Jul 242018
 
Anne Montgomery
Anne Montgomery

By Anne Montgomery

Imagine a meeting in your community — perhaps later this fall or next year — where you assemble a group of like-minded peers: health care providers, organizations offering supportive services, advocates, local leaders, policymakers and other interested stakeholders. You are calling them together because they all have an interest in improving the health and well-being of older adults in the area. Now, further imagine that at this meeting, you are aiming to craft a strategy that will establish, using current programs, a more efficient system of service delivery that reduces spending — in a way that keeps any resulting savings in the community.

If this sounds like something you may want to consider, keep reading! Altarum’s Program to Improve Eldercare has created a financial simulation model that contains essential data, and which can be used to benchmark costs for creating community-anchored eldercare systems. We call this tool “Financial Forecasting for MediCaring Communities.”

Here’s how the tool works:

First you’ll need to know (or create a good estimate for) how many older adults live in the area and require a mix of calibrated services – usually including medical care and supportive services delivered at home. Then you need to examine the improvements that evidence shows are likely to keep them more stable and out of medical crisis more of the time. Next you need a willing group of providers in the area – inclusive of hospitals, physicians and supportive services providers – who are interested in creating a more coherent system for older adults who are living with advanced illnesses and functional limitations. Interested parties you may want to talk to include PACE organizations, Emergency Room clinicians, long-term care providers, Medicare Advantage plans that offer expanded supplemental benefits (which have recently been enabled to look at supportive services in the context of expanded supplemental benefits), home-based primary care programs, and other service arrangements.

Using the tool, you can construct baseline cost estimates for each major service category, from inpatient hospitalization through lab services, durable medical equipment, vision, dental, long-term services and supports (LTSS), and more – on a per-person basis. Then your team projects expected changes in spending over several years, which will come from shifting the mix of services to focus more on primary care, skilled home health care and supportive home care, as well as supportive services (e.g., home-delivered meals, adapted housing and transportation. Because a rapidly expanding body of evidence shows that when lower-cost geriatric care and supportive services are emphasized, utilization of costly inpatient hospitalization and long-stay nursing home placements decline, this then yield targets for reduced overall spending.

After that, the tool will calculate projected savings, taking into account projected enrollment targets. Next you estimate start-up and ongoing administrative costs to implement that changes and to cover an entity (possibly comprised of some of the individuals at your meeting) that will monitor and track how well providers in the area are doing in delivering cost-effective services to frail elders. That entity, which we’ll call an “eldercare council” will be sustained from the savings that the improvements generate, so your team will need a plan for capturing and using at least part of the savings in your community.

Intrigued? We invite you to click on this link and watch the 14-minute video demonstration — https://youtu.be/K8rKW48Felw -– and send us an email if you’d like us to help you create a simulation for your own community: [email protected].org

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Mar 282018
 

By Les Morgan

The following reports were produced as deliverables for our project “Aggregating Care Plans to Manage Supportive Care Services for Elders” (Joanne Lynn, M.D., Principal Investigator).This project is funded by the Gordon and Betty Moore Foundation through Grant GBMF5662 to Altarum Institute. Dr. Lynn will provide a more detailed report on the project as a whole in a following blog post.

We are releasing these reports now particularly to help some of the community groups we are working with on data projects. The first three reports cover technical details of how care plans can be structured, stored, and shared in electronic information systems. Those three reports taken together provide useful information that can be used by community groups seeking insight into eldercare through the use of data aggregation methods.

Communities that are seeking to improve eldercare need trustworthy data to use in setting priorities and in monitoring improvements. One appealing approach is to aggregate existing health-related records and analyze the data for key indicators of how their local system is functioning. However, for most of the communities we have worked with, on a practical level the aggregation of this sort of data seems to be very difficult or impossible, given important concerns over privacy and the serious penalties associated with breaches of privacy obligations. Our hope is that these reports will help overcome some of the obstacles that stand in the way of improving care for some of our most vulnerable citizens.

To read the full reports in PDF format, click on the report name you wish to view.

Report 1

Interim Report on the Variety and Merits of Care Plan Templates and Regulations in Use, Including Implications for Information Technology [PDF]

Joanne Lynn and Les Morgan. October 20, 2017

Effective multidisciplinary clinical teams know their patients but document only a skeletal summary of the case. That summary generally includes diagnoses, basics of the living situation, medications, treatments, and supportive services in use or recommended. The various biases, omissions, and lack of long-term perspectives in the clinical documentation are substantial, as summarized in the report.

Our scan of forms and data formats for care plan documentation shows a wide variety of approaches. All made heavy use of free-text narrative elements. The most complete and up-to-date set of care plan records that we have seen was done longhand on a typewritten sheet by a single care coordinator responsible for over one hundred high-need patients seen at one hospital.

The electronic record systems that we reviewed used only to carry the minimal information needed for a C-CDA transmission mostly limited to immediate and near-term needs. None of the electronic records we examined were being used to record the caregivers with their roles, the prognosis, or an advance directive. None used the existing FHIR data format standards for complete care plans.

Report 2

Interim Report Summarizing Data Aggregation Methods in Use To Date and Their Strengths and Weaknesses [PDF]

Les Morgan. October 20, 2017

This is a high-level Information Technology (IT) architectural review discussing major variations in system design approaches for care plan data aggregation, based on a content analysis of interviews with vendors and some key users. A series of architectural diagrams is included to classify approaches. Our interviews with technology vendors are ongoing, and this preliminary summary of methods will evolve as we see more examples of working systems.

Report 3

Aggregating Patient-Level Data: Regulatory, Ethical, and Privacy Issues for Communities [PDF]

Les Morgan and Joanne Lynn. March 2018

This report gives an overview and assessment of regulatory, ethical, and privacy issues specifically related to the use of aggregated care plan and related health data for analytical use across defined geographical catchment areas. The literature covering regulation and privacy of healthcare data is extensive and often contentious. Our review here highlights some major sources for authoritative guidance, then moves on to the specific situation of using aggregated and de-identified data sets for geographic analysis. Regulations that are specific to requirements for maintaining care plans were covered in our prior project report (Interim Report on the Variety and Merits of Care Plan Templates and Regulations in Use, Including Implications for Information Technology) and are not repeated in this report.

A key conclusion of our review is that using aggregated and de-identified data on a broad geographic basis is probably not restricted as much as many of our community stakeholders and leaders think. Some uses of such data are specifically exempted from key privacy laws when appropriate protections are in place. Some regional health care payer systems and Health Information Exchanges (HIEs) have mechanisms to enable such research now, using very large data sets they have already compiled. This means that it is feasible to carry out pilot projects to demonstrate practical methods for data aggregation and analysis for a community or region in many parts of the United States.

Report 4

Benchmarking the Eldercare Workforce: A Community Focus [PDF]

Meghan Hendricksen and Joanne Lynn. February 2018

The overall purpose of this report is to provide an initial, alpha-version, benchmark of the workforce within geographic communities to use for illuminating comparisons with their own workforce estimates.

This baseline benchmark will provide a tool for consideration, and then feedback for improving the tool. In essence, we are creating the start of a learning system for optimizing the workforce in a geographic community. Once the estimates and ranges become substantiated in multiple communities and improvement activities, the maturing benchmarks will provide a trustworthy source of guidance for communities, where evidence is currently lacking, on what the priority needs are for the workforce that is serving older adults living in the community and also will provide a tool for monitoring improvements. Measuring the local workforce capacity also helps engaged community leaders to envision their whole system and its products, even though that “system” is owned and operated by many different entities that are not necessarily coordinated.

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Jan 232018
 
A photograph of a group of Zuni elders
Zuni Elders Community

On December 5, 2017 the “It Takes YOUR Community” symposium was hosted by Altarum’s Center for Elder Care & Advanced Illness in Washington, DC. This post provides an edited videocast of the event and the edited transcript with links to presentation slides as well as a Resource POD. The primary goal of this symposium was to bring together fellow stakeholders and interest groups involved in addressing the needs of the growing elder population at the policy and grassroots level, and to discuss possible strategies as to how we can stay engaged and think about building community-anchored care systems across the country.

Our diverse and dynamic group of speakers and panelists provided in-depth insight, as well as actionable and practical tools of advocacy models necessary to plan for the community-based health and long-term service and support (LTSS) needs of a growing older population.

The Symposium Transcript has been edited for clarity and readability and includes links the background resources that presenters provided [for additional resources see our Resource POD]. Additionally, here is the final agenda, for your reference.

The Full Videocast can be viewed or you can use the individual links to the agenda below (so you can select which panel discussions you wish to watch). Click on the discussion title [blue text] to link to start the recording of that discussion. You can navigate in the whole recording from any of the links below, for example you can view the entire session by clicking the opening link.

0:00 – 6:29 ~ Opening: Communities and the “Age Wave”
6:30 – 1:04:40 ~ Three Communities: What Are the Driving Factors?
1:04:41 – 1:52:52 ~ The Role of the Federal Government in Supporting Community-Anchored Care
1:52:53 – 2:31:46 ~ Panel Discussion: Drilling Down
2:31:47 – 3:10:04 ~ Financing Projections by Communities and Getting a Handle on Services and Costs: How You Can Approach This as a Community Planning Initiative
3:11:46 – 3:47:28 ~ Where Can Communities Go To Find Some Money to Get Started?
3:47:28 – 3:49:44 ~ Leveraging Action

Copyright © 2017 Altarum, All rights reserved.

Altarum is a national nonprofit whose mission is to create a better, more sustainable future through ideas and action that transform health and health care in America. Learn more at www.altarum.org

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Jun 202016
 

MediCaring Communities: Getting What We Want and Need in Frail Old Age at an Affordable Cost
Published June, 2016
194 pages, 6″ x 9″ (15.24 x 22.86 cm)

ISBN-10: 1481266918

List Price $9.95 at Amazon.com

Americans want a long life and most of us will get to live into our 80’s and beyond, but we have not squarely faced the challenges of living well in the last years of long lives. This book lays out a thoroughly pragmatic way to organize service delivery and financing so that Americans could count on living comfortably and meaningfully through the period of disability and illness that most will experience in the last years of life – all at a cost that families and taxpayers can sustain. MediCaring Communities offers to customize care around the priorities of elders and their families and to manage the local care system so it is reliable and efficient.

MediCaring Communities book cover

MediCaring Communities book (click cover to view on Amazon.com)

Three out of four of us will need long-term care. The period of needing someone’s help every day now lasts more than two years, on average. Most of us will not have saved enough to get through this part of life without financial help from family or government – indeed, we’ll spend almost half of our total lifetime healthcare expenditures in this last part of life, mostly on personal care that is not covered by Medicare. We have not yet required housing to be modified for living with disabilities or secured a ready supply of home-delivered food, and we certainly have not required medical care to focus on the patient and family priorities in order to enable the last years to be meaningful and comfortable. Family caregiving will be a crisis as families become smaller, more dispersed, older, and facing inadequate retirement income for the younger generation.

MediCaring Communities improve care by building care plans around the health needs and living situation of the elderly person and family, and especially from respecting their choices about priorities. The improvements in service delivery arise from integrating supportive services at home with customized medical care and installing local monitoring and management. The improvements in finance arise from harvesting savings from the current overuse of medical tests and treatments in this part of life. These come together in MediCaring Communities.

Strong evidence supports each component, but the real strength is in the combination, where savings support critical community-based services, communities build the necessary environment, and elders and their families craft their course with the help of interdisciplinary teams. This book lays it out, using expansion of PACE (The Program of All-Inclusive Care of the Elderly) as the test case. The book provides a strong and complete guide to serious reform, and just in time for the aging of the Boomers which will escalate the needs dramatically during the 2030’s. Now is the time to act.

You can read extracts online.

Advance Praise for MediCaring Communities

“For decades, Joanne Lynn’s has been the clearest, strongest, most soulful voice in America for modernizing the ways in which we care for frail elders. This essential book is her masterpiece. It offers a magisterial, evidence-based vision of that new care, and an entirely plausible pathway for reaching it. Facing a tsunami of aging, our nation simply cannot afford to ignore this counsel.”
—Donald M. Berwick, MD, President Emeritus and Senior Fellow, Institute for Healthcare Improvement, and former Administrator, Centers for Medicare & Medicaid Services.

“MediCaring Communities integrates good geriatrics and long-term services and supports, and building upon an expanded PACE program can be a tangible start. We should try this!”
—Jennie Chin Hansen, Lead in Developing PACE; Past President, AARP; and Past CEO of On Lok Senior Health Services and the American Geriatrics Society.

About Joanne Lynn

Joanne Lynn, MD, MA (Philosophy and Social Policy), MS (Quantitative Clinical Sciences), is Director of Altarum Institute’s Center for Elder Care and Advanced Illness. Dr. Lynn has served thousands of persons in their last years of life in home care, office practice, hospice care, and nursing homes. She was one of the first hospice physicians in the United States. Dr. Lynn has been a tenured professor at Dartmouth and George Washington University, a quality measurement expert on the staff at the Centers for Medicare & Medicaid Services, the Bureau Chief for Cancer and Chronic Disease in the public health office for Washington (DC), a senior researcher at RAND, and on the Institute for Healthcare Improvement’s quality improvement faculty. She is a member of the National Academy of Medicine, a Master of the American College of Physicians, a Fellow of the Hastings Institute and the American Geriatrics Society, and an author of more than 280 peer-reviewed publications, 80 books and chapters, and a dozen amicus briefs and publications for public commissions.

The reader can learn more about our work and give us advice and insights at MediCaring.org.

About Altarum Institute

Altarum Institute (Altarum.org) is a nonprofit research and consulting organization based in Ann Arbor, Michigan. Altarum integrates independent research and client-centered consulting to create comprehensive, systems-based solutions that improve health. One focus has been addressing the challenges of living with advanced illnesses and disabilities in old age through the Center for Elder Care and Advanced Illness. The dozen staff at the Center aim to help the United States achieve social arrangements that ensure that, when we must live with serious chronic illnesses associated with advancing age, we can count on living meaningfully and comfortably, at a sustainable cost to our families and society.

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Dec 162014
 

by Stephen F. Jencks, M.D., M.P.H.

[Also see companion post by Joanne Lynn, M.D.]

Issue.

The Medicare Readmission Reduction Program (MRRP) encourages hospitals to reduce readmissions within 30 days of discharge by imposing substantial financial penalties on hospitals with more readmissions than would be expected if the same patients were discharged from an average hospital.[1] But some hospitals and communities have succeeded too well and reduced discharges even more than readmissions so that their readmission rates, as currently calculated, do not improve much, which puts them at higher risk for penalties. There are two underlying problems:

First, there are two ways of thinking about, and therefore measuring, the rate of readmissions; and they often lead to quite different results and quite different decisions on penalties. One is discharge-based; the other, population-based. The relationship between the two is simple: (readmissions/discharges) X (discharges/(beneficiary population (1,000s) ) ) = readmissions / (beneficiary population (1,000s))

Patients who are admitted but die during hospitalization or are transferred to another hospital are not counted as discharges from the first hospital.

Second, effective interventions to reduce 30-day readmissions have an effect on admissions that extends far beyond 30-days after discharge and they reduce a lot of other admissions, especially if implemented in partnership with community providers and services.

When Congress created the MRRP, many stakeholders had become aware (and dismayed) that 20% of people enrolled in Medicare fee-for-service and discharged from a hospital were readmitted within 30 days of hospital discharge. Clinical trials had shown that improved processes around hospital discharges could prevent many of these readmissions. The aim of establishing accountability also made a hospital focus desirable. In this view, readmission is a burden resulting from poor hospital discharge processes, whether clinically premature or poorly executed. With that emphasis on discharge processes as cause and cure for readmissions, it was natural for the Centers for Medicare & Medicaid Services (CMS) to choose to estimate each hospital’s expected readmissions as the number of patients whom the hospital discharged and who would be expected to be readmitted after discharge from an average hospital. Most readmission reduction initiatives use this discharge-based readmission rate to measure performance. This discharge-based perspective effectively defines the readmission rate as the percentage of discharges that are followed by a readmission. In this way of thinking, the number of hospital discharges is simply a fact of life, much like the fact that a year has 365.24 days. This view does not see that hospital actions might reduce the number of patients they discharge, and this blind spot causes trouble.

Hospitals actually have a great deal of influence on how many patients they admit and discharge because so many of their discharges are admitted through their emergency department or by hospital-affiliated physicians and because they can collaborate with community services and providers who can forestall patients even coming to the hospital. Population-based hospital discharge rates vary substantially across regions, and they can change over time.

Some policy makers worried that the discharge-based rate could behave in unexpected ways if hospitals took steps that reduced total discharges by more than the reduction in 30-day readmissions. As a result, several programs, such as the Partnership for Patients and the Quality Improvement Organizations’ (QIOs) Care Transitions Program, were designed using a population-based readmission rate or converted to such a rate after evaluating early findings. The population-based rate is the number of readmissions for every 1,000 fee-for-service Medicare beneficiaries in the hospital’s service area. This view sees readmissions as a community health problem, a burden on a population of beneficiaries and the Medicare trust funds that is associated with that population’s use of hospitals just as hospital-acquired infections are associated with use of hospitals. From this perspective, preventing hospitalizations, improving discharge transitions, and improving post-discharge care are equally valid ways to reduce readmissions. Whether the hospital reduced hospitalizations in order to reduce readmissions is less important than being sure that we do not penalize hospitals for taking such steps. Population-based rates are closely aligned with the three-part aim of the National Quality Strategy (individual care, population health, and affordability), not only because they are population-based but also because they reflect the close relationship between care in the community and a hospital’s apparent performance.

Thus, a program can reduce burdens on beneficiaries and Medicare through significant reductions in the population-based discharge and readmission rates but see much smaller reductions in the discharge-based readmission rate. In a companion blog to this piece, Joanne Lynn presents evidence that this attenuation of changes in discharge-based rates has happened repeatedly in community-based readmissions programs. We do not know, at this point, whether attenuation of changes translate into financial penalties but it seems very likely to increase a hospital’s risk.

We also do yet fully understand what specific changes produce these decreases in the population-based discharge rate, but the most parsimonious explanation is that the causes are pretty much the causes of reduced readmissions: Provide urgent care with support for keeping the patient in the community, and you are likely to reduce all admissions, not just readmissions. Enroll more patients in medical homes, and the benefits will not disappear 30 days after hospital discharge. Improve nursing home communications with emergency rooms, and the benefits will not be limited to patients within 30 days after hospital discharge.

What we can foresee is that hospitals, already wary of readmissions reduction because it directly reduces revenue, will become doubly wary if they conclude that reducing discharges may also cause or increase the MRRP penalty. If CMS is penalizing hospitals and communities for succeeding at improving care and reducing costs, the reaction may threaten a very successful set of initiatives. The examples we report are for community-based efforts to reduce readmissions. Hospital-level calculations are generally beyond our capability. CMS can, however, easily determine whether, all else being equal, penalties are more likely or larger in areas where the population-based hospital discharge rate is declining substantially than elsewhere. That information is urgently needed.

What to do.

The purpose of the MRRP is to reduce the burden of readmissions on Medicare beneficiaries and the Medicare trust funds, so the important indicator of progress is the number of readmissions, not the percentage of discharged patients that are readmitted.

Healthcare quality measurement needs to catch up with the National Quality Strategy and add measures of the impact of care on the health of the population that will complement measures of the quality of individual episodes of care such as hospitalizations. In the case of readmission measurement for the MRRP, this need is substantially more urgent because there is good reason to fear that a hospital that engages with its community and does exactly what the MRRP hopes for is more liable to financial penalties under the current, discharge-based measure than it would be under a population-based measure.

The first step is to assess the degree of urgency by examining national evidence on actual penalties. If unreasonable penalties are at all frequent then the problem is far more urgent. This will be complex, because Epstein has already shown in cross-sectional studies that population-based hospitalization rates and readmission rates are positively correlated.[2] At the same time it will be important to develop population-based measures of readmissions and compare their impact on penalties with the impact of discharge-based measures. The obstacles are bureaucratic, technical, and political.

Bureaucratically, the most important obstacle has been a widespread belief that the Patient Protection and Affordable Care Act requires calculating discharge-based rates. In fact, the Act says only that penalties are to be determined from the ratio of observed to expected numbers of readmissions and is silent on how the expected number is to be calculated. The other bureaucratic problem is less tractable: Under current procedures, the steps laid out for implementing a new measure, both at CMS and at the National Quality Forum (NQF) would likely take several years. The process should be expedited if the analysis of current penalties indicates that hospitals are being penalized for success in reducing admissions.

The technical challenges of creating a population-based readmission measure for hospitals are substantial. First, the procedure must find a way to measure each hospital’s population-based hospitalization rate. Second, a method of risk adjustment must be developed and applied so that population-based readmission rates for each hospital and community can be compared. Although these methods are still evolving, adjustments for factors such as neighborhood deprivation[3] are actually easier at the population level. These are difficult tasks, but a first step good enough to improve on the existing model should be possible within a year.

Politically, hospitals will be concerned about accountability for the community hospitalization rate. They will recognize that if hospitals in areas with low hospitalization rates are protected, then hospitals in areas with high hospitalization rates will be more vulnerable.

Some have hoped that traditional risk adjustment could solve this problem, because the most likely scenario is that average risk of readmission increases as the number of discharges decreases. That prospect is not promising, because the most assiduous work on risk adjustment has produced tools of only moderate power. The prospects for solving this problem with improved risk adjustment are not promising.[4],[5]

When you find yourself in a hole you should stop digging. It seems prudent for NQF to suspend endorsement of the pending discharge-based readmission measures and for CMS to delay implementing discharge-based measures if NQF endorses them until CMS has studied and reported the extent to which readmission penalties punish hospitals that are actually reducing both admissions and readmissions and has laid out an approach to any problems found. Finally, the problem identified here underlines the importance of placing a population-based foundation under at least some measures of health care system performance.

Footnotes:

[1] Centers for Medicare and Medicaid Services. Readmission reduction program. Retrieved from http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/AcuteInpatientPPS/Readmissions-Reduction-Program.html

[2] Epstein, A. M., Jha, A. K., & Orav, J. E. (2011 December 15). The relationship between hospital admission rates and rehospitalizations. New England Journal of Medicine 365(24).

[3] Kind, A. J. H., Jencks, S., Brock, J., Yu, M., Bartels, C., Ehlenbach, W., & Smith, M. (2014 December 2). Neighborhood socioeconomic disadvantage and 30-day rehospitalization: a retrospective cohort study. Annals of Internal Medicine 161(11) 765-775.

[4] Yale New Haven Health Services Corporation/Center for Outcomes Research & Evaluation. (2014, July). 2014 measure updates and specifications: Hospital-wide all-cause unplanned readmission – version 3.0. Retrieved from https://altarum.org/sites/default/files/uploaded-publication-files/Rdmsn_Msr_Updts_HWR_0714_0.pdf.

[5] Kansagara, D., Englander, H., Salanitro, A., Kagen, D., Theobald, C., Freeman, M., & Kripalani, S. (2011 October 19). Risk prediction models for hospital readmission: A systematic review. Journal of the American Medical Association 306(15) 1688-1698.

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May 282014
 

While diligently trying to improve care for frail elders, often by filling gaps in the care system, even our most innovative programs tend to work within the constraints that created those gaps in the first place. Dr. Joanne Lynn, Director of the Center for Elder Care and Advanced Illness (CECAI), has been visiting and often coaching many innovative programs as they work to do a better job for their community’s frail elders.

Dr. Lynn reports being inspired and sometimes awed by the deep personal and professional commitments of their program staff. Yet she finds more and more evidence that genuine reforms to create sustainable and reliable arrangements for the services that frail elders need will require breaking out of our increasingly archaic habits. Even the most innovative leaders and programs continue to accept historic barriers and red tape that stymie enduring improvements.

Rules Changes as Game Changers

Think about what you accept in your own work or what you feel that you are forced to accept because of rules and regulations that, in your experience, have simply always been there. Remember, the Centers for Medicare & Medicaid Services Innovation Center can waive most regulations, and even an act of Congress can be undone by later laws. So why do we keep working with the assumptions that home care means being homebound, that skilled nursing facility use means only rehabilitation, and that hospice care requires refusing what the Medicare statute called “curative” treatment? Think about other important changes that we have made in the health care system. Would labor and delivery have changed if we had persisted in thinking that women should be unconscious during delivery? Would hospice have emerged if we had adhered to the belief that randomized controlled trials aiming for small improvements in survival time were all that mattered to cancer patients? Not likely.

Not Just a Body Shop

Yet even our forward-thinking programs continue to categorize people by disease or prognosis. A prominent efficiency contractor (a business working under contract with managed care, bundled payment, or accountable care organizations to reduce expenditures, especially in the post-hospital period) said that its work in the 90 days after hospitalization did not extend to long-term care. Really? A frail elder who needs long-term care is likely to need that care during the first 90 days after hospitalization and planning for the time beyond that. People needing long-term supports need a service delivery system that works with a comprehensive care plan for a good life, not just for a few months of rehabilitation services.

A modern folk song by David Mallet has the wonderful line, “We are made of dreams and bones.” Indeed, each unique individual comes to old age not only with a medical history but, often more importantly, with a lifetime of connections to others, personal and family histories and aspirations, and an array of resources.

Our bodies are not like cars, which can go to the repair shop just for tires. Perhaps a person can sometimes see a doctor for preventive maintenance or repairs to just one body part. But once someone is living with serious illnesses or disabilities, the central challenge is how to live well with those conditions and their treatments. Still, whole sectors of the health care industry continue to operate like repair shops, addressing one treatment, diagnosis, or setting and therefore regularly falling short in providing good care for frail elders.

Comprehensive Care for Frail Elders

Imagine a service delivery system that really worked for frail elders. A key member of a multidisciplinary team would know each person well and understand the particulars of each situation, including strengths, fears, and priorities. The frail elderly person, his or her family, and the care team would develop and agree to a plan of services that optimally helps attain important and achievable goals.

At the same time, an organization representing the community would be continually working toward making available an optimal array of services. Making such an arrangement a reality will require developing new rules and procedures that enable the community to improve service supply and quality. We will have to learn how to evolve from the currently dysfunctional structure, a legacy developed for a different time and a different population with a different set of challenges.

MediCaring Communities

CECAI is now working with several communities whose visionary leaders are moving toward our comprehensive MediCaring® model, learning how to work within current limitations without accepting them. MediCaring offers a strategy that spans settings and time, through to the end of life (and even beyond to support the bereaved). This model goes beyond our traditional focus on medical services by including important services such as housing, nutrition, transportation, social connections, and caregiver support. One idea behind MediCaring is to balance the resources available for medical services with those needed for social supports within each community.

We know that many other communities and organizations are working to similar ends, and we would enjoy hearing more about just what you are doing. Share some compelling stories of how you are using the flexibility of Center for Medicare & Medicaid Innovation waivers or the adaptability granted by capitation or local funding to make a difference for frail elders now! Write us, comment, or share on social media. We are eager to learn from you.

Want to learn more?

The MediCaring reforms:
https://medicaring.org

Building reliable and sustainable comprehensive care for frail elderly people:
https://jamanetwork.com/journals/jama/article-abstract/1769897

Health Affairs blog on efficiency contractors by Dr. Joanne Lynn:
http://healthaffairs.org/blog/2014/04/24/only-evidence-based-after-hospital-care-where-should-the-savings-go/

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Apr 272012
 

On April 13, 2012, Altarum Institute and the Center for Elder Care and Advanced Illness, cosponsored a special event: The Last Word: Influential Women Discuss What Matters When Loved Ones Face Aging.” Moderated by Pulitzer-Prize winning columnist Ellen Goodman, the program featured panelists Cheryl Woodson, Muriel Gillick, Susan Jacoby, Francine Russo, and Joanne Lynn. The group discussed experiences as family caregivers, interactions with patients and families, and myths about what it means to grow old in America. Their conversation sparked lots of enthusiasm and interest.

To watch the entire program, follow this link:

http://www.youtube.com/watch?v=wMDO1RE1vbY&feature=youtu.be

Key words:  Ellen Goodman, Susan Jacoby, Francine Russo, Cheryl Woodson, Muriel Gillick, Joanne Lynn, Janice Lynch Schuster, Altarum Institute, end of life, public policy, aging, caregiving

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Mar 212012
 

By Janice Lynch Schuster

During two days of sessions at the Institute for Healthcare Improvement’s 13th International Summit, I was struck by repeated messages from plenary speakers and learning lab leaders. No matter the particulars of their presentation, each riffed in one way or another on the fact that we can all act now to change and improve health care so that we obtain better care, better outcomes, and lower costs. More than that, each pointed to the unique convergence of social, political, and health care factors that have set us up to get it right this time, to improve care for patients and their loved ones, to create a better environment for health care providers, and to imagine and implement a system in which health and health care are seen as human rights.

In his keynote address, former CMS Administrator and IHI founder Don Berwick, MD, left the audience with five principles on which to base change. In a nutshell: Put the patient first. Protect the disadvantaged. Start at scale—think big and act big. Return the money—drive waste out of the system and return that money to the community. And act locally.

In the spirit of acting locally, Altarum’s Center for Elder Care and Advanced Illness has developed two guides that we hope will help you to apply Dr. Berwick’s five principles to your work. The first of these is our “Get Started” guide (https://medicaring.org/action-guides/get-started/) to help activist service providers and community leaders imagine, design, and implement community-based systems to improve care transitions. The second of these, “The Agitator’s Guide,” (https://medicaring.org/action-guides/agitators-guide/) offers specific things you can do—RIGHT NOW—to improve the lives of frail elders in your community. Both documents embody the principles Dr. Berwick outlined, and give you an opportunity to test out the improvement mantra: What can you do by Tuesday?

If you test these ideas, we’d like to hear about and report your experiences, insights, and progress. Send a note to ([email protected]).

Key Words:  IHI, Don Berwick, Agitator’s Guide, local improvement

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Dec 052011
 

Patients just discharged from the hospital urgently need rapid follow-up in the community. Dr. Joanne Lynn describes the care coordination needed among patients, community providers, hospitals, and other settings, and what’s needed to make it work.

Key words: rapid follow-up, care transitions, discharge planning, quality improvement, rehospitalization

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