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Innovative Healthcare for Chronically Ill Older Persons: Results of a National Survey
Abstract
To describe the origin, scope, operations, funding, and outcomes of innovative healthcare programs for chronically ill older persons.
Cross-sectional survey.
A national expert panel nominated chronic illness programs they believed to be innovative and field tested. The directors of the 31 eligible programs provided descriptive information in 60-minute semistructured telephone interviews.
The innovative programs we surveyed tended to target their services to high-risk patients, use teams of providers to deliver care, designate providers to coordinate multiple components of complex care plans, and shift care from higher- to lower-cost environments and/or redesign the delivery of primary care.
Recent innovations in healthcare programs hold considerable promise for improving the outcomes of chronic care, but most have yet to be rigorously evaluated.
... Thus, the impact of the aging of the population, the need to incorporate therapeutic innovations in clinical therapy (Decreto Real Ley 16/2012, Section I) and the development of personalized medicine and regenerative medicine are going to suppose, undoubtedly, an increase in health expenditure (HSCIC, 2015;Busse, Blümel, Scheller-Kreinsen, & Zentner, 2009;Curtis , 2012). Therefore, reforms and new forms of management are needed to strengthen sustainability, improve efficiency and introduce new models and management tools with coordination of socio-health services (Barr, et al. 2003;Boult, Kane, Pacala, & Wagner, 1999;Cabo-Salvador, de-Castro, Cabo, Ramos, & López, 2017;Cabo-Salvador, Ramírez, Cabo, Ramos, & de-Castro, 2018;Coleman, Austin, Brach, & Wagner, 2009;Sylvia et al., 2008;Weiss, 2007;Wagner, 1998;WHO, 2002;Zwar et al., 2006). Currently, having into account a greater longevity and life expectancy of the population, as well as an increase in the number of people over 60 years of age, the increase in chronic pathologies has meant an increase in healthcare costs in a global manner. ...
... Así, el impacto del envejecimiento de la población, la necesidad de incorporar las innovaciones terapéuticas en la terapia clínica" (Real Decreto-ley 16/2012, Sección I) y el desarrollo de la medicina personalizada y de la medicina regenerativa van a suponer, sin duda, un incremento del gasto sanitario (HS-CIC, 2015;Busse, Blümel, Scheller-Kreinsen, & Zentner, 2009;Curtis, 2012). Por eso, son necesarias reformas y nuevas formas de gestión que permitan reforzar la sostenibilidad, mejorar la eficiencia e introducir nuevos modelos y herramientas de gestión con coordinación de los servicios socio-sanitarios (Barr et al., 2003;Boult, Kane, Pacala, & Wagner, 1999;Cabo-Salvador, de-Castro, Cabo, Ramos et al., & López et al., 2017;Cabo-Salvador, Ramírez, Cabo, Ramos, & de-Castro, 2018;Coleman, Austin, Brach, & Wagner, 2009;Sylvia et al., 2008;Weiss, 2007;Wagner, 1998;WHO, 2002;Zwar et al., 2006). Actualmente, con una mayor longevidad y esperanza de vida de la población, y un incremento del número de personas mayores de 60 años, el incremento de patologías crónicas ha supuesto un incremento de los costes sanitarios de manera global. ...
... El incremento de la longevidad y el aumento de patologías crónicas implica un incremento en la demanda de servicios asistenciales, ya de por sí hoy saturados, lo que implica un incremento en la necesidad de recursos, tanto estructurales y materiales, como humanos, y una oportunidad para la telemedicina y la teleasisten- (Barr et al., 2003;Boult et al., 1999;Cabo-Salvador et al., 2017;Cabo-Salvador, 2017;de-Castro et al., 2014;López et al., 2014;NPHS, 2006;Nolte & McKee, 2008;Oeseburg et al., 2009;Ovretveit & Staines, 2007;Parchman, Zeber, Romero, & Pugh, 2007;Parchman & Kaissi, 2009;Shojania et al., 2006;Sperl-Hillen, 2004;Wagner et al., 2001;Wagner, Davis, Schaefer, Von-Korff, & Austin, 1999). ...
This paper proposes an integrated model of social-health resources management. The authors present the actual challenges for health care, in an environment characterized by longer life expectancy and an increase in the number of patients with chronic pathologies, in a scenario of both, economic and financial crises. Their presentation includes management and financial issues, and the technological trends –such as the development of personalized and regenerative medicine– which will lead to an increase in health spending. The task of facing these challenges, they explain, cannot be postponed, the goals should be to improve: the efficiency in the use of health resources, the quality of health care and the level of patient satisfaction. Finally, they present some concepts about the application of information and communications technologies in health, show its relationship with the chronic patient care and present both, the current management models for this type of patient and the new proposed model.
... Multiple studies in the past have noted the prevalence of chronic diseases in the aging populationseven of the most prevalent chronic illnesses in the US (and their associated in-patient expenses) include: coronary artery diseases ($25.6 billion), heart failure ($15.2 billion), chronic obstructive pulmonary diseases ($6.2 billion), mental health disorders ($3.9 billion), diabetes ($3.8 billion), hypertension ($3.2 billion) and asthma ($1 billion) [6]. Medicare's high-risk patients, approximately 8 million currently, with five or more chronic diseases account for approximately 78% of all health care spendingwell over a trillion dollar per year and/or over two-thirds of Medicare's annual spending [3,6,17]. Many healthcare experts agree that current Medicare expense patterns are a reflection of chronic illnesses managed unsuccessfully [6]. ...
... The conceptual model is designed to meet the healthcare needs of the Medicare's high-risk patients (approximately 8 million) with five or more chronic conditions accounting for over two-thirds of Medicare's annual spending [3,6]. A large percentage of chronic diseases deteriorate to the point where a crisis is reached resulting in long term hospitalization and monitoring of patients at huge costs to the healthcare sector. ...
... A large percentage of chronic diseases deteriorate to the point where a crisis is reached resulting in long term hospitalization and monitoring of patients at huge costs to the healthcare sector. The proposed study focuses on the following chronic illnesses in the US (and their associated in-patient expenses) include: heart failure ($15.2 billion), diabetes ($3.8 billion), hyperten-sion ($3.2 billion) accounting for a total of $22.2 billion in total Medicare expenses [3,6]. ...
Healthcare costs in the US are approximately 15% of GNP and are anticipated to reach 17% of GNP in the near future. Management of chronic diseases via technology based ubiquitous patient monitoring services has been widely proposed as a viable option for economizing healthcare resources, and providing efficient, quality healthcare. The process of ubiquitous patient monitoring is information intensive, the information generated is not only fragmented but also spans multiple processes, artifacts, parameters, and decision criteria. The current study explores the complexities associated with the process of ubiquitous patient monitoring and the enabling technologies. The key contribution is a framework that captures the complex processes, the parameters involved, and the decision criteria for ubiquitous patient monitoring. The decision protocols and enabling technologies supporting the processes are detailed in the study along with the opportunities and challenges of ubiquitous patient monitoring. A conceptual model of ubiquitous patient monitoring is developed by leveraging the proposed framework and is validated by a usage scenario. Finally, the implications of future research and contributions of the current research are discussed.
... They continue: "perhaps most difficult of all -there are few models of implementation by individual physicians, large medical groups, or healthcare delivery systems to draw upon" (Coye et al., 2009). Continuing to ask why? will even tually lead us to the "principal barriers" to innovation in chronic care: the (poor) effects of benefit design and reimbursement mechanisms (Baron and Cassel, 2008;Bodenheimer, 2008;Boult et al. ,1999). ...
Purpose: The purpose of this paper is to describe an alternative approach to telemonitoring patients suffe ring from Chronic Heart Failure (CHF), i.e. the BusinesstoConsumer model (B2C), by extending the current BusinesstoBusiness model (B2B). The B2C model is the one where the customer, in this case the patient, is the payer for the services consumed. We describe and perform an initial evaluation of the extension of the B2B to the B2C model for telemonitoring patients with CHF. Design/Methodology/Approach: We explored the problems in implementation of telemonitoring via the B2B model by means of a Root Cause Analysis, including the 5-whys method to help us understand the shortco mings of the B2B approach, and then the 5W1H method to explore whether the B2C is a better strategy. The extension of the model was executed in the Business Model Generation framework. By using qualitative con tent analysis techniques we supported our argumentation with findings from other studies. Findings: The B2C model is based on the interplay of four agents-Healthcare Provider, Equipment Manufac turer, Payer/Regulator and Distributor/Promotor-all working together to improve health related outcomes in a jurisdiction. The success of the extended model in telemonitoring CHF hinges on Telemonitoring Center and Telehealth Nurses being repositioned in the outofthe hospital setting. Social implications: We believe that penetration of mobile telehealth via the B2C model will allow for greater availability, access and equity in healthcare for patients with CHF. Originality/Value: We introduced a fourth pillar to the existing B2B model, i.e. Distributors and/or Promotors. The B2C model we propose does not exist currently but might allow for scalability, generalizability and trans ferability of telemonitoring currently unattained with the B2B model.
... The Next Generation -As reported in the September 1999 American Journal of Managed Care, geriatric care experts have determined that the ideal care of chronically ill older persons should be proactive, comprehensive, continuous, coordinated, efficient, evidence based, and predicated on the preferences and involvement of patients and their families. 3 Thus far, the practical application of this level of care has been elusive for innovative leaders in geriatric care. Clearly, the evolving innovations in the care for chronically ill older persons have produced mixed results, and the few evidence-based "best practices" have achieved only a modest penetration into mainstream care. ...
... "In a capitated environment, organizations bearing financial risk have strong financial incentives to identify their high-risk members early and to provide them with special care designed to optimize their health and avert health-related crises. They have longer-range incentives to promote continued good health among older enrollees who are not chronically ill." (Boult, 1999) Capitated plans can be much more flexible than the traditional Medicare program in establishing innovative services, and many of the innovative programs for patients with chronic disease have been based in health maintenance organizations. Unfortunately, capitated risk-contracting in Medicare is not doing well at this time -for reasons that go well beyond the scope of this paper. ...
... The relative reduction in the burden of communicable diseases and rapid ageing of the population have produced a boom in chronic-degenerative conditions and an increasing imbalance between the most prevalent health problems and the care provided by health and social systems. All stakeholders in these sectors, and their leaders, should be increasingly encouraging the adoption of a different model to enable effective care to be provided for chronic conditions [35,36]. ...
The aim of this research is to highlight the current relevance of the Innovative Care for Chronic Conditions (ICCC) Framework, as a model for change in health systems towards better care for chronic conditions, as well as to assess its impact on health policy development and healthcare redesign to date.
The authors reviewed the literature to identify initiatives designed and implemented following the ICCC Framework. They also reviewed the evidence on the effectiveness, cost-effectiveness and feasibility of the ICCC and the earlier Chronic Care Model (CCM) that inspired it.
The ICCC Framework has inspired a wide range of types of intervention and has been applied in a number of countries with diverse healthcare systems and socioeconomic contexts. The available evidence supports the effectiveness of this framework's components, although no study explicitly assessing its comprehensive implementation at a health system level has been found.
As awareness of the need to reorient health systems towards better care for chronic patients grows, there is great potential for the ICCC Framework to serve as a road map for transformation, with its special emphasis on integration, and on the role of the community and of a positive political environment.
... Se describen los requerimientos de la plataforma tecnológica diseñada para soportar los proyectos y ensayos de las fases 1 y 2. Como ejemplo de actuación en la fase 2 se describe un ensayo sobre hipertensión arterial. tean y buscan alternativas más efectivas y eficientes [4][5][6] . Aspectos como la educación del paciente respecto a su enfermedad, la importancia de un seguimiento adecuado, o la coordinación entre profesionales y niveles asistenciales, son centrales en los nuevos modelos propuestos. ...
Se presenta una metodología para la introducción progresiva y ordenada de servicios específicos de e-Salud para el seguimiento extrahospitalario de pacientes crónicos. Identificado como un modelo de pasos con filtro para la gestión del proceso global de introducción, se presenta formalmente estructurado en tres pasos: 1) exploratorio (fase de proyecto piloto); 2) evaluación en profundidad (fase de ensayo clínico), y 3) despliegue (fase de uso tutelado). En la primera fase, controlada por el equipo de I+D, los criterios predominantes son los de funcionalidad y utilidad de las tecnologías involucradas. En la segunda fase, controlada por una Agencia de Evaluación de Tecnologías Sanitarias, prevalece el criterio científico asociado con los resultados obtenidos en el ensayo clínico. La tercera fase es controlada por decisiones de las administraciones sanitarias sobre la introducción de nuevas tecnologías y su financiación. Se describen los requerimientos de la plataforma tecnológica diseñada para soportar los proyectos y ensayos de las fases 1 y 2. Como ejemplo de actuación en la fase 2 se describe un ensayo sobre hipertensión arterial.
... Furthermore, the fragmentation of health service delivery is particularly problematic for the frail elderly as it results in discontinuity and poorer quality of care[5]. In response to these challenges, public policies have been increasingly directed at coordinating actions and improving public health by integrating services with long-term case management[6,7]. Integrated health service networks (IHSNs) have been developed to improve continuity and increase the efficacy and efficiency of services, especially for older and disabled populations. ...
While the active participation of general practitioners (GPs) in integrated health services networks (IHSNs) plays a critical role in their success, little is known about the incentives and barriers to their actual participation.
Data were gathered through semi-structured interviews and a mail survey with GPs enrolled in SIPA (system of integrated care for older persons) at 2 sites in Montreal. A total of 61 GPs completed the questionnaire, from which 22 were randomly selected for the qualitative study, with active and non-active participation in the IHSN.
The key themes associated with GP participation were clinician characteristics, consequences perceived at the outset, the SIPA implementation process, relationships with the SIPA team and professional consequences. The incentive factors reported were collaborative practices, high rates of elderly and SIPA patients in their clienteles, concerns about SIPA, the selection of frail elderly patients, close relationships with the case manager, the perceived efficacy of SIPA, and improved professional practices. Barriers to GP participation included high expectations, GP recruitment, lack of information on SIPA, difficult relationships with SIPA geriatricians and deterioration of physician-patient relationships. Four profiles of participation were identified: 2 groups of participants active in SIPA and 2 groups of participants not active in SIPA. The active GPs were familiar with collaborative practices, had higher IHSN patient rates, expressed more concerns than expectations, reported satisfactory relationships with case managers and perceived the efficacy of SIPA. Both active and non-active GPs reported quality care in the IHSN and improved professional practice.
Throughout the implementation process, the participation of GPs in an IHSN depends on numerous professional (clinician characteristics) and organizational factors (GP recruitment, relationships with case managers). Our study provides guiding principles for establishing future integrated models of care. It suggests practical guidelines to support the active participation of GPs in these networks such as physicians with collaborative practices, recruitment of significant number of patients per physicians, the information provided and the accompaniment by geriatricians.
... As the Medicare health maintenance organisation industry has evolved during the past 15 years, a substantial body of research has shown the cost effectiveness of several new approaches to caring for chronically ill older people. [2][3][4] The new interventions are summarised in the table; some change how and where health care is provided while others focus on educating patients and adapting their behaviour. ...
... The participation of nurse case managers in primary care practices, for instance, has shown benefits in elderly patient mortality and physician satisfaction (Schraeder et al., 2001). As yet, however, such interventions have met with very little acceptance by health care organizations or third party payers (Boult, Kane, Pacala, & Wagner, 1999;Wagner, Davis, Schaefer, Von Korff, & Austin, 1999). None of our participants had access to such personnel. ...
Many primary care physicians find caring for elderly patients difficult. The goal of this study was to develop a detailed understanding of why physicians find primary care with elderly patients difficult.
We conducted in-depth interviews with 20 primary care physicians. Using an iterative approach based on grounded theory techniques, a multidisciplinary team analyzed the content of the interviews and developed a conceptual model of the difficulty.
Three major domains of difficulty emerged: (i) medical complexity and chronicity, (ii) personal and interpersonal challenges, and (iii) administrative burden. The greatest challenge occurred when difficulty in more than one area was present. Contextual conditions, such as the practice environment and the physician's training and personal values, shaped the experience of providing care and how difficult it seemed.
Much of the difficulty participants experienced could be facilitated by changes in the health care delivery system and in medical education. The voices of these physicians and the model resulting from our analysis can inform such change.
... By the year 2010, the number of individuals with one or more chronic illnesses is expected to reach 120 million (2). Among the elderly, as much as 75% of the total cost of direct medical care in the United States is spent on individuals suffering from chronic illnesses (3). In view of the enormity of these numbers, the need for a healthcare system that is able to provide effective care for individuals with chronic conditions is obvious. ...
Current estimates are that there are 2.3 million individuals with epilepsy among 99 million Americans suffering from chronic medical conditions. The healthcare system is designed to treat acutely ill patients and, as a result, often fails to meet the needs of the chronically ill. Care is provided in brief, problem-focused visits. Multiple studies have shown that this type of standard practice produces suboptimal care and outcomes, and is unsatisfactory to both patients and care providers. We developed the Chronic Care Model in an effort to synthesize system and practice changes associated with better outcomes. In patient care as described in this model, patient-provider interactions are planned in advance in accordance with evidence-based guidelines. A primary focus is on assisting patients and their families in becoming competent self-managers. The Chronic Care Model has been successfully implemented by more than 200 healthcare systems. In this paper, we explore the applicability of the Chronic Care Model in managing patients with epilepsy.
... Se describen los requerimientos de la plataforma tecnológica diseñada para soportar los proyectos y ensayos de las fases 1 y 2. Como ejemplo de actuación en la fase 2 se describe un ensayo sobre hipertensión arterial. tean y buscan alternativas más efectivas y eficientes [4][5][6] . Aspectos como la educación del paciente respecto a su enfermedad, la importancia de un seguimiento adecuado, o la coordinación entre profesionales y niveles asistenciales, son centrales en los nuevos modelos propuestos. ...
A methodology is presented for a smooth, orderly implementation of specific e-Health services for monitoring chronic patients outside of the hospital setting. Identified as a stage-gate model for the management of the overall implementation process, this methodology is presented formally structured into three steps: a) exploratory examination (pilot project stage); 2) in-depth evaluation (clinical trial stage); and 3) deployment (guided use stage). In the first stage, controlled by the R+D team, the predominant criiteria are the functionality and usability of the technologies involved. In the second stage, controlled by an associated Health Technology Evaluation Agency, the predominant criterion is the scientific aspect related to the results obtained in the clinical testing. The third stage is controlled through decisions made by the health administrations as to the implementation of new technologies and the financing thereof. A description is provided as to the requirements of the technological platform designed to serve its the medium for the projects and tests from stage 1 and 2. As an example of what is done in stage 2, a description is given of a trial related to hypertension.
... Medicare requires interdisciplinary, team care for inpatient, rehabilitation reimbursement. 1 The Committee on Accreditation of Rehabilitation Facilities (CARF) regards team care as an indicator of provider quality. 2 In the Institute of Medicine report, Crossing the Quality Chasm, 3,4 effective teams featured prominently as a means to improve quality of care. Observational studies show the value of a team approach for chronic disease management [5][6][7] and in acute hospital settings 8,9 and recent clinical trials provide evidence for enhanced patient outcomes when care is delivered by a patient team compared with a nonteam. [10][11][12][13] Throughout the last decade, the Veterans Affairs (VA) Rehabilitation Teams Project has examined the relationship between interdisciplinary rehabilitation team functioning and patient outcomes. ...
To evaluate the relationship between rehabilitation team functioning and stroke patient outcomes.
Prospective observational study.
Veterans Administration (VA) inpatient and subacute rehabilitation units.
Forty-six VA rehabilitation teams, including 530 rehabilitation team members from 6 disciplines (medicine, nursing, social work, physical therapy, occupational therapy, speech language pathology) and 1688 stroke patients treated by the teams.
Not applicable.
Ten scales assessing team member perceptions of team functioning (communication, perceived effectiveness, physician involvement, physician support, teamness, utility of quality information, innovation, interprofessional relationships, order and organization, task orientation) and 3 primary patient outcome variables-functional improvement, discharge home, and length of rehabilitation stay (LOS).
Three of the 10 measures of team functioning were significantly associated with patient functional improvement ( P <.05): task orientation, order and organization, and utility of quality information. One measure of team functioning-effectiveness-was significantly associated with LOS ( P <.05). None of the team variables predicted discharge destination. Aspects of team functioning that were important to outcomes differed depending on the outcome of interests. Efforts directed toward improving team activities and relationships, including collaborative planning and problem solving and the use of feedback information, may enhance rehabilitation treatment effectiveness.
Characteristics of team functioning predict selected rehabilitation outcomes.
... Medicare requires interdisciplinary, team care for inpatient, rehabilitation reimbursement. 1 The Committee on Accreditation of Rehabilitation Facilities (CARF) regards team care as an indicator of provider quality. 2 In the Institute of Medicine report, Crossing the Quality Chasm, 3,4 effective teams featured prominently as a means to improve quality of care. Observational studies show the value of a team approach for chronic disease management [5][6][7] and in acute hospital settings 8,9 and recent clinical trials provide evidence for enhanced patient outcomes when care is delivered by a patient team compared with a nonteam. [10][11][12][13] Throughout the last decade, the Veterans Affairs (VA) Rehabilitation Teams Project has examined the relationship between interdisciplinary rehabilitation team functioning and patient outcomes. ...
To test whether a team training intervention in stroke rehabilitation is associated with improved patient outcomes.
A cluster randomized trial of 31 rehabilitation units comparing stroke outcomes between intervention and control groups.
Thirty-one Veterans Affairs medical centers.
A total of 237 clinical staff on 16 control teams and 227 staff on 15 intervention teams. Stroke patients (N=487) treated by these teams before and after the intervention.
The intervention consisted of a multiphase, staff training program delivered over 6 months, including: an off-site workshop emphasizing team dynamics, problem solving, and the use of performance feedback data; and action plans for process improvement; and telephone and videoconference consultations. Control and intervention teams received site-specific team performance profiles with recommendations to use this information to modify team process.
Three patient outcomes: functional improvement as measured by the change in motor items of the FIM instrument, community discharge, and length of stay (LOS).
For both the primary (stroke only) and secondary analyses (all patients), there was a significant difference in improvement of functional outcome between the 2 groups, with the percentage of stroke patients gaining more than a median FIM gain of 23 points increasing significantly more in the intervention group (difference in increase, 13.6%; P=.032). There was no significant difference in LOS or rates of community discharge.
Stroke patients treated by staff who participated in a team training program were more likely to make functional gains than those treated by staff receiving information only. Team based clinicians are encouraged to examine their own team. (ClinicalTrials.gov identifier NCT00237757).
Building effective interprofessional (IP) teams is an important process for healthcare systems across the world. In order to be truly effective, professional degree programs must teach our future health professionals to learn and collaborate on teams during their education. The goal of building effective IP healthcare teams will be achieved when each healthcare system effectively supports IP collaboration, the development of dynamic teams, and the appropriate use of resources. Advancing the effort to build effective IP healthcare teams will take an investment from key stakeholders such as educators, faculty and students, leaders and researchers in academic medicine, hospital and system administrators, policymakers, as well as patients and their families to create a culture of IP collaboration and provide the resources necessary to be sustainable and successful. This chapter will serve to show that effective IP healthcare teams can successfully improve patient outcomes, provide quality care, improve the healthcare team's experience, and reduce costs.
The purpose of this article is to analyze the performance of and support for case management using a policy framework in order to increase case managers’ awareness of policy making and facilitate successful planning for future policy initiatives. Feldstein’s (1996) theory of opposing legislative outcomes indicates that legislation can be viewed on a continuum, ranging from legislation that meets the needs of the public to legislation considered to be in the self-interest of the participants and legislators. The current health care system requires that case managers working for publicly funded health care organizations balance the need for stewardship of U.S. tax dollars and the health care needs of consumers. It is apparent from the literature that case managers are successfully achieving this balance. However, certain conditions should exist that allow for case manager decision-making that promotes effective and efficient utilization of health care resources. Case managers must work within the context of the health care policy environment. Realizing that it is more likely that the conflicts between stewardship and the provision of health care services will continue, case managers’ knowledge and influence regarding policy making becomes imperative in order to ensure that these conflicting goals do not become mutually exclusive.
A critical component of comprehensive patient monitoring is reliability in communication between the patients and the healthcare professionals without any time and location dependencies. Patient monitoring applications largely rely on infrastructure based wireless networks for signal transmission. However, infrastructure based wireless networks till date, suffer from unpredictable network coverage and have thus been attributed to the unpredictable communication reliability of patient monitoring applications. This research investigates an approach based on leveraging mobile ad hoc network to address the challenge of enhancing communication reliability in the context of patient monitoring. Mobile ad hoc network, formed among patient monitoring devices, has the potential of enhancing network coverage and enabling signal transmission from an area which has low or non-existent coverage from infrastructure based networks. In order to utilize mobile ad hoc network in the context of patient monitoring we propose (1) power management protocols that address the challenge of managing the low battery power of patient monitoring devices while maximizing communication reliability and (2) a framework that models the complex decision logic involved in leveraging mobile ad hoc network for diverse patient monitoring scenarios. Analytical evaluation of the proposed approach supports the premise that mobile ad hoc network formed among patient monitoring devices can enhance the reliability of signal transmission thereby improving the quality of patient monitoring applications. Technical and managerial implications of the research findings and the direction of future research are discussed.
We evaluated hypertension management among enrollees in Just for Us (JFU)—an approach to providing coordinated, in-home care to medically fragile, low-income older or disabled adults living independently. The sample was 264 JFU patients who enrolled between January 1, 2002 and December 31, 2004, lived in a JFU building, and had blood pressure (BP) recorded 1 year from baseline. BP change was analyzed with paired t tests, and control status change with McNemar’s. Characteristics associated with change were explored with ordinary least squares (OLS) regression. For the 225 individuals with hypertension at baseline, average systolic pressure dropped 7.73 mmHg (p < .001) and diastolic 4.41 mmHg (p < .001). In the same group, 57.4% of those not in control at baseline were in control 1 year later; 19.7% of those in control at baseline moved out of control (p < .001). BP declined across subgroups and was greater for African Americans, the predominant racial group. Additional evaluation of such models is warranted.
We hypothesized that the medical home model is an effective intervention to decreasing health care disparities in minority patients with diabetes.
Set in a community-based health initiative in Jacksonville, Florida, the study's mission was to support and enhance the primary care infrastructure in an effort to improve quality of care and increase access while reducing costs.
We preformed a retrospective analysis of outcomes on 457 patients identified by registry specialists and enrolled in the diabetes rapid access program (DRAP). Data were obtained on 457 diabetic patients enrolled in the 6 clinic centers of the program between June 1, 2006, and December 31, 2009.
Improvements in hemoglobin A1c and proportion of patients with hemoglobin A1c of more than 8% according to gender, race, and clinic location.
The average hemoglobin A1c at the beginning of the study was 8.2% (+/-2.3), and decreased significantly by an average of 0.5% (p<.005). The mean improvement in hemoglobin A1c did not differ significantly by clinic location, race, or gender. Both African American and Caucasian patients as well as men and women with a hemoglobin A1c of at least 8% showed a significant improvement in their A1c after the intervention (p<.005).
The DRAP medical home model presents an opportunity to decrease disparities in care and improve diabetes care.
Clinical inertia is defined as lack of treatment intensification in a patient not at evidence-based goals for care. Clinical inertia is a major factor that contributes to inadequate chronic disease care in patients with diabetes mellitus, hypertension, dyslipidemias, depression, coronary heart disease, and other conditions. Recent work suggests that clinical inertia related to the management of diabetes, hypertension, and lipid disorders may contribute to up to 80 percent of heart attacks and strokes. Clinical inertia is, therefore, a leading cause of potentially preventable adverse events, disability, death, and excess medical care costs. This paper addresses three specific objectives: (1) to present a conceptual model of clinical inertia that takes into account recent developments in human factors research, cognitive science, and organizational behavior; (2) to operationally define clinical inertia and propose simple clinical protocols that can be used to identify and map its incidence across populations of patients and physicians; and (3) to propose future research to reduce clinical inertia by specifically targeting the root causes of the problem. Ultimately, a better understanding of clinical inertia and the development of specific interventions to reduce it may be a productive strategy to reduce passive errors that contribute to hundreds of thousands of adverse events and tens of thousands of premature deaths annually in the United States.
As one of four work groups for the November 1999 conference on Behavioral Science Research in Diabetes, sponsored by the National Institute on Diabetes and Digestive and Kidney Diseases, the health care delivery work group evaluated the status of research on quality of care, patient-provider interactions, and health care systems' innovations related to improved diabetes outcomes. In addition, we made recommendations for future research. In this article, which was developed and modified at the November conference by experts in health care delivery, diabetes and behavioral science, we summarize the literature on patient-provider interactions, diabetes care and self-management support among underserved and minority populations, and implementation of chronic care management systems for diabetes. We conclude that, although the quality of care provided to the vast majority of diabetic patients is problematic, this is principally not the fault of either individual patients or health care professionals. Rather, it is a systems issue emanating from the acute illness model of care, which still predominates. Examples of proactive population-based chronic care management programs incorporating behavioral principles are discussed. The article concludes by identifying barriers to the establishment of a chronic care model (e.g., lack of supportive policies, understanding of population-based management, and information systems) and priorities for future research in this area needed to overcome these barriers.
This article examines the challenges and opportunities inherent in the idea that home care organizations may be able to reinvent themselves into managed care systems for the frail elderly and chronically ill. Data come from three sources: (a) existing literature, (b) a survey with experts, and (c) insights from an organization with direct experience in designing and implementing first- and second-generation managed care programs. The authors conclude that although even the best-positioned home care organizations will face significant challenges in transitioning to managed care systems (e.g., establishing medical linkages, building managed care capacity, securing funding, dealing with regulatory hurdles), changes in the environment may enable these challenges to be overcome. Home care organizations are beginning to use innovative techniques to manage care, and those with a strong commitment to the chronically ill may be interested and capable of pursuing the option of becoming home-based managed chronic care programs.
Ken Iverson, a technology entrepreneur, almost single-handedly revived the moribund US steel industry. His success contains important lessons for health care. Nucor, the steel-focused factory Iverson managed, differed from the everything-for-everybody steel behemoths of yore, like Bethlehem Steel, with its specialty steel products and relatively small mini-mills, as did his egalitarian, productivity-based management practices. Nucor paid its nonunionized workers like owners, primarily with productivity-based incentives. In contrast, Bethlehem Steel’s unionized workforce was paid wages, largely regardless of their productivity.
The results of this revolution in focus and incentives? Nucor required 1 man-hour per ton of steel and Bethlehem 2.7; Nucor’s workers earned $60 000 ($40 000 from bonuses), and Bethlehem’s $50 000; and Nucor was highly profitable, earning $100 million in recessionary 2002, whereas Bethlehem lost $2 billion.1
Nucor did good for its customers, employees, and the US economy, and it did well for its shareholders, including Ken Iverson, currently hailed as the second Andrew Carnegie of the industry.
Sadly, were Iverson a cardiologist or cardiac surgeon, he could not create the “do good–do well” healthcare-focused factory equivalent of Nucor.2 Rival everything-for-everybody hospitals would allege that he was robbing them of their most profitable business, leaving them with the money-losing dregs, while federal government regulations would inhibit doctors’ ownership stakes.3
The combination of negative press and legislative prohibitions creates daunting obstacles for productivity-minded entrepreneurial physicians. For example, MedCath, a partially physician-owned heart hospital firm, spends up to $200 000 to counter hospital complaints per project per year.4 Not surprisingly, relatively few focused healthcare facilities exist. A 2003 study found only 92 specialized hospitals, fewer than 2% of the market, and, more importantly, other physician-owned facilities that integrate care are sparse.5
These results are unfortunate: Specialized healthcare facilities, partially owned by entrepreneurial physicians, represent the best …
The PeaceHealth Senior Health and Wellness Center (SHWC) provides primary care coordinated by geriatricians and an interdisciplinary office practice team that addresses the multiple needs of geriatric patients. The SHWC is a hospital outpatient clinic operated as a component of an integrated health system and is focused on the care of frail elders with multiple interacting chronic conditions and management of chronic disease in the healthier older population. Based on the Chronic Care Model, the SHWC strives to enhance coordination and continuity along the continuum of care, including outpatient, inpatient, skilled nursing, long-term care, and home care services. During its development, a patient-centered approach was used to identify senior service needs. The model emphasizes team development, integration of evidence-based geriatric care, site-based care coordination, longer appointment times, "high touch" service qualities, utilization of an electronic medical record across care settings, and a prevention/wellness orientation. This collection of services addresses the interrelationships of all senior issues, including nutrition, social support, spiritual support, caregiver support, physical activity, medications, and chronic disease. The SHWC provides access in an environment sensitive to the special needs of seniors, with a staff trained to meet those needs. The SHWC business model attempts to improve access and quality of care to seniors in a mostly noncapitated healthcare setting, while also attempting to remain financially viable.
The importance of teams for improving quality of care has received increased attention. We examine both the correlates of self-assessed or perceived team effectiveness and its consequences for actually making changes to improve care for people with chronic illness. STUDY SETTING AND METHODS: Data were obtained from 40 teams participating in the national evaluation of the Improving Chronic Illness Care Program. Based on current theory and literature, measures were derived of organizational culture, a focus on patient satisfaction, presence of a team champion, team composition, perceived team effectiveness, and the actual number and depth of changes made to improve chronic illness care.
A focus on patient satisfaction, the presence of a team champion, and the involvement of the physicians on the team were each consistently and positively associated with greater perceived team effectiveness. Maintaining a balance among culture values of participation, achievement, openness to innovation, and adherence to rules and accountability also appeared to be important. Perceived team effectiveness, in turn, was consistently associated with both a greater number and depth of changes made to improve chronic illness care. The variables examined explain between 24 and 40% of the variance in different dimensions of perceived team effectiveness; between 13% and 26% in number of changes made; and between 20% and 42% in depth of changes made.
The data suggest the importance of developing effective teams for improving the quality of care for patients with chronic illness.
The object of this study was to examine the effect of population-based disease management and case management on resource use, self-reported health status, and member satisfaction with and retention in a Medicare Plus Choice health maintenance organization (HMO).
Study design consisted of a prospective, randomized controlled open trial of 18 months' duration. Participants were 8504 Medicare beneficiaries aged 65 and older who had been continuously enrolled for at least 12 months in a network model Medicare Plus Choice HMO serving a contiguous nine-county metropolitan area. Members were care managed with an expert clinical information system and frequent telephone contact. Main outcomes included self-reported health status measured by the Medical Outcomes Study 36-Item Short-Form Health Survey (SF-36), resource use measured by admission rates and bed-days per thousand per year, member satisfaction, and costs measured by paid claims.
More favorable outcomes occurred in the intervention group for satisfaction with the health plan (P < .01) and the social function domain as measured by SF-36 (P = .04). There was no difference in member retention or mortality between groups. Use of skilled nursing home services was significantly lower in the intervention group than in the control (616 vs 747 days per thousand members per year, P = .02). This reduction, however, did not lead to lower mean total expenditures in the intervention group compared with the control (6828 dollars per member for 18 months vs 7001 dollars, P = .61).
Population-based disease management and case management led to improved self-reported satisfaction and social function but not to a global net decrease in resource use or improved member retention.
Despite strong interest in improving care for high-risk elders, demonstration projects typically show negative results. This paper examines one large foundation-sponsored initiative to gain insight on why success often is so elusive. The findings indicate that specific flaws in concept, design, and implementation each make it more challenging for demonstrations to achieve their intended goals, especially those involving cost and utilization reductions. We speculate that part of the reason for this is that organizational and political processes lead to fundamentally conservative demonstrations that assume that small amounts of resources directed at incremental change can be effective in generating substantial change in organizations and can do so rapidly.
An ambulatory senior health clinic was developed using the chronic care model (CCM), with emphasis on an interdisciplinary team approach. To determine the effect of this care model approach in a nonprofit healthcare system, an observational, longitudinal panel study of community-dwelling Medicare beneficiaries was performed to examine the effect on physical function and health-related quality of life (HRQL). Participants in the study were recruited from a community sample of 6,864 eligible Medicare beneficiaries. Informed consent and baseline data were obtained from 1,709 individuals (recruitment response rate=25%) and complete data across 30 months from 1,307 (completion response rate=76%). Participants receiving care in the CCM-based senior healthcare practice (n=318) were compared with patients of primary care physicians supported by care managers (n=598) and a group without care managers (n=391). Self-reported data were collected over the telephone to measure physical function and HRQL at baseline and 6, 18, and 30 months. A multiple group mixture growth model was used to analyze physical function and HRQL across the 30 months. Physical function and HRQL mean scores decreased across time in all participants and were moderately correlated at each wave (correlation coefficient=0.74-0.79). Two latent growth classes were identified. In class 1, physical function decreased, and HRQL remained stable across time. In class 2, physical function and HRQL decreased in parallel. Ninety-seven percent of intervention group patients were in class 1, and 99% of patients in comparison groups 1 and 2 were in class 2. Despite physical function decline, patients in a senior health clinic care model maintained HRQL over time, whereas patients receiving traditional care had physical function and HRQL decline. An interdisciplinary team CCM approach appears to have a positive effect on HRQL in this population.
Presented in this article are aggregate utilization and financial data from the four social health maintenance organization (S/HMO) demonstrations that were collected and analyzed as a part of the national evaluation of the S/HMO demonstration project conducted for the Health Care Financing Administration. The S/HMOs, in offering a $6,500 to $12,000 chronic care benefit in addition to the basic HMO benefit package, had higher start up costs and financial losses over the first 5 years than expected, and controlling costs continues to be a challenge to the sites and their sponsors.
Older persons who re hospitalized for acute illnesses often lose their independence and are discharged to institutions for long-term care.
We studied 651 patients 70 years of age or older who were admitted for general medical care at a teaching hospital; these patients were randomly assigned to receive usual care or to be cared for in a special unit designed to help older persons maintain or achieve independence in self-care activities. The key elements of this program were a specially prepared environment (with, for example, uncluttered hallways, large clocks and calendars, and handrails); patient-centered care emphasizing independence, including specific protocols for prevention of disability and for rehabilitation; discharge planning with the goal of returning the patient to his or her home; and intensive review of medical care to minimize the adverse effects of procedures and medications. The main outcome we measured ws the change from admission to discharge in the number of five basic activities of daily living (bathing, getting dressed, using the toilet, moving from a bed to a chair, and eating) that the patient could perform independently.
Twenty-four patients in each group died in the hospital. At the time of discharge, 65 (21 percent) of the 303 surviving patients in the intervention group were classified as much better in terms of their ability to perform basic activities of daily living, 39 (13 percent) as better, 151 (50 percent) as unchanged, 22 (7 percent) as worse, and 26 (9 percent) as much worse. In the usual care group, 40 (13 percent) of the 300 surviving patients were classified as much better, 33 (11 percent) as better, 163 (54 percent) as unchanged, 39 (13 percent) as worse, and 25 (8 percent) as much worse (P = 0.009). The difference between the groups remained significant (P = 0.04) in a multivariable model in which we controlled for potentially confounding base-line characteristics of the patients. Lengths of stay and hospital charges were similar in the two groups. Fewer patients assigned to the intervention group were discharged to long-term care institutions (43 patients [14 percent], as compared with 67 patients [22 percent] in the usual-care group; P = 0.01). Among the 493 patients discharged to private homes, similar proportions (about 10 percent) in the two groups were admitted to long-term care institutions during the three months after discharge.
Specific changes in the provision of acute hospital care can improve the ability of a heterogeneous group of acutely ill older patients to perform basic activities of daily living at the time of discharge from the hospital and can reduce the frequency of discharge to institutions for long-term care.
Evaluating the performance of long-term care (LTC) demonstrations requires longitudinal assessment of multiple outcomes where selective mortality and disenrollment, if not accounted for, can give the appearance of reduced (or enhanced) efficacy. We assessed outcomes in social/health maintenance organizations (S/HMOs) and Medicare fee-for-service (FFS) care using a multivariate model to estimate active life expectancy (ALE). S/HMO enrollees and samples of FFS clients in four sites were analyzed and outcome differences assessed for a 3-year period. Results provide insights into S/HMO performance under different conditions and, more generally, into evaluating LTC demonstrations without randomized client and control groups.
The care of patients with chronic diseases, especially those with diabetes mellitus, has been less than ideal. However, despite clear national guidelines, various examples of better care models, and multiple attempts to improve care, an effective process for facilitating and replicating diabetes care improvements in typical primary care practices has been elusive.
Hospitalization often marks the beginning, and may be partially responsible for, a downward trajectory characterized by declining function, worsening quality of life, placement in a long term care facility, and death. At the University Hospitals of Cleveland, an Acute Care for Elders (ACE) unit that reengineered the process of caring for older patients (> or = 70 years of age) to improve functional outcomes was established in September 1990. DESCRIPTION OF INTERVENTION: The general principles of ACE included an approach to care guided by the biopsychosocial model and recognition of the importance of fitting the hospital environment to the patient's needs. The design of the intervention was consistent with principles of comprehensive geriatric assessment and continuous quality improvement. Care, which focused on maintaining function, was directed by an interdisciplinary team that considered the patient's needs both at home and in the hospital. The major components of the ACE Unit intervention included patient-centered nursing care (daily assessment of functional needs by nursing, nursing-based protocols to improve outcomes, daily rounds by a multidisciplinary team), a prepared environment, planning for discharge, and medical care review.
In a randomized trial comparing ACE with usual care, patients receiving ACE had improved functional outcomes at discharge. The costs to the hospital for ACE unit care were less than for usual care. The functional status of ACE and usual care patients was similar 90 days after discharge.
The ACE unit intervention is being expanded to preserve the improvements observed during the hospitalization in the outpatient setting. In addition, needs other than function which are critical to patients' long-term quality of life are being considered.
The objective of this project was to describe geriatric care provided under Medicare-risk contracts in HMOs with established Medicare programs. These findings provided the basis for an invitational workshop, sponsored by the National Institute on Aging and the Robert Wood Johnson Foundation, to formulate a research agenda for geriatric care in HMOs. The case study method involved site visits to seven HMOs by a physician with expertise in geriatrics, a managed care specialist, and a program development specialist. Representatives from the HMOs included senior executive officials, physicians recognized for providing and promoting geriatric care, research and program development staff, and various clinical staff including pharmacists, geriatric nurse practitioners, nurses, and social workers. The most frequently encountered geriatric care programs were categorized by the following six objectives: (1) identifying high risk patients, (2) assessing multi-problem patients, (3) treating multi-problem patients, (4) rehabilitating patients following acute events, (5) reducing medication problems, and (6) providing long-term care and home health care. Unique programs identified from these site visits included screening methods for new enrollees, approaches to comprehensive geriatric assessment, use of skilled nursing facilities for intensive rehabilitation and postacute care, and drug profiling and review. Utilization of geriatric nurse specialists and programs aimed at coordination with social services were pervasive in many of these HMOs. Workshop participants proposed several research and demonstration projects in all six areas. Overall consensus emerged that HMOs with Medicare-risk contracts provide a valuable setting for experimentation in geriatric care. Given the current health policy emphasis on managed care and capitated payment methodologies, geriatric care research in HMOs should be a high priority.
This study identified consistently high and low users of medical care services in a group of older HMO members continuously enrolled for six years. Consistently high users made up 26% of the sample, but accounted for more than 50% of total outpatient contacts and hospital admissions. Average ambulatory care costs were more than four times greater for the high users compared with the low users. Consistently high users were older than consistently low users, but did not differ significantly in other sociodemographic characteristics. Compared with the low users, the high users reported more total medical conditions and were more likely to indicate they had arthritis, high blood pressure, heart conditions, and other chronic problems. They perceived themselves to be in poorer health and reported higher levels of psychologic distress. The low users tended to be less satisfied, but the two user groups were not significantly different regarding use of services outside the HMO.
Providing high-quality, comprehensive care for elderly Americans is becoming increasingly challenging because of the aging of society, the shortage of primary care physicians, and rising health care costs. These trends are encouraging health care delivery systems to adopt alternative models of patient care. This article reports on one such model, the complementary practice model, which incorporates a team approach to geriatric case management. The complementary practice model targets the frail elderly who are near the end of life, or are at highest risk for either hospitalization or cognitive decline. It includes a diverse, multidisciplinary team to provide patient care by involving the patient, family, physician, nurse practitioner, social worker, and registered nurse as core team members. This team approach assesses and identifies patients' problems, utilizes the expertise of multiple health care disciplines, and encourages patients and families to be active participants in developing and implementing the case management plan.
The community nursing organization (CNO) demonstration is a three-year Medicare program to develop, manage, and evaluate a new capitated, nurse-managed system of community and ambulatory care. Since February 1994, four national sites have started CNOs. The CNO at Carondelet Health Care in Tucson, Arizona, shares early experiences in designing and implementing an exciting new community practice model.
This article describes the Coordinated Care Partnership Project, operated by The St. Joseph Healthcare System. Funded as one of several demonstration sites by The John A. Hartford Foundation, this project places social work and nurse care managers in selected primary care physician practices in Albuquerque, NM. Lessons learned from the first year of operation are presented, along with implications for the role of case management in primary care practice.
To determine the extent to which health maintenance organizations (HMOs) with Medicare risk contracts utilize geriatricians and selected aspects of "organized" geriatric practice.
A telephone interview survey.
Eighty-two percent (64 of 78) of the HMOs with Medicare risk contracts as of June 1991.
Questions to medical directors of the Medicare HMOs on (1) the presence of geriatricians, (2) the roles of geriatricians, and (3) "organized" geriatric practice.
Fifty-three percent of the Medicare HMOs have one or more geriatricians, but only 19% have attempted to recruit geriatricians. Geriatricians provide primary care in 76% of the HMOs with geriatricians and serve as specialist consultants in 61%. Geriatricians are reported to be used actively in 32% of the HMOs that have them. The proportion of HMOs utilizing "organized" geriatric activities ranges from a high of 58% for a general health information questionnaire to a low of 12% for a special form(s) for comprehensive geriatric assessment. While the percentage of HMOs using each of the "organized" strategies is higher for the HMOs with geriatricians than for those without, this is statistically significant for only one strategy--the use of special approaches or formal protocols for problems frequently found in the elderly (P = 0.04).
The perception of Medicare HMO medical directors is that about half of the HMOs utilize geriatricians and that there is evidence of "organized" geriatric practice. However, it appears that geriatricians and many of the elements of organized geriatric practice are used to a much lesser extent than experts recommend. Medicare HMOs must themselves test the various components of organized geriatric practice in order to determine their utility.
This study measures the impact of integrated community nursing services on hospital use and costs for elderly people in a health maintenance organization (HMO). We tracked 4,943 HMO patients over three consecutive five-month periods (one preintervention and two postintervention). We compared 326 patients who entered a program of integrated services during period 2 with 301 patients who entered during period 3 and 4,316 nonprogram patients in respect to their utilization and costs during periods 2 and 3. Regression results reveal that patients receiving integrated services had significantly higher utilization and costs during the period of enrollment and significantly lower utilization and costs during the period following enrollment, compared to nonprogram patients. These results were replicated when considering only patients with observed episodes of care in these periods, when controlling for hospital use and costs in the prior period, and when controlling for the risk of selection into the program. The findings suggest that integrating services at the community level may achieve substantial cost savings.
In summary, the promise of HMOs in caring for older adults far exceeds their performance to date. Until recently they had neither the motivation nor the knowledge to revamp their delivery systems to better needs of older, chronically ill patients. Market pressures and skyrocketing costs have provided the motivation. Physicians and researchers trained in epidemiology and health services research from programs such as that at UCLA are providing the knowledge. Based on the literature and experience described above, HMOs with the characteristics supportive of population-based care can put into place an approach to geriatric care likely to improve outcomes if they heed their patients and professionals rather than their accountants. These organizations will give highest priority to preserving function and will be guided by explicit clinical guidelines. Care will be rendered by organized primary care teams supported by systematic self-management approaches, standardized interventions for key risk factors, clinically useful computer systems, and available geriatric expertise. It will require a small revolution as old approaches, roles, and relationships will not go quietly. We are in the early phases of this revolution, and it's not too late to join us on the barricades.
Usual medical care often fails to meet the needs of chronically ill patients, even in managed, integrated delivery systems. The medical literature suggests strategies to improve outcomes in these patients. Effective interventions tend to fall into one of five areas: the use of evidence-based, planned care; reorganization of practice systems and provider roles; improved patient self-management support; increased access to expertise; and greater availability of clinical information. The challenge is to organize these components into an integrated system of chronic illness care. Whether this can be done most efficiently and effectively in primary care practice rather than requiring specialized systems of care remains unanswered.
The Program of All-inclusive Care for the Elderly (PACE) is a long-term care delivery and financing innovation. A major goal of PACE is prevention of unnecessary use of hospital and nursing home care.
PACE serves enrollees in day centers and clinics, their homes, hospitals and nursing homes. Beginning at On Lok in San Francisco, the PACE model has been successfully replicated across the country. In 1995, PACE was fully operational in 11 cities in nine states.
To enroll in PACE, a person must be 55 years of age or older, be certified by the state as eligible for care in a nursing home and live in the program's defined geographical catchment area. PACE participants are ethnically diverse. In 1995, the average PACE enrollee was 80.0 years old and had an average of 7.8 medical conditions and 2.7 dependencies in Activities of Daily Living. A significant number have bladder incontinence (55%). Many enrollees (39%) live alone in the community, and 14% have no means of informal support.
Medicare and Medicaid waivers allow delivery of services beyond the usual Medicare and Medicaid benefits. The PACE service delivery system is comprehensive, uses an interdisciplinary team for care management, and integrates primary and specialty medical care. PACE receives monthly capitation payments from Medicare and Medicaid. Patients ineligible for Medicaid pay privately.
Outcomes of PACE programs have been positive. There has been steady census growth, good consumer satisfaction, reduction in use of institutional care, controlled utilization of medical services, and cost savings to public and private payers of care, including Medicare and Medicaid. However, starting up a PACE program requires substantial time and capital, and the model has not yet attracted large numbers of older middle income adults.
The growing number of older people in the United States challenges healthcare providers and policy makers alike to provide high quality care in an environment of shrinking resources. The PACE model's comprehensiveness of health and social services, its cost-effective coordinated system of care delivery, and its method of integrated financing have wide applicability and appeal.
To compare the impact of group outpatient visits to traditional "physician-patient dyad" care among older chronically ill HMO members on health services utilization and cost, self-reported health status, and patient and physician satisfaction.
A 1-year randomized trial.
A group model HMO in the Denver Metropolitan area.
Three hundred twenty-one members aged 65 and older, randomized to a group visit intervention (n = 160) or to usual care (n = 161).
Patients with high health services utilization and one or more chronic conditions had monthly group visits with their primary care physician and nurse. Visits included health education, prevention measures, opportunities for socialization, mutual support, and for one-to-one consultations with their physician, where necessary.
Health services utilization and associated cost, health status, and patient and physician satisfaction.
Outcome measures obtained after a 1-year follow-up period showed that group participants had fewer emergency room visits (P = .009), visits to subspecialists (P = .028), and repeat hospital admissions per patient (P = .051). Group participants made more visits (P = .021) and calls (P = .038) to nurses than control group patients and fewer calls to physicians (P = .019). In addition, a greater percentage of group participants received influenza and pneumonia vaccinations (P < .001). Group participants had greater overall satisfaction with care (P = .019), and participating physicians reported higher levels of satisfaction with the groups than with individual care. No differences were observed between groups on self-reported health and functional status. Cost of care per member per month was $14.79 less for the group participants.
Group visits for chronically ill patients reduce repeat hospital admissions and emergency care use, reduce cost of care, deliver certain preventive services more effectively, and increase patient and physician satisfaction.
To compare the hospital costs of caring for medical patients on a special unit designed to help older people maintain or achieve independence in self-care activities with the costs of usual care.
A randomized controlled study.
A total of 650 medical patients (mean age 80 years, 67% women, 41% nonwhite) assigned randomly to either the intervention unit (n = 326) or usual care (n = 324).
The hospital's resource-based cost of caring for patients was determined from the hospital's cost-accounting system. The cost of the intervention program was estimated and included in the intervention patients' total hospital cost.
The development and maintenance costs of the intervention added $38.43 per bed day to the intervention patients' hospital costs. As a result, the cost per day to the hospital was slightly higher in the intervention patients than in the control patients ($876 vs $847, P = .076). However, the average length of stay was shorter for intervention patients (7.5 vs 8.4 days, P = .449). As a result, the hospital's total cost to care for intervention patients was not greater than caring for usual-care patients ($6608 in intervention patients vs $7240 in control patients, P = .926). Sensitivity analysis demonstrated that the cost of the intervention program would need to be 220% greater than estimated before intervention patients would be more expensive then control patients. There were no examined subgroups of patients in whom care on the intervention unit was significantly more expensive than care on the usual-care unit. Ninety-day nursing home use was lower in intervention than control patients (24.1% vs 32.3%, P = .034). Ninety-day readmission rates (36.7% vs 41.1%, P = .283) and caregiver strain scores (3.3 vs. 2.7, P = .280) were similar.
Caring for patients on an intervention ward designed to improve functional outcomes in older patients was not more expensive to the hospital than caring for patients on a usual-care ward even though the intervention ward required a commitment of hospital resources.
This study was undertaken to review the impact of utilizing geriatric nurse practitioner/physician (GNP/ MD) teams on cost and utilization for a cohort of Medicare HMO enrollees residing in long-term care facilities. The results would be used by the organization for further development of the GNP Program.
A 1-year retrospective data analysis on revenues and cost for 1077 HMO enrollees residing in 45 long term-care facilities.
Proprietary and not-for-profit, licensed long term care facilities in the HMO's service area of central Massachusetts. Facilities in the study had both skilled (Medicare-certified) and custodial beds.
Data were collected retrospectively on overall cost, revenues, emergency department (ED) transfers, hospital, and subacute days.
Of 1077 residents, 414 were cared for by GNP/MD teams compared with 663 by physicians alone. Acute care and ED costs were significantly lower for the GNP/MD-covered patients. There was a gain of $72 per resident per month (PRPM) with the GNP/MD-covered patients compared with a loss of $197 PRPM for physicians alone. There were no significant differences in ancillary services or prescriptions.
The use of GNPs in collaboration with physicians reduced ED and acute care utilization costs as well as overall costs for a cohort of HMO enrollees in long-term care. This encouraged the HMO to support the concept that all long-term care HMO residents should be covered by GNP/MD teams.
To measure the rates of hospital use and mortality of nursing homes residents who received their primary care from nurse practitioner-physician teams.
A cohort study.
Thirty nursing homes in Southern California.
Older, long-term residents of nursing homes enrolled in a Medicare HMO (n = 307).
Primary care by an accessible interdisciplinary team supported by clinical guidelines, continuous quality improvement techniques, and increased availability of clinical services at the nursing homes.
The residents (mean age 83.5 years, 69.0% women) had a high prevalence of dementia (83.5%) and functional disability (87.2% were dependent in two or more activities of daily living). About half (50.8%) expressed a preference for "no hospitalization and no resuscitation." Compared with other nursing homes populations, this cohort experienced a lower annual rate of hospital use (518 days/1000 residents) and a similar rate of mortality (23.8%).
Integration of the efforts of physicians, nurse practitioners, and nursing home staff can lead to low rates of hospital use by nursing home residents. The effects on residents' quality of life and mortality require further study.
To an HMO with a Medicare risk contract, providing high-quality medical care to a nursing home resident may generate considerable costs. To address this issue, Fallon initially assigned each primary care physician to just one nursing home. The program was successful in that coverage of all Fallon patients admitted to nursing homes was assured. In a pilot project 5 years ago, a geriatric nurse practitioner (GNP) was hired to provide primary and episodic visits to nursing home residents in three area nursing homes. Research was conducted to determine the effectiveness of a GNP-MD team. Based on positive outcomes, additional GNPs were recruited. In the current follow-up study, a review of the 1992 fiscal and utilization data for nursing home patients revealed significantly lower rates of emergency room transfers, hospital lengths of stay and specialty visits for patients covered by GNP-MD teams, as compared to patients covered by physician only. Nursing home drug costs, skilled nursing days and primary care visits were higher for patients covered by the teams, but the differences were not statistically significant. Overall costs were 42% lower for the aggregate pool (skilled nursing plus intermediate care) and 26% lower for those with long-term stays.
A Kaiser Permanente pilot project demonstrates that managing health status with patients on a group basis versus one-on-one office visits can improve health care delivery services and reduce unnecessary resource utilization. Kaiser's Cooperative Health Care Clinic (CHCC) in Denver, Colorado, uses a multidisciplinary team to successfully provide care to elderly members with chronic conditions.
In this paper we have examined various aspects of the patterns of medical care use and costs of the elderly Medicare population. First, to summarize the major points, we found the following: 1. Although per capita costs increase with age among the elderly, the distribution of costs among individuals does not vary much across different age groups. Small changes in the shape of the cost distribution were observed, including a small decrease with age in the coefficient of variation of Medicare costs, and a spreading out or diffusion of the degree concentration of acute hospital utilization over single- and multiyear time frames. 2. Costs associated with mortality account for a large proportion of Medicare reimbursements; the 20 percent of elderly who are in their last 4 years of life account for over half of all Medicare expenditures over that period. The cost levels and the time span over which costs are high prior to death appears to vary systematically with the cause of death and with age. 3. The elderly population is quite similar to the younger population in that there is a subpopulation of individuals who are found to be frequent users of acute hospital care over an extended period of time. Among the elderly, we estimate that 85 percent are only routine users of the hospital, requiring one hospitalization every 8 years. The remaining 15 percent are frequent hospital users who often live on for many years. A key requirement of a Medicare payment system will be to identify these high-cost users and establish a fair payment for them. 4. Acute hospital use associated with certain marker conditions--heart attacks, strokes, and cancer, among others, is found to be associated with future high Medicare reimbursements, and the high costs persist over an extended period of time. Moreover, it may be possible to use these hospitalizations as morbidity indicators that are not sensitive to the discretionary behavior of physicians and can thus be used to detect differences in the expected costs of different groups of individuals. 5. There is a significant relationship between Medicare reimbursements and the extent of functional impairments. Disability level is an independent predictor of higher costs, even after controlling for prior utilization. In practice, the acute care utilization observed among severely impaired individuals participating in long-term care demonstrations is substantially higher than what is predicted from unidimensional measures of disability.
This study evaluated the effectiveness (changes in health behaviors, health status, and health service utilization) of a self-management program for chronic disease designed for use with a heterogeneous group of chronic disease patients. It also explored the differential effectiveness of the intervention for subjects with specific diseases and comorbidities.
The study was a six-month randomized, controlled trial at community-based sites comparing treatment subjects with wait-list control subjects. Participants were 952 patients 40 years of age or older with a physician-confirmed diagnosis of heart disease, lung disease, stroke, or arthritis. Health behaviors, health status, and health service utilization, as determined by mailed, self-administered questionnaires, were measured.
Treatment subjects, when compared with control subjects, demonstrated improvements at 6 months in weekly minutes of exercise, frequency of cognitive symptom management, communication with physicians, self-reported health, health distress, fatigue, disability, and social/role activities limitations. They also had fewer hospitalizations and days in the hospital. No differences were found in pain/physical discomfort, shortness of breath, or psychological well-being.
An intervention designed specifically to meet the needs of a heterogeneous group of chronic disease patients, including those with comorbid conditions, was feasible and beneficial beyond usual care in terms of improved health behaviors and health status. It also resulted in fewer hospitalizations and days of hospitalization.
Integrating nursing homes and managed care
- Be Lewis
- J Burl
Lewis BE, Burl J. Integrating nursing homes and managed care. Nurs Home Med 1997;5:277-282
Posthospital subacute care: An example of a managed care model
- T Vonsternberg
- K Hepburn
- P Cibuzar
vonSternberg T, Hepburn K, Cibuzar P, et al. Posthospital subacute care: An example of a managed care model. J Am Geriatr Soc 1997;45:87-91
Cost savings associated with implementation of a specialized geriatric acute care unit (abstract)
- Dw Craig
- Ma Flaum
- Morrison
- Es
Craig DW, Flaum MA, Morrison ES, et al. Cost savings associated with implementation of a specialized geriatric acute care unit (abstract). J Am Geriatr Soc 1997;45:S139
Cost savings associated with implementation of a specialized geriatric acute care unit (abstract) Posthospital subacute care: An example of a managed care model
- Dw Craig
- Ma Flaum
- Es Morrison
Craig DW, Flaum MA, Morrison ES, et al. Cost savings
associated with implementation of a specialized geriatric
acute care unit (abstract). J Am Geriatr Soc 1997;45:S139.
30. vonSternberg T, Hepburn K, Cibuzar P, et al. Posthospital
subacute care: An example of a managed care model. J Am
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