3.2 How would MediCaring Communities develop the workforce?

In just about every area, some physicians are already providing good care to frail elderly people, despite adverse incentives and challenges. MediCaring Communities would identify those clinicians and teams and build on their successes. Other primary care physicians might well want to follow their lead and focus effectively on the special needs of these very fragile patients. Often, the challenges of serving this population are made even worse when the quality measures in use are misleading. Medicare’s quality metrics at this point are inattentive to personal preferences, calibrated for preventing illnesses and complications in persons with conventionally long lives, and focused entirely on health outcomes. Obviously, the metrics needed for frail elders would start with personal preferences, would adjust to the limited expectation of survival time, and would balance joys and satisfactions in living with realistically limited possibilities for health outcomes. It should be high-quality care to allow a frail elder to eat what is satisfying, to ignore long-term complications of hypertension and diabetes, and to avoid troublesome cancer screening and prevention strategies that have little chance of affecting their remaining lives. But this approach will lead to the physician being judged wrongly to be providing poor quality care.

So, the MediCaring Community could act to remove or reduce some of these barriers and thereby enable a broader set of primary care physicians to serve frail elders well.[63] Most areas will need a service to provide medical care at home. The home-based primary care model from the Veterans Health Administration is very appealing.[64] Implementing the model more broadly in Independence at Home has gone well.[65],[66] Generally, patients will need to shift into this model as it becomes too difficult to come to the doctor’s office. In order to be available to the homebound population and to capitalize on efficiencies of not supporting the overhead of a conventional office, the home-based primary care physician may do best to focus upon this delivery mode, rather than doing home visits during or after office hours.

The Hartford Institute for Geriatric Nursing has developed or referenced a remarkable array of resources, which make it easier to excel at training nurses to serve frail elders with confidence and high standards.[67]

The workforce issues are especially serious for personal care, particularly of persons with dementia. Personal care aides usually have very little training and mostly work without direct supervision. They often come from very different backgrounds than their elderly clients and their families, so language and culture may clash. And the jobs are dramatically underpaid, so many aides work two jobs or very long hours, just to pay essential bills. MediCaring Communities might well undertake to provide more training, a more reasonable wage and benefit structure, and a career ladder, if the availability of skilled aides is a priority concern.

Of course, all of the people providing services need to know the special characteristics of elders in general and of the particular elderly person they are serving. From wound healing to dementia behaviors to dentures and hearing aids, being old and frail is different and requires adjustment of the usual approaches.

[63] (American Geriatrics Society Expert Panel on the Care of Older Adults 2012)

[64] (Edes, et al. 2014)

[65] (Centers for Medicare and Medicaid Services, Independence at Home (IAH) Demonstration: Year 1 Practice Results 2015)

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

[67] (Hartford Institute for Geriatric Nursing 2016)