3.4 What is already known about how to improve medical services for frail elders?

A number of elder care reform programs have demonstrated improvements in care for frail elders by, for example, providing comprehensive care planning, provision of services in the home when appropriate, and ensuring access to community-based services. These programs have reduced use of hospitals and nursing homes and improved quality of life for frail elderly people. The summary below provides evidence for the effectiveness of some of the most prominent programs. As you will see in these examples, there is no shortage of proven strategies. What is missing is the means for financing and spread, which the MediCaring Communities approach provides and which we will explain in Chapters 6 and 7.

Here is a summary of findings on some of the prominent and proven improvements in geriatric medical care that are relevant to the MediCaring Communities model. A MediCaring Community can implement any of these strategies and eventually will incorporate the core improvements in these and more. For each intervention we summarize a description, the evidence for effectiveness, and the evidence for cost savings (when available).

Table 3.1: Evidence-Based Clinical Improvement Examples

Program of All-Inclusive Care for the Elderly (PACE)

Description: Provides health care and LTSS to nursing home eligible seniors 55 and up. Interdisciplinary care teams provide care management and plan service delivery based on each enrollee’s assessed needs. Nearly all enrollees have dual capitation: both Medicare and Medicaid. The PACE program is responsible for all necessary services. The PACE program has been Congressionally authorized for about 30 years and has grown to serving about 35,000 elders.[69] PACE enjoys a good reputation for quality, reliability, and comprehensiveness but has been very slow to replicate. In some states the program is called Living Independence for the Elderly (LIFE). The possibilities of building the MediCaring Community on the PACE foundation are explained in Chapter 7. Read more at http://www.npaonline.org.

Evidence for Effectiveness:

Enrollees compared to similarly frail community-dwelling older adults over a 2-year period showed PACE enrollees had 75% less hospital utilization per enrollee.[70]
PACE enrollees were also less likely to experience pain that interferes with their routine (p<.01) and had better self-reported health than a comparison group in a Home and Community-Based Service (HCBS) program (p<.01).[71]
PACE enrollees were also significantly less likely than the comparison group to have unmet needs in getting around (8%, p<.05), bathing (8%, p<.01), and dressing (6%, p<.05).

Cost-Savings Evidence:

PACE’s Medicaid capitation was 28% lower than predicted fee for service payments for similar patients in alternative LTSS programs.[72]
Another study found a 14% reduction in the months using nursing homes.[73] Since social service needs have no clear boundary, PACE is not expected to save overall costs beyond establishing a reasonable operating reserve. Instead, PACE is expected to serve beneficiaries much better than the usual poorly coordinated and planned service array and to stay within current costs.

Aetna Compassionate Care Program

Description: Care managers (CM) completed a comprehensive assessment of the patient’s needs, provided education and support, gave assistance with pain medications and psychosocial needs, and helped ensure that advance directives were in place and implemented. Some beneficiaries were given expanded hospice benefits, including receipt of “curative treatment” (aggressive or disease-targeted treatment that is usually not part of hospice care).[74]

Evidence for Effectiveness:

Hospice use increased 30.8% to 71.7% for all groups receiving CM compared to control groups, and from 27.9% to 69.8% for the group with CM and enhanced hospice benefits.
All groups receiving CM had between 40 and 85% fewer acute hospital days per thousand members compared with their historical control groups (p<.0001 for all). Medicare Advantage members receiving CM had 2,309 hospital days per thousand members versus 15,217 per thousand members for those not receiving CM (p<.0001).[75]

Cost-Savings Evidence:

Estimated net cost decrease of 22% for Aetna’s commercially insured population compared with a historical control group.[76]

The Bridge Model

Description: Social work-based transitional care intervention that begins in the hospital and continues after discharge to the community. It includes biopsychosocial assessment, integration of psychotherapeutic techniques into care coordination and case management activities to increase patient engagement in their own care, and a standardized approach to hospital-community-Aging Network collaboration.

Evidence for Effectiveness:

20% reduction in 30 day readmissions compared with controls who did not receive Bridge services (p<.05).[77]

Care Transitions Intervention®

Description: During a 4-week program, patients with complex care needs receive specific tools, are supported by a Transitions Coach®, and learn self-management skills to ensure their needs are met during the transition from hospital to home.[78]

Evidence for Effectiveness:

Patients in one trial had reduced rehospitalization rates at 30 days(8.3% vs 11.9%, p=.048) and 90 days (16.7% vs 22.5% p=.04).[79]

Cost-Savings Evidence:

Mean hospital costs were lower for patients in the CTI program ($2,058 vs $2,546, p=.049).[80]

Geriatric Resources for Assessment and Care of Elders (GRACE)

Description: Advanced practice nurse and social worker care for low-income seniors in collaboration with the patient’s primary care physician and a geriatrics interdisciplinary team. The program includes comprehensive geriatric assessment by the GRACE support team, an individualized care plan, and a home visit by the nurse and social worker. GRACE uses a set of evidence-based protocols to manage a number of specified geriatric conditions.[81]

Evidence for Effectiveness:

Decreased emergency department (ED) utilization rates by 5% (year 1), 35% (year 2), and 21% (year 3, post-intervention) for those at highest risk of hospitalization.[82]

Cost-Savings Evidence:

Randomized controlled trial of GRACE in primary care health centers enrolling 951 low-income seniors aged 65+. Increased primary care costs but reduced hospital costs; Group that showed high risk of hospitalization averaged net savings of $1,487 per person-year or 23% in the third year ($5,088 vs. $6,575; p<.001).[83]

Guided Care®

Description: Registered nurse works with two to five physicians in a primary care practice to provide high-risk multi-morbid patients with eight services: home-based assessment of patients’ needs and goals, evidence-based care planning, proactive monitoring, care coordination, transitional care, coaching for self-management, caregiver support, and access to community-based services.[84]

Evidence for Effectiveness:

6% reduction in hospital admissions;
13% reduction in 30-day hospital re-admissions;
26% fewer skilled nursing facility days.[85]

Cost-Savings Evidence:

One cluster-randomized controlled trial found that Guided Care produced a net savings of $75,000 per Guided Care Nurse per year.[86]

Hospital at Home Program

Description: Patients requiring hospital-level treatment receive appropriate diagnostic exams and treatments in the home.[87]

Evidence for Effectiveness:

Patients and family members in the Hospital at Home group rated their satisfaction on a number of care domains significantly more highly than those in the control group. Ratings were higher for Hospital at Home patients on a median of 7 domains compared with 6 domains for the control group (p<.001) and a median of 6 vs. 5 domains (p<.001) for family members.

Cost-Savings Evidence:

The mean cost of care was significantly lower for hospital-at-home care than for acute hospital care ($5,081 vs. $7,480) (p<.001).[88]

Independence at Home

Description: Primary care practices provide home-based primary care to chronically ill beneficiaries with ADL limitations and prior hospitalizations for a three-year period, and make in-home visits tailored to an individual patient’s needs and coordinate their care. This is a congressionally authorized demonstration program.[89]

Evidence for Effectiveness:

Beneficiaries have fewer hospital readmissions within 30 days;
Participants are more likely to have their preferences documented by their provider; and to use inpatient hospital and emergency department services less.[90]

Cost-Savings Evidence:

Demonstration showed overall cost savings of $25 million, and an average of $3,070 per beneficiary in its first year.[91]

Interventions to Reduce Acute Care Transfers (INTERACT)

Description: This program provides a set of evidence-based clinical practice tools and strategies to reduce hospitalizations from nursing homes (NH). The model includes identifying, assessing, and managing conditions proactively to prevent them from becoming severe, managing selected conditions in the NH, and improving advance care planning.[92]

Evidence for Effectiveness:

25 NHs that completed the 6-month INTERACT II intervention had a 17% reduction in hospitalization rates (p=.02).[93]

Cost-Savings Evidence:

Estimated Medicare savings of intervention in a 100-bed nursing home would be about $125,000 per year.[94]

Project RED (Re-Engineered Discharge)

Description: A nurse discharge advocate works with patients during their hospital stay to arrange follow-up appointments, confirm medications reconciliation, and conduct patient education with an individualized instruction booklet. A clinical pharmacist calls patients 2 to 4 days after discharge to review medications.

Evidence for Effectiveness:

Participants receiving the RED intervention had a 30% lower rate of hospital utilization than those receiving usual care. (p<.01)[95]

Cost-Savings Evidence:

Costs were 33.9% lower for those receiving the intervention, an average savings of $412 per person.[96]

Sutter Health Advanced Illness Management (AIM) Program

Description: AIM is an integrated system of care for patients with late-stage chronic illnesses that provides home-based transitional and palliative care and counsels patients and families with the goal of increasing hospice use and decreasing the use of unwanted acute care.[97]

Evidence for Effectiveness:

Hospice referral was compared between AIM enrollees and two Usual Care cohorts, one drawn from the same home health branch as the AIM program (Usual Care I), and one drawn from a demographically similar Sutter branch without AIM (Usual Care II). 28% more AIM enrollees were referred to hospice compared with Usual Care I, (p<.003) and 67% more than Usual Care II (p<.0001).[98]
413 AIM patients who lived at least 90 days following enrollment experienced 54 % fewer hospitalizations over those 90 days compared with the 90-day period before enrollment. Over the same period, intensive care unit days were reduced by 80 percent and length of stay on subsequent admissions was reduced by 26 percent.[99]

Cost-Savings Evidence:

The program resulted in cost savings to Medicare of $760 per AIM enrollee per month, and Net health system savings amounted to $213 per enrollee per month.[100]

Veteran’s Affairs Home-Based Primary Care (HBPC)

Description: Program serves aging Veterans with complex chronic diseases in their homes. Target population is simply “too sick to come to clinic.” The services include primary care visits at home, care planning, coordination of services by a social worker, and caregiver support.[101]

Evidence for Effectiveness:

HBPC veterans had 59% reduction in hospital bed days of care and 89% reduction in nursing home bed days of care.[102]
VA and Medicare-paid hospitalizations combined were 25.5% lower than observed without home-based primary care.[103]

Cost-Savings Evidence:

The HBPC program provided a mean total VA cost of care decrease of 24% in 2002 ($38,000 to $29,000 per patient per year). (p<.001).[104]
During HBPC program Medicare costs were 10.8% lower than projected, and VA plus Medicare costs were 11.7% lower.[105]

[69] (National PACE Association n.d.)

[70] (Meret-Hanke 2011)

[71] (Beauchamp, et al. 2008)

[72] (Wieland, et al. 2013)

[73] (JEN Associates 2013)

[74] You can read more about the Aetna Compassionate Care Program at: https://www.aetna.com/individuals-families/member-rights-resources/compassionate-care-program.html.

[75] (Spettell, et al. 2009)

[76] (Krakauer, et al. 2009)

[77] (Boutwell, Johnson and Watkins in press )

[78] You can read more about the Care Transitions Intervention® at http://caretransitions.org.

[79] (Coleman, et al. 2006)

[80] (Coleman, et al. 2006)

[81] You can read more about Geriatric Resources for Assessment and Care of Elders (GRACE) at http://graceteamcare.indiana.edu/home.html.

[82] (Hong, Siegel and Ferris 2014)

[83] (Counsell, et al. 2009)

[84] You can read more about Guided Care® at http://www.guidedcare.org.

[85] (Boult, et al. 2013)

[86] (Leff, Reider, et al. 2009)

[87] You can read more about the Hospital at Home Program at http://www.hospitalathome.org.

[88] (Leff, Burton, et al. 2005)

[89] You can read more about Independence at Home at https://innovation.cms.gov/initiatives/independence-at-home.

[90] (Centers for Medicare and Medicaid Services, Affordable Care Act payment model saves more than $25 million in first performance year 2015)

[91] (Centers for Medicare and Medicaid Services, Affordable Care Act payment model saves more than $25 million in first performance year 2015)

[92] You can read more about Interventions to Reduce Acute Care Transfers (INTERACT) at http://interact2.net/.

[93] (J. G. Ouslander, et al. 2011)

[94] (J. G. Ouslander, et al. 2011)

[95] (Jack, et al. 2009)

[96] (Jack, et al. 2009)

[97] You can read more about the Sutter Health Advanced Illness Management (AIM) Program at http://www.sutterhealth.org/quality/focus/advanced-illness-management.html.

[98] (Ciemens, et al. 2006)

[99] (Agency for Healthcare Research and Quality 2013)

[100] (Agency for Healthcare Research and Quality 2013)

[101] You can read more about Veteran’s Affairs Home-Based Primary Care (HBPC) at http://www.va.gov/geriatrics/guide/longtermcare/home_based_primary_care.asp.

[102] (Beales and Edes 2009)

[103] (Edes, et al. 2014)

[104] (Beales and Edes 2009)

[105] (Edes, et al. 2014)