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."

While the move for healthcare reform legislation continues to be under quiet discussion in the House and Senate, one Republican congressman has moved forward with a revamped bill that calls for Congress to think somewhat outside the box when it comes to healthcare reform.

Rep. Paul Ryan (R-WI), a ranking member of the House Banking Committee, has reintroduced his bill, which he calls "A Roadmap to America's Future, Version 2.0."

Last Friday, when the President met with Republican congressional leaders at a retreat in Baltimore, the President—while differing with several items in Ryan's measure—did acknowledge that Ryan "has made a serious proposal" and that it has "some ideas in there that I would agree with."

With this "roadmap," Ryan suggests ways to keep Medicare and Social Security solvent. He also calls for promoting universal access to health insurance by restructuring the tax code and shifting the ownership of health coverage. This would be done by:

• Providing a refundable tax credit—$2,300 for individuals and $5,700 for families—that would be made available to help individuals purchase coverage in any state; this coverage would be kept in the event a move or new job enters the picture.
• Establishing transparency in healthcare price and quality data, and making this data readily available before an individual needs health services.
• Reforming high risk pools by giving states flexibility to tailor Medicaid programs to the specific needs of their populations.
• Allowing Medicaid recipients to take part in the same variety of options by using tax credits to purchase high quality care.
• Establishing state based high-risk pools as a way of making affordable care available to those with pre existing conditions.
• Providing supplemental payments to low income recipients, in addition to the tax credit, so individuals can obtain health coverage of their choice.
• Preserving the existing Medicare program for Americans currently 55 or older so they can receive the benefits they planned for throughout their working lives.
• Creating for individuals under 55—as they become Medicare-eligible—a Medicare payment, initially averaging $11,000, to be used to purchase a Medicare-certified plan.
• Funding Medical Savings Accounts (MSAs) for low income beneficiaries, while continuing to allow all beneficiaries, regardless of income, to set up tax free MSAs.

While the plan has provisions that are likely to run counter to current healthcare reform efforts, it has captured the attention of others in the White House, such as Office of Management and Budget Director Peter Orszag.

Orszag, speaking on Monday during the unveiling of the fiscal 2011 budget, commented that Ryan's proposal "succeeds in addressing our long-term fiscal problems—which is a significant accomplishment." Orszag said, though, that he thought the proposal shifted too much risk and costs on individuals. However, he added, "He has put forth an interesting plan."

Employer-provided group health plans now must offer the same level of coverage for treatments related to mental health or substance abuse disorders as for other medical or surgical procedures, according to a federal regulation issued Friday by the Department of Health and Human Services (HHS).

The new interim final rule implementing the Wellstone-Domenici Mental Health Parity and Addiction Equity Act of 2008 was developed following HHS' review of more than 400 public comments on how these mental health parity measures should be written.

"The rules we are issuing today will, for the first time, help assure that those diagnosed with these debilitating and sometimes life threatening disorders will not suffer needless or arbitrary limits on their care," said HHS Secretary Kathleen Sebelius in a statement.

The interim final rule expands an earlier law, the Mental Health Parity Act of 1996, which required parity only in aggregate lifetime and annual dollar limits. It did not extend to substance use disorder benefits.

The measure also requires that group health plans' mental health and group medical and surgical benefits be treated equally in terms of out of pocket costs, benefit limits, and practices, such as prior authorization and utilization review. The practices must be based on the same level of scientific evidence used by an insurer for medical and surgical benefits.

The rule applies to employers with 50 or more employees whose group health plan chooses to offer mental health or substance use disorder benefits. The new rules are effective for plan years beginning on or after July 1, 2010.

Comments on the interim final rules are still being solicited—specifically in the areas of "non quantitative" treatment limits that pertain to the scope and duration of covered benefits and how formularies are determined. Comments are due 90 days after the publication date.

The Wellstone Domenici Act is named the late Sen. Paul Wellstone (D MN), who was a strong advocate for parity throughout his Senate career, and former Sen. Pete Domenici (R NM), who first introduced legislation to require parity in 1992. The issue of parity dates back more than 40 years to President John F. Kennedy, and was also supported by President Clinton and the late Sen. Edward Kennedy.

Three groups are coming together to form a new statewide initiative to assist in reducing avoidable readmission rates and emergency room visits in Michigan.

The new program, created by The Society of Hospital Medicine (SHM), Blue Cross Blue Shield of Michigan, and the University of Michigan, will soon select 15 hospital and physician care sites in Michigan to participate, with training beginning in May.

The program is based on SHM's Project BOOST (Better Outcomes for Older Adults through Safer Transitions) model, and will be managed by the University of Michigan in collaboration with Blue Cross Blue Shield of Michigan. The Michigan Blues currently provide and administer health benefits to 4.7 million Michigan residents.

Project BOOST, which is just over a year old, is working with hospitals to reduce readmission rates by providing them with proven resources and mentoring to optimize the discharge transition process, enhance patient and family education practices, and improve the flow of information between inpatient and outpatient providers. Project BOOST was developed through a grant from The John A. Hartford Foundation.

Each improvement team will be assigned a mentor to coach them through the process of planning, implementing, and evaluating Project BOOST at their site, according to Mark Williams, MD, who is the principal investigator for Project BOOST. Program participants will receive face to face training and monthly coaching sessions with their mentors—what he calls the "secret sauce" of the program. The sites also participate in an online peer learning and collaboration network.

"BOOST is ongoing at over 30 hospitals right now. What we plan to do with this initiative is bring 15 more online with efforts focused on Michigan hospitals," says Scott Flanders, MD, FHM, director of hospital medicine at the University of Michigan and president of the Society of Hospital Medicine.

Examining readmissions and care transitions have been "in the spotlight recently and a major potential area for quality improvement in how we do the care discharge from hospitals," Flanders says. "I think Blue Cross Blue Shield of Michigan recognized that this was a great target area. They were also very interested in partnering with hospitalists [since] hospitalists increasingly are involved in the care of a larger percentage of hospitalized general medical patients across the country, and certainly in the state of Michigan."

Williams added that Project BOOST initially rolled it out in six pilots in fall 2008.Hospitals enrolled in the program can now be found throughout the country.

Some of the early results from the program are:

• At Piedmont Hospital near Atlanta, the rate of unplanned readmissions among patients under the age of 70 participating in BOOST is 8.5%, compared to 25.5% among nonparticipants. The rate among BOOST participants over the age of 70 was 22% versus 26% of nonparticipants at Piedmont Hospital.
• Unplanned 30 day readmissions dropped from 12% to 7% within three months at SSM St. Mary's Medical Center in St. Louis after the facility implemented BOOST at its 33 bed hospitalist unit.