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:

Building reliable and sustainable comprehensive care for frail elderly people:

Health Affairs blog on efficiency contractors by Dr. Joanne Lynn:

Nov 222013

The last few weeks have included a flurry of excellent articles, books, and ideas to review and ponder as we continue to explore ways to improve systems of care for frail older adults. To our mind, of course, chief among these was the November 12 Critical Issues edition of JAMA, which featured a “Viewpoint” by Dr. Joanne Lynn, Director of the Center for Elder Care and Advanced Illness [now the Program to Improve Eldercare] at Altarum. In her article, “Reliable and Sustainable Care for Frail Elderly People,” Lynn outlines the structure for a MediCaring model that would re-balance medical treatment with social services and supports, that would build care plans based on careful assessment of individuals, and that would anchor management in local authorities. The entire article can be accessed at the JAMA Website.

On November 21, The Washington Post featured an editorial by former U.S. Senator Tom Daschle and former Governor and former Secretary of Health Tommy Thompson, describing a new project underway at The Bipartisan Policy Center, which Daschle co-founded. The two will co-chair the Long-Term Care Project with  former Senate majority leader Bill Frist (R-Tenn.) and former White House Office of Management and Budget director Alice Rivlin. Their article, “Who Will Care for America’s Aging Population” notes four key issues that “stand out”:

First, we must figure out how to build a more integrated, efficient, person- and family-centered system of long-term care that ensures that people can access quality services in the settings they choose.

Second, the huge burdens on family caregivers must be more widely shared.

Third, more and better financing tools must be established to help people pay for services.

Fourth, Americans must be educated about how to make smart financial and health-care decisions earlier in life so that the odds of postponing a long-term-care event are increased and the odds of being financially ruined by such an event are decreased.

The December issue of The Atlantic features an essay by Jonathan Rauch, The Hospital Is No Place for the Elderly. The information will not surprise those immersed in these issues, but it provides a clear and compelling story that might attract others, and provide a basis for understanding what is wrong with the current system, and how it might change. Rauch quotes Dr. Lynn, who describes the “frailty course.”

And finally, yesterday’s [11/21/13] New York Times included Dr. Pauline Chen’s take on a new book, The American Health Care Paradox, by Dr. Elizabeth H. Bradley and Lauren A. Taylor on how it is that America can spend so much money on health care–and come up with less-than-remarkable outcomes. As Chen writes:  “the reason the richest country in the world doesn’t have the best health is because it takes more than health care to make a country healthy.”  Chen writes, “…the most thought-provoking writing focuses on America’s previous attempts to integrate social services and health care delivery. It is a sobering list of near-misses and “what-if’s,” testimony to the intractable power of cultural attitudes.”

It is all worth considering. Share your thoughts, too, on what you make of this work, and where we need to head.

key words: Joanne Lynn, Jonathan Rauch, Pauline Chen, Elizabeth Bradley, Lauren Taylor, frail elders,