As the American population ages, our health care delivery system must embrace significant changes in payment strategies, as well as value-based service provision, to meet the demands of this demographic shift. Health care leaders are clear that without change, the system will suffer destabilizing financial distress, access to needed services will be limited, and the quality of care received by older adults will deteriorate. We will likely experience all of the above unless we continue to shift to new ways of providing and paying for health care.
As a result of the aging demographic doubling and skewing older, the demand for health care services is predicted to rise more than 200 percent. With aging, there is a confluence of physiologic and pathophysiologic changes that require anticipatory planning, for an older person to maintain well-being and function, and for the health care system to respond. Two out of three older adults have multiple chronic conditions. Some older adults are on five or more medications, and that creates further complexity if they have multiple chronic conditions.
The Affordable Care Act (ACA) of 2010 was enacted to increase access and affordability of health insurance to the nation’s uninsured citizens. Older Americans, already insured by Medicare, were less affected in terms of coverage, but the changes brought about by the ACA to the overall health care system, as well as the incentives for changing care based on new payment structures, have been dramatic. These shifts have been further underscored by the fact that today, hospitals—still the lynchpin of health care delivery—are experiencing a profound transformation.
Shifting Focus From Hospitals To Health Systems
Hospitals today are dramatically different than those of the past. They are no longer defined by brick and mortar. In the age of “population health” and financial risk beyond the hospital stay, hospitals are consolidating into health systems with a disparate array of service lines from home health care, hospice, postacute rehabilitation, primary care, Program of All-Inclusive Care for the Elderly (PACE) programs, to contracts with social services agencies.
More than a decade ago, the “Triple Aim” (better care, better health, and lower costs) spurred health policy makers to consider new approaches to care delivery and payment. The ACA has been transformational in the way our country thinks about health systems and reimbursement strategies. The Center for Medicare and Medicaid Innovation, value-based purchasing, bundled payments, and other new terminology underscore how transformative the change must be.
Instead of a system in which the volume of hospital and health care services defines success, the new paradigm for an age-friendly health system is based on patients’ goals and values, and on improved outcomes and lower costs of care within the walls of the hospital and beyond. This new environment of care, in which health systems assume more risk and potentially share in cost savings, will spur those systems to develop better coordination and integration of care across the continuum of care. The health systems’ high-cost resources must be efficiently used to meet the goals and preferences of older adults, given that one in every five Medicare beneficiaries is hospitalized one or more times each year, according to the American Hospital Association.
We are confident that health systems will be able to redefine how they provide care to older adults.
We at The John A. Hartford Foundation are looking to reimagine the twenty-first century health system so as to provide care that is age-friendly, respects the goals and preferences of the older adult, and meaningfully and substantially includes the family caregiver in the plan of care. We see progress in the numerous transitional care models that address continuity and inclusion of the family and reduce hospital admissions. But much is yet to be done in response to the growing population of older adults, the complexity of managing multiple chronic diseases, and the importance of end-of-life conversations.
As health systems redefine care for older adults, they will bring to bear the full resources of all involved. Health professionals will need to adopt a new way of thinking that replaces paternalism and foisting of expensive, unwanted care on patients. This means seamless care transitions; real-time information sharing; and ongoing, meaningful engagement with patients, families, and community-based services essential to meeting these challenges.
Defining An Age-Friendly Health System
Age-friendly health systems have:
- Leadership commited to addressing ageism
- A geriatric care prototype specific to older adults (See Table 1.)
- Clinical staff who are specifically trained and expert in the care of older adults
- Care teams that are high performing and can show measurable results for care of older adults
- A systematic approach for coordinating care with organizations beyond their walls
- A strategy to identify, coordinate with, and support family caregivers
- A clear process for eliciting patient goals and preferences so as to define a plan of concordant care.
An Age-Friendly Health System:
- Provides care that is concordant with the person’s goals
- Promotes physical function and independence
- Prevents polypharmacy (too many medications, inappropriate medication, or the wrong dosage of medication for older adults)
- Addresses common geriatric syndromes like falls, delirium, and incontinence
- Manages pain and symptoms
- Recognizes and supports the needs of family caregivers
- In the community, recognizes increased risk and prevents needless decline
- In the hospital, restores health
- In transitions, proactively arranges for the necessary supports and services
- Seamlessly provides coordination between settings and providers.
What To Do?
Our challenge is to apply and fully integrate the considerable evidence and expertise produced through investments by The John A. Hartford Foundation over the past thirty years to improve care for older adults, reduce hospital admissions and readmissions, integrate social supports and services, strengthen primary care, expand access to hospital- and community-based palliative care, and improve the geriatric competence of the health care workforce.
The John A. Hartford Foundation has funded training of the expert geriatric workforce, advanced the nation’s understanding of geriatric care teams, and supported the creation of care models that address the elements of an age-friendly health system, all recommendations of the Institute of Medicine. All health systems should, and likely do, feel a sense of urgency related to the growing Medicare population, changing care payment structures for that population through accountable care organizations (ACOs), and the public demand for care that supports the goals of patients and family members. Eradicating the common phrase “Hospitals are dangerous” will require a health systems–focused approach to reduction of both harmful events and dissatisfaction with the hospital, prehospital, and posthospital experience.
One marker of poor health care quality for older adults is the $17.5 billion in avoidable hospital readmissions annually. Readmissions can only be prevented with purposeful strategy, excellent communication, coordination, and planning with all of the relevant people and entities that are engaged in that age-friendly care. Age-friendly health systems should interact with community-based organizations, the long-term care system, families, and older adults who require care and care partnership.
The John A. Hartford Foundation Models Of Care
Since the 1980s, The John A. Hartford Foundation has invested more than $500 million to assist in training a well-prepared workforce and developing cost-efficient, evidence-based models of care that reduce complexity and harm as well as improve quality of care and satisfaction for older adults requiring acute and chronic care. (See Table 1.) The foundation now seeks to capitalize on that highly qualified workforce and the evidence-based models to accelerate improvement in the care experience and care outcomes for older adults.
The media is replete with messages that tout geriatric programs in selected health care systems. However, aside from a few high-performing systems, there has been little progress in systematically requiring quality metrics for care of older adults in hospitals and across health systems. Currently, there are no certification programs and, under fee-for-service (FFS) Medicare, few financial incentives for high-quality care of older adults. In fact, the opposite may be true: FFS Medicare pays for care in ways that promote more tests and interventions that can interfere with high-quality care of older adults.
On the other hand, when it comes to hospital care, the pressures to reduce length-of-stay often work against the well-being of older adults and their caregivers. Too often, discharges fail to include careful assessments of family preparedness, resources in place, and follow-up plans. We are hopeful that with the advent of electronic health records, care may become more seamless and continuous, but we are years away from a consistent and reliable system of care that effectively assists older adults and their caregivers.
The movement to outpatient care has been a positive step for older adults and their caregivers. However, disincentives for inpatient care have now created new problems such as the delivery of care in emergency department (ED) “observation areas” to avoid potential readmission penalties. There are few EDs that have specific programming for older adults, and even fewer specialty practices have it.
To change this fact, our foundation has put a considerable amount of resources into the redesign of EDs and specialty practices to meet the needs of an aging demographic. We have the opportunity to examine how those resources are impacting the quality of the care experiences for older adults.
While hospitals alone are the wrong target for a focused program to improve care for older adults, we recognize that the “hospital event” is one critical nodal point for assessment and measurement of the entire care experience. Older adults and their families are often in crisis while at the hospital, and the media is replete with stories of harm and disillusionment. Differing perspectives of clinicians, patients, and families related to the use of life-sustaining technologies such as resuscitation dialysis, feeding tubes, antibiotic therapies, and countless other interventions that are fraught with ethical implications, coupled with inadequate attention to advance care planning, complicate the issue. And, of course, while hospital costs are the biggest component of Medicare spending, hospitals hold the greatest financial and workforce resources, and therefore they are a meaningful lever for change.
|Model of Care||Program Director||Funding|
|Care Transitions Intervention||Eric Coleman, University of Colorado Denver||$4.2 million|
|IMPACT Evidence-based Depression Care||Jürgen Unützer, University of Washington||$8.2 million|
|Center to Advance Palliative Care||Diane Meier, The Mount Sinai Hospital||$3.3 million|
|NICHE (Nurses Improving Care for Healthsystem Elders)||Eileen Sullivan Marx, New York University Rory Meyers College of Nursing||$1.75 million|
|Hospital at Home||Bruce Leff, Johns Hopkins University; Al Siu, The Mount Sinai Hospital||$3.3 million|
|Hospital Elder Life Program||Sharon K. Inouye, Harvard University/Hebrew Senior Life||$450,000|
|Care Management Plus||David Dorr, OHSU||$1.6 million|
|Geriatric Interdisciplinary Team Training||Terry Fulmer, New York University Rory Meyers College of Nursing Resource Center & Sites||$10.3 million|
|Transitional Care Model||Mary Naylor, University of Pennsylvania||$473,000|
|Acute Care for the Elderly (ACE) Unit||C. Seth Landefeld, University of Alabama Birmingham||$1.2 million|
|HomeMeds||June Simmons, Partners in Care Foundation||$1.6 million|
|Program for All-inclusive Care of the Elderly||Jennie Chin Hansen, On Lok; Peter Fitzgerald, National PACE Association||$434,000|
|Guided Care||Chad Boult, Johns Hopkins University||$3.7 million|
|GRACE (Geriatric Resources for Assessment and Care of Elders)||Steven Counsell, Indiana University||Pilot support through Hartford Center of Excellence in Geriatric Medicine grant|
The challenge for our foundation—and health care delivery broadly—is to scale age-friendly innovations in an environment affected by innovation fatigue. How do we scale across care delivery systems what we know clearly produces value? How do we move from a model at a time to a set of strategies that transform systems, drive improved health and cost outcomes, efficiently utilize available resources, deploy them strategically to those at greatest risk, and create the least amount of stress on the care delivery system?
To address these challenges and build on the foundation’s investment of more than half a billion dollars in health care redesign efforts, we aim to test an Age-Friendly Health Systems approach to care by measuring its impact on health systems where it is used. Those health systems will be compared with systems lacking such an approach.
To this point, the staff members of The John A. Hartford Foundation have reviewed the literature, worked closely to educate our trustees, held discussions with world-class experts, and held a series of meetings to validate our strategy and our capacity to take on this topic.
As a next step, we are working with the Institute for Healthcare Improvement (an organization originally founded through the support of The John A. Hartford Foundation), along with more than two dozen leading experts in health care redesign for the geriatric population, and health system leaders and stakeholders including the American Hospital Association and the Joint Commission.
This group of thought leaders will be charged with synthesizing the critical elements of our previous geriatric models of care and testing the new Age-Friendly approach in a number of health systems. This effort aims to build the evidence for improved care of older adults by demonstrating that it is possible to improve health and lower costs of care. This work will create the velocity we need to make bold and strategic inroads in age-friendly health care and establish a new design for American health systems and the care of older adults.