The Case for Local Management in Care of Frail Elders

 Posted by on May 1, 2014  No Responses »  Tagged with: , ,
May 012014
 

In 1980, American business discovered W. Edwards Deming and his quality improvement work in the Japanese automotive industry. In fact, that work helped to launch the application of Total Quality Management (TQM) strategies in the American healthcare system.In his final book, The New Economics, Deming outlined a way of seeing, a lens for looking at work and at life. He called this lens The System of Profound Knowledge (SoPK), and using it was to enable improvement in the quality of every facet of business life, including the quality of management, as well as the quality of our interactions with one another and with the environment.

To learn more about SoPK, one can find much detail on a website devoted to Deming’s life and work. And the video narrated by Ian Bradbury provides a good overview, too.

Deming considers the whole of a system. He wrote, “A system consists of components. Any company, any industry, consists of components that are different activities. All the components of the system must contribute to the system, not exist for their individual gains.”

Deming’s work has influenced more than twenty years of healthcare quality improvement efforts; healthcare system leaders have embraced an array of methods and techniques, including rapid-cycle quality improvement, Lean, and others. In general, successful quality improvement efforts require five essential elements:

  • Foster and sustain a culture of change and safety.
  • Develop and clarify an understanding of the problem.
  • Engage key stakeholders.
  • Test change strategies.
  • Conduct continuous monitoring of performance and reporting of findings to sustain the change.

These improvement essentials are a foundation upon which MediCaring communities can begin to improve care for frail elders, in part by addressing the very systems in which they live: Their communities. As Deming notes, systems are everything, in business and in communities. By focusing on local improvements in care for frail elders, MediCaring considers the environments in which frail elders live: in communities, tied to local norms, traditions, standards, resources, and so on. Indeed, frail elders are often tied to geography and local community: They get meals at senior centers or from Meals-on-Wheels, they do not have the resources or the reserves to travel far and search for something better.

Local leadership is able to respond to local needs, priorities, and preferences. It can assess what its residents need, what it can offer, and how to allocate resources. Local leadership in the form of a local board or authority can provide the five elements essential to improved quality in community care of frail elders. Such a board—an MediCaring Board, an ElderBoard—would provide the locus for assessing, monitoring, and managing services.

How might this begin to work? In a community of 50,000 people, it is reasonable to expect that about 500 frail elders need services at any point in time. Imagine how different frail elders’ lives would be if each one had a comprehensive, longitudinal care plan developed in concert with a multidisciplinary MediCaring team. That team would have ready access to those plans, and a commitment to ensuring that priorities were known and addressed. That team would also track outcomes, and shift course to correct gaps.

Such an approach would be a real advance in delivering reliability, quality, and efficiency in care. Those care plans could be used to evaluate a community’s overall services system, both in terms of quantity and quality. Planners and providers could readily see, for example, instances in which a particular service was oversupplied and overutilized, when a less costly service could have met the need. Consider, for instance, that our community has so many nursing home beds that it is simply routine and expedient to house people in those beds, and not in the community.

Aggregating care plans and using them in system planning would allow for ongoing monitoring that could in turn enable system managers to more readily address variations and anomalies that affect utilization and outcomes. For example, perhaps the 50 people who had a major fall with injury last year had widely varying response, ranging from some who received many tests and procedures followed by rapid institutionalization, to those who got short-term treatment, focused assessment including in-home evaluation, and modifications and supports in the home. If the more streamlined treatment group were found to have equal or better outcomes, and was in other ways similar to the other cohort, perhaps clinicians responsible would decide to change their practice patterns.

Taking a broader view, we could begin to plan for greater efficiencies. Consider another example. Let’s assume that a dozen people in one apartment building need home care aides. Rather than sending in a dozen workers for morning activities and another dozen for evening, with a 3-hour minimum work requirement for each, perhaps we could move a few around within a small area – say a few square blocks or miles — and cover all service needs with half as many aides, who would also know with greater certainty how many hours they would be working. It is also possible with a more efficient system to pay these workers higher wages, and concentrate their time on providing services, rather than driving or commuting between far-flung homes.

Periodic review of aggregated care plans would also make it possible to rapidly identify and investigate ineffective services that are being recommended. For example, many persons with a vertebral fracture do not need multiple scans and procedures. Likewise, an elder with attentive family in the area is unlikely to need grocery delivery.

However, there is no such planning, monitoring and rational management of the services for frail elders, or for other vulnerable populations. We are thoroughly inattentive to the per-person costs and quality of the care we provide across all relevant settings, combined with a magical belief that disparate service providers will somehow end up right-sizing their services and optimizing their quality. This is obviously implausible. Without a way to look across the care system for a community, hospitals maximize hospital revenues, nursing homes optimize nursing home investments, nutrition providers optimize grants and budgets for their services, and so on. There is no requirement that these myriad services somehow end up doing “just right” by the population, and it is not at all likely that they ever will.

MediCaring aims to change this status quo. And developing a local authority to start the change is a key step in the right direction.

References

W. Edwards Demming. Interview in Automobile Magazine, Ann Arbor, Michigan, June 1991

key words: MediCaring book, Joanne Lynn, Janice Lynch Schuster, frail elders

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A Future So Bright? Or So Old? Challenges for an Aging America

 Posted by on April 29, 2014  No Responses »  Tagged with: , , , , ,
Apr 292014
 

As much  as we tell ourselves and each other that 80 is the new 60, or 60 is the new 40, we are kidding ourselves, and setting up a future in which the needs of very frail elders are unseen, misunderstood, and unmet. Popular culture and its pressure to be forever young  ignores the reality of aging: That those of us lucky to survive chronic conditions, such as cancer and heart disease, will just grow very old. There are benefits to living—look how many of us prefer to do just that—but there are challenges to aging. We will change: physically, mentally, emotionally and spiritually. Our circumstances will change: independence may give way to dependence, our homes may give way to nursing homes, our working income may give way to financial uncertainty.  Very frail elders, like very young children, have unique and particular circumstances that require attention and care from family and friends, and from communities and government. To understand these needs,  it helps to first understand who frail elders are—or who we mean when we speak of them.

The last century heralded major changes in American health, and in public health. These, in turn, have led to longer lives;  the average US life expectancy for a child born in 2010 was 78.7 years, a thirty-year gain from 1900.  There are simply millions more of us! alive.  Since 1900 the number of Americans over 65 has increased from 3.1 to 41.4 million persons. The increase among the older population will accelerate as the Baby Boomer generation ages. In fact, the Baby Boomers are estimated to reach 80 million persons by 2040.

It is not just that people are aging, but that they are aging into very long lives.  In 2011, the 75-84 group (12.8 million) was 16 times larger and the over 85 group (5 million) was 40 times larger than their populations than at the turn of the 20th century. Those over 85 is projected to triple from 5.7 million in 2011 to 14.1 million in 2040. This is an unprecedented rate of growth for those over 65.

The very old face challenges of inhabiting such old bodies.  More than half of older adults have three or more chronic diseases. Alzheimer’s and related dementias also plays a role in increasing illness and disability. Over 5 million persons over the age of 65 report having Alzheimer’s or a related dementia disease.  By 2050, the number of people age 65 and older with Alzheimer’s disease will nearly triple to 16 million. Currently, nearly one in three deaths are attributable to Alzheimer’s or dementia-related diseases, and Alzheimer’s is the sixth leading cause of death.

People who are frail and have multiple chronic conditions experience problems in completing tasks of daily living, and almost one third of adults over 65 have problems with tasks such as eating, dressing or bathing.  Increasing age comes with increasing struggles;  almost half of those over 85 report difficulty walking and a quarter report difficulty bathing and showering.

We say that these people are frail, but what is frailty and why does it matter?  Geriatricians define frailty as “a clinical syndrome in which three or more of the following criteria were present: unintentional weight loss (10 lbs in past year), self-reported exhaustion, weakness (grip strength), slow walking speed, and low physical activity.” (Fried et al, 2001). A person with none of the indicators is robust, a person with 1 or 2 indicators is pre-frail, and a person with 3 or more indicators is frail.

As we develop and test  MediCaring, it is important to have a standard way to identify frail elders, and to coordinate and deliver the array of services they need. Doing so is imperative: Millions of Americans will now experience an extended period of frailty. We have unprecedented change on the horizon—and an urgent need to respond to the challenges change brings.

References

LP Fried et al. J Gerontol A Biol Sci Med Sci(2001) 56 (3):M146-M157. doi:10.1093/gerona/ 56.3.M146

key words: MediCaring book, Joanne Lynn, Janice Lynch Schuster, aging, frailty

[1] Life expectancy at birth, at age 65, and at age 75, by sex, race, and Hispanic origin: United States, selected years 1900–2010. Centers for Disease Control and Prevention. http://www.cdc.gov/nchs/data/hus/hus12.pdf#018

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The Very, Very Old: The Challenges of Increased Longevity

 Posted by on April 21, 2014  No Responses »  Tagged with: , , ,
Apr 212014
 

A new entry for our forthcoming book on the MediCaring model for care for frail elders. 

Living to be very, very old–advanced old age, the oldest of the old–is not just middle age with gray hair.  It is not. And yet even though we know what is ahead,  very old age will come as a shock to most of us. We have been lulled into thinking that we will all age well–that we will be 90 and still dancing with the stars, or jumping from airplanes. Or we think that we will die with a golf club or a steering wheel in our hands,  a lover in our arms. We expect to go on forever as we always have done, making our own choices, providing for ourselves and our families, and living out our triumphs and despairs surrounded by kith and kin.  We are sustained by complex social and cultural arrangements that influence each of us,and that we influence.  For most of our lives, that framework is almost unnoticed and is enough to meet our needs.  When living with serious limitations in old age, we find that we urgently need assistance for daily needs.

The realities of living with multiple chronic conditions (MCC) and in a challenging economy have changed the experience of retirement. Millions of Boomers will age with  MCCs, such as hypertension, diabetes, glaucoma, arthritis, and even cancer, that will require increasing levels of clinical management to get by. And, at some point, those who survive to  advanced age, will find that at the usual  supports and arrangements no longer match our needs, either for medical care or social services. As we have grown better at preventing or treating diseases like cancer and heart disease,  millions of us will manage to live  into our ninth and tenth decades, developing serious chronic medical problems, and eventually becoming quite old and very frail. Indeed, the fastest growing demographic in America is the 85 and older crowd.

This demographic reality is forcing us to consider another reality:  the challenges often associated with living  into “older” old age, when long-term disability and the confluence of multiple chronic medical problems and diminishing social and financial resources makes a new and unfamiliar set of life challenges. This is truly the new old age: the predictable, but often unexpected, result of better health care and improved public health.

Quite simply, most Americans now face a long slow decline, rather than a short course to death.  For the most part, we will endure this period because life, even when we live with significant health problems, is sweet. But in our current medical and social services environment, enduring will be a real challenge, one that will require significant levels of direct personal help, medical care, and financial resources . We will find that thriving in advanced older age requires  major rearrangements of assumptions about relationships, meaningfulness, and life in general. And many of us will find the task made even more difficult by our collective failure to address what lies  ahead.

Such simple things will throw us off course: One bad fall, and we often cannot live alone in the family home again.  A little more loss of sight, and we cannot drive to get food or to visit friends.  The margin between living as we wish and being in serious trouble becomes quite thin.  Physiologically, people in their eighties and   beyond have very little reserve in most organ systems, so a challenge to the heart, or lungs, or kidneys, or any other organ system leads to evident and serious illness. Unlike younger people, what was once  a minor setback that is behind us within a few days can now lead to death.

The rate of cognitive failure increases dramatically with age: those who make it to age 85 have a 50-50 chance of having serious memory loss as a major part of their life course (1).  Many will have Alzheimer’s type dementia, but some will have strokes, dementia associated with Parkinson’s disease, or another etiology. And those who evade chronic failures of the mind are still at risk of distorted thinking from delirium with a fever, a change in medication, or even dehydration.  The rate of disability for self-care — often called functional disability, or dependency in activities of daily living — also increases dramatically with age.  Most older adults eventually have some problems  walking and moving about.  Many have challenges with communication, incontinence, tooth loss, arthritis, and other troublesome body malfunctions.   These problems continue, and generally worsen, for several (sometimes many) years, through to the end of life.

To live well in late old age, we really have to depend on one another more than we do at any other time in life, except, perhaps, for infancy and early childhood  Sometimes, devices, medications, or simplifying one’s daily routine helps a great deal.  But even then, another person usually must be “on call” in case something goes wrong.  For most of us, there comes a time when we depend on other adults to help us with the most routine acts of daily life, from getting out of bed to getting to the bathroom, from surviving from dawn to dusk.

And yet we do not now have the structures in place that will support our survival. MediCaring offers a new, better, and more affordable model for providing medical care and social services to frail elders and their families. Building it will require ingenuity, trial-and-error, and investment. Whether we build it or not, the very old will come. Build it now, and the future might be easier on us all.

key words: Dr. Joanne Lynn, Medicaring, frail elders

(1) Alzheimer’s Foundation of America. Alzheimer’s Statistics. http://www.alzfdn.org/AboutAlzheimers/statistics.html. Accessed April 21, 2014.

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Sink or Swim: We Urgently Need Better Care for Frail Elders

 Posted by on April 18, 2014  No Responses »  Tagged with: , , ,
Apr 182014
 

This post is the first in a series aimed at describing MediCaring, a new, better, and more affordable model for providing medical care and social services to frail elders and their families. In the next several weeks, we plan to post dozens of articles describing why we need such change, and how to make it happen. These materials will be the heart of a forthcoming book by Dr. Joanne Lynn and the Center for Elder Care and Advanced Illness. We invite you to read, comment, and share, as we build the ideas–and the momentum.

On a family rafting trip several years ago, I found myself bruised and battered after tumbling from a raft  into the raging waters. I was left standing on a rock in the middle of the river–my raft and mates ahead, trying to hold steady and not panic. Desperate though I was to get to them, the last thing I wanted to do was  jump back into the turbulent waters. My initial relief about the safety of my rock was doomed to be temporary. My only course to safety was  to plunge into the dangerous current and swim.  Convinced that I had no other choice, I jumped.

That experience may illustrate how so many of us feel when it comes to navigating the increasingly difficult currents of living to be very old in America. We cling to a false security created by programs like  Medicare, Medicaid, and Older Americans Act, and other social services that have  kept so many afloat for so long. And yet although there are millions of us now, and millions more on the way, we too often find ourselves alone in the currents of a  steadily rising current–one full dangerous and deadly undercurrents of poorly funded supportive services, medical overtreatment, and multiplying health care costs. No way  can we all cling to the same rock, or jump and hope to make it.

We simply cannot keep on this way.  If we do, we will force one another from the rock of current social arrangements. And for as long as the rest of us insist on clinging to that rock, hoping for a miracle rescue, millions of our fellow travelers will experience devastating consequences, as services shrink and costs explode. And we will not sink alone, but will take the fabric of society with us, as essential and important investments in healthy children and a healthy economy become impossible.

Even worse, if we fail to  tackle the challenges of right-sizing services for a much larger population of very old people, we are likely to be forced to   pick and choose who to pull from the river,and who to leave behind. We could attempt to sustain the illusion of helping some by providing the existing supports and services to an ever- shrinking percentage of those in need, while learning to accept that others will not have adequate housing, food, and health care.

That path is unacceptable.

Who among us wants to be saved from suffering and destitution while our friends and loved ones are swept away? Tradition and culture guarantee that we are all in this together. We will have to take our chances, jump in, and swim to a safer but unknown shore, despite our fears and uncertainty about what we might encounter.

We did not, of course, plan for this journey with the idea that we would wind up stuck on a rock in an increasingly threatening environment.  Decades ago, we designed a health care system that was well-suited to the needs and realities of those times. But circumstances have changed, and our systems must now change, too.

The first jump is to understand  a new set of facts and develop a new set of understandings. We can build our future in a way that treats us all fairly as we age, and achievesreliability and efficiency. Success is possible. We can get through the next fifty years of a rapidly aging society, having cared well for one another, and having avoided slowing our overall economic development.

However, the journey will entail some risks, and failing to get underway will only make it harder to succeed. When I plunged into the rapids, I had some strengths to build on. I could swim; I wore a helmet; and my loved ones were cheering me on. I  successful re-emerged on shore. And so too, our society  will improve our chances of navigating to the other side if we build on  our strengths, marshall our resources, deliberately plan for what’s ahead, and encourage and support one another along the way.  We may occasionally wash up in a spot that turns out not to be the best, but we can learn from that, and move on.

Doing nothing, we can continue to tread water and keep afloat a while longer. But eventually, even that hard work will fail.

 

We have a long national tradition of joining forces to solve seemingly intractable problems and challenges. We have never shied from taking on threats to our health, well-being, and security. And although the facts of aging seem so remote, so far away, the risks inherent in doing nothing are hitting us even now. One by one, family by family, we need to jump in and swim.

 

key words: Dr. Joanne Lynn, Medicaring, frail elders

 

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Goodreads Start Here: Articles and Books about Improving Care for Frail Elders

 Posted by on November 22, 2013  No Responses »  Tagged with: , ,
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,

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JAMA Theme Issue features MediCaring article by Dr. Joanne Lynn

 Posted by on November 12, 2013  No Responses »  Tagged with: , , ,
Nov 122013
 

The new theme issue of JAMA (Journal of the American Medical Association) features a dozen opinion pieces that address critical issues in US health care,  including “Reliable and Sustainable Comprehensive Care for Frail Elderly People,” by Dr. Joanne Lynn, director of the Center for Elder Care and Advanced Illness [now the Program to Improve Eldercare] at Altarum.  In her “Viewpoint” essay, Lynn describes the MediCaring model for improving care for frail older adults by integrating health and social services, with monitoring and management by local communities.  Today, she joined JAMA editor-in-chief , Howard Bachner, M.D., Hamilton Moses III, M.D., Ezekiel Emanuel, M.D., and Ph.D., Joshua Sharfstein, M.D., for a  briefing at the National Press Club in Washington, D.C. (Dr. Lynn is among the audience in the cover art, included here.)

This article is article are available on the JAMA web site.

You can watch a 35-minute video of Joanne Lynn’s remarks via the YouTube video shown below. You also can download the PowerPoint presentation that she speaks about in the video.

You can also view a YouTube video of the entire press conference:

Lynn said, “We almost all get to grow old; it’s the terrific success of modern medicine.” Indeed, she noted that  those lucky enough to grow old—including millions of Boomers now on their way—face a health care system not designed or equipped to meet the essential needs of very old people for continuity of care, community-based services, access to nutrition and transportation, and help for family caregivers. Lynn writes that requiring a comprehensive, realistic assessment of each frail elderly person’s situation and development of a shared plan of care,  is the keystone of highly reliable, effective and affordable care. These care plans would inform and direct a person’s care,  and build the delivery system we need in advanced old age. Anchoring the effort in the communities where people live will make them more effective and will allow savings from more efficient medical care to be used to support social services, a plan that Dr. Lynn calls “MediCaring ACOs.”

Lynn concluded today’s remarks with a sense of urgency, and a call to action. “It’s not a hotshot pill anymore, it’s how people are going to live with these conditions,” she said. “We have about a decade to get it right.”

key words: Joanne Lynn, JAMA, MediCaring

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Improving Life for the Oldest Among Us: Altarum Roundtable Highlights Options

 Posted by on October 17, 2013  No Responses »  Tagged with: , , , ,
Oct 172013
 

Nearly 300 people participated in a September Altarum Roundtable, “Advanced Old Age in America: What Can We Count On?” For now, it seems, very little – beyond the urgent need to improve the current fragmented and costly system, which fails to meet the diverse needs of older adults, their families, and their communities.  Panelists, who included congressional representatives, journalists, thought leaders, and community organizers, addressed the intertwined issues of medical services, long-term care and social supports, providing a deeper perspective on the current sorry state of affairs, and exploring new strategies to make our collective future a better place for aging people.

Susan Dentzer, a senior health policy advisor at the Robert Wood Johnson Foundation, moderated the three panels. The first, kicked-off by U.S. Senator Johnny Isakson (R-GA) and Elizabeth Falcone from the office of U.S. Senator Mark Warner (D-VA), included an in-depth look at The Care Planning Act of 2013. That bill would reimburse interdisciplinary teams to help Medicare and Medicaid beneficiaries map out options for living with advanced illness, and document a care plan geared to their own values and preferences and guide the course of their treatment. Other panelists included Shannon Brownlee, a writer who shared her family’s story of the fragmented care her mother received, and how such experiences have become the norm for many aging Americans.  Jennie Chin Hansen, CEO of the American Geriatrics Society, described how we might affect the forces that influence the current system. She suggested that we must address  “the space in between,” the years in late life that are often characterized by increasing dependency, disability, and frailty.

A second panel discussed economic trends, as well as national strategies that could help to create a framework for improving care in advanced old age. This session highlighted ideas by health economist Joseph Antos, from the American Enterprise Institute and John Rother of the National Coalition on Health Care. A third panel examined trends at the community level, with remarks from Mimi Toomey of the Administration for Community Living; Suzanne Burke of the Council on Aging of Southwestern Ohio; John Feather, CEO of Grantmakers in Aging; and Joanne Lynn, Director of the Center for Elder Care and Advanced Illness at Altarum Institute.

Roundtable cosponsors included Grantmakers In Aging, Grantmakers In Health, LeadingAge, National Alliance for Caregiving, National Coalition on Health Care, National Consumer Voice for Quality Long-Term Care, and OWL – The Voice of Midlife and Older Women.

 

key words: Altarum Institute, public policy, aging, elder care, Joanne Lynn

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