Seeking Quality Healthcare for Today's Seniors

Nearly 11 million Americans receive long term services and support. More than half of this population is 65 or older—and their demand for these services is anticipated to double in the near future. But with this projection comes a serious question: Can we continue to take care of—and pay for—this population the same way we have in the past? The answer is becoming evident: No.

"This is the population that's on the front lines, and it accounts for the bulk of those costs and opportunities for improvements in care," said Mark McClellan, MD, PhD, director of the Brookings Institution's Engelberg Center for Health Care Reform in Washington. Last week, the center held a forum on what changes the healthcare system should consider to maintain quality healthcare for older citizens.

"This is the population that accounts for the bulk of costs—people with multiple chronic diseases," said McClellan, the former head of the Centers for Medicare and Medicaid Services and the Food and Drug Administration. But this is also a population where "effective long term services and community support can promote" independence, better quality of life, self management, and new evidence based approaches to prevent complications of chronic diseases."

Basically, this population represents "the greatest opportunity for getting us more bang for the buck in healthcare—much more value for our healthcare spending," McClellan said. But to get there, health leaders must find new ways to identify and deliver that care.

New Models of Care
One of the biggest costs associated with healthcare delivery to the older population is the workforce. Currently, about $160 billion is spent annually for long term services and support, with about half of that amount going to the payment and support of this workforce, said Steven Dawson, president of the Paraprofessional Healthcare Institute.

Much of this workforce consists of "over 3 million direct care workers in the country. They are the fastest growing occupation in the United States," he said. Within the next six years, that number will climb to 4 million.

"That means there'll be more direct care workers than there will be grade school teachers . . . and clerks or fast food workers or RNs," Dawson said. However, it's an area of high turnover and low pay.

"We have a business model that has an unfortunate low investment, high turnover, low-return model," he said. It's a system that uses providers inefficiently—with low rates of return.

"What we really have throughout the system [is] rather than the 'highest and best-use' kind of model—where we try to get the most out of each of our levels of providers—we have the 'lowest and the least use' model,' he said."We have doctors who do what RNs can do. We have RNs doing what LPNs can do. We have LPNs doing what aides can do. And with proper support and training, we have aides doing what family members can do."

While this least-use model works when money is no object, it can be problematic when times are tough. Dawson called for creating new models of care "in which we are making the best use of what we're already paying for—what we already have available" in terms of home care workers. This can be done through "additional training that allows for a little bit more responsibility and a little bit more pay."

"What we really have to do is create a very positive argument that these [direct home care workers] are of enormous value to the system" instead of being underutilized, he said. "What we need to do is design models in which the direct care workforce and family caregivers together are supported so they can play a much more value-added role in the system."

Working with Guided Care
Chad Boult, a professor of health policy and management with Johns Hopkins University, noted how nurses can play important roles through the concept of "guided care," which was developed at Hopkins. It starts with having a primary care practice hire a "very skilled registered nurse," and adding that nurse to the staff, Boult said.

That nurse then works with the primary care doctors "in the service of the patients of the practice who have multiple chronic conditions"—specifically "the ones that are the most complex and difficult to care for," Boult said.

The nurse then begins a home visit for about two hours, and then does a comprehensive assessment at the patient's home "of everything—not only the biomedical aspects of care, but the nutritional, the environmental, the family caregivers," Boult said. "It's part of a structured assessment."

The nurse then enters that data into a health information technology system that generates for the nurse and others an evidence-based plan of care that incorporates all of the individual patient's chronic conditions. The nurse gets feedback on that plan from the patient, family, and primary care physician, "with the idea that if everyone contributes, then everyone will own it," he said.

"This is all in the way of just setting up the system: Once it's set, the nurse, working with the physician, then monitors these patients, proactively, every month," he said. The nurse doesn't "wait for the patient to get sick and show up in the office or the emergency department."

"All this is part of these monthly contacts, and, over time, the idea is that the patient [and] the family [become] more involved in self-care. At the same time the nurse is monitoring how they're doing," he said.

The nurse also may wear the hat of a coordinator. Since many of these patients are seeing eight or ten different doctors and lots of other healthcare providers during a typical year, the physicians those are "on different wavelengths. They're not communicating with each other. So the nurse uses this care plan that's developed as a communication tool to make sure everyone knows the same plan, even with updates."

The nurse also "provides support for family caregivers," realizing that they're the "unsung heroes" of chronic care. "They're the ones doing all the work in the background, with no acknowledgment, no training, and certainly little reward," he said.

Better Care Transitions
Today's system of providing long-term and community care is a "disorganized program that's patched together," said Bruce Chernof, president and CEO of the nonprofit SCAN Foundation. "The single most difficult time for a patient, [and] the single greatest risk is when you have a transition of care."

"It's not getting into the hospital that's hard. It's not the move from the emergency room to the hospital bed. That is one is the easy step," Chernof said. "The single most challenging step is from a [hospital] floor bed back into the community."

"I think one of our challenges today then is to think beyond just the medical tools that are a part of that transition but also the social tools that are part of that transition," he said.

A "thoughtful investment" there "can actually lead to a meaningful transition—one that's about quality of life, one that's about personal and individual self determination, and one that's also about quality of health."