money?” Dr. Lynn responded with a provocative comment, which she expands on here. This is reposted with permission of IPH, and is cross-posted on Altarum Institute’s blog, Health Policy Forum).

Key words: population health, frail elders, local integrator function, public health

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