Getting Past the Complexity

When it comes to providing quality acute care for senior patients, at least half a dozen models have been identified and tested successfully by hospitals and health systems. However, a problem exists: These programs have generated little excitement among the healthcare community that may view them as cost centers as opposed to profit centers. Two geriatricians who have found ways to improve care for older patients want to change that thinking.

Bruce Leff, MD, a professor of medicine at Johns Hopkins University School of Medicine in Baltimore, and Albert Siu, MD, professor and chairman of Geriatrics and Adult Development at the Mount Sinai School of Medicine in New York City, are behind the launch of the Medicare Innovations Collaborative, or Med-IC (www.med-ic.org), a pilot program designed to spread these ideas to hospitals and health systems across the country.

Med-IC is not just specifically an expansion of work by JHU and Mount Sinai. "It's an effort to try to disseminate work that's been done with [other] geriatric models of care," Siu says. Since November, six organizations have been on a one-year pathway with Med-IC to find out what models can work for them: Aurora Sinai Medical Center, Milwaukee; Carolinas HealthCare System/Mercy Hospital, Charlotte, NC; Crouse Hospital, Syracuse, NY; Geisinger Health System/Geisinger Clinic, Danville, PA; Lehigh Valley Health Network, Allentown, PA; and University Hospitals Case Medical Center, Cleveland.

"You have all these models for which there is a real good evidence base. But they tend not to get implemented because putting one of these models into a hospital is very different than putting in a new CAT scanner or prescribing a pill," says Leff, who also has a joint appointment with JHU's Department of Health Policy and Management. "These models are complex. You need staff. You just can't pull them off the shelf."

He adds that while the academic community has been "very good at putting the scientific information" out there, it has fallen short in getting healthcare leaders to actually implement that information. "You have to change your organization. You have to integrate it with your information systems," Leff says. "[There are] lots of barriers to getting complex clinical models into practice."

Heaped onto this is the idea that geriatrics is "just not viewed in a positive way," says Leff. "I think that geriatrics has carried a lot of negative marketing baggage: Hospital leaders and system leaders think of taking care of older people as the cost of doing business as opposed to a business opportunity to improve."

The initiative is aimed particularly at community-based hospitals for which Medicare is still perhaps a desirable line of business, Leff says. While Medicare patients "probably are not the most profitable," there are ways to provide quality care outside of the hospital and, if they are admitted, ways to "move through the hospital safely, effectively, and efficiently."

Leff has had the opportunity to see how one model developed at JHU, called Hospital at Home, has made a difference during its 15-year history. The program helps patients stay in their homes—rather than in the hospital—to receive acute care services with fewer complications, as seen in several studies. While the program may not appeal to all hospitals (especially because it generates fewer inpatient dollars), it may attract those hospitals with concerns about limited bed capacity.

Likewise, Siu has seen positive results at the 1,171-bed Mt. Sinai through the use of Acute Care for Elders, a patient- centered model that provides geriatric assessments, quality improvement, interdisciplinary team rounds, and medical care review. Mt. Sinai also provides consultative services with one of the nation's largest palliative care programs.

When Med-IC, working with a grant from Atlantic Philanthropies, decided to form a collaborative, it received 20 applications from organizations—each with a record of good geriatric care, Siu says. The goal was that each site test one or more innovative programs designed to improve care for its Medicare patients with multiple chronic conditions.

Senior patients with challenging conditions are making up an increasingly significant portion of the hospital population, Siu says, and their care is complex and expensive. The six sites are serving as "learning laboratories." Aside from Hospital at Home, ACE, and palliative care, the other models include:

• NICHE (Nurses Improving Care to Healthsystem Elders), a program providing clinical and organizational tools for improving hospital care of older adult patients, with oversight by a nursing team.
• HELP (Hospital Elder Life Program), designed to prevent delirium among hospitalized older patients using trained volunteers and skilled interdisciplinary staff.
• Care Transitions Intervention, a program for patients with complex care needs and family caregivers that helps them learn self-management skills and meets their needs during the transition from hospital to home.

While Med-IC is supplying ongoing consultative support, the sites are mostly paying for their own costs related to the collaborative program. The leaders in the collaborative organizations are those who saw "that you couldn't run away from Medicare"—which now accounts for 37% of hospital admissions and 50% of hospital bed days, Siu says. "Medicare will become a part of hospitals' businesses, and hospitals need to learn better ways of managing this population without losing their shirts."

One of those hospitals taking up the challenged is the 457-bed Carolinas Medical Center/Mercy. Prior to the collaborative, the medical center only had a palliative care model. It is looking to test all of the models during the year—and eventually disseminate its findings to others in the 30-hospital Carolinas HealthCare System.

CMC/Mercy saw this as a chance "to learn more about how to develop a senior service line" that was part of a strategic business plan created three years ago, says Phyllis Wingate Jones, the medical center's president. "We saw it as a real opportunity, particularly for a community hospital, to do more to in terms of providing a continuum of services to seniors and to do that in a quality manner," she adds.

Meanwhile, Aurora Health Care, a Milwaukee-based integrated healthcare system, is looking to expand its ACE program for cardiac patients—such as through the e-Geriatrician program, which helps geriatricians perform "virtual rounds" via telemedicine, says Michael Malone, MD, medical director of Aurora's senior services.

Aurora is also looking to expand palliative care, with healthcare professionals who see older patients working with palliative care experts to improve the "ability to use palliative care principles in daily care," Malone says. "We posed that primary care providers should be stepping forward to help patients and their families with their skills—instead of taking a step backward and letting someone who doesn't even know the person address those needs."