Better Care for Older People With Chronic Diseases: Title and subTitle BreakAn Emerging Vision

With the increase in life expectancy and aging of the baby boom generation, the United States is rapidly becoming a country in which health care needs are driven by older persons with chronic diseases. Unfortunately, the current health care system is unable to provide high-quality care for this population, particularly for those who have geriatric conditions such as dementia, falls, and urinary incontinence.¹ In response to poor quality, the Institute of Medicine has called for fundamental changes in how care is provided.² Such change has been exceptionally difficult because of an outmoded financing system, slow adoption of information technology, and overwhelming inertia in all sectors of the health care delivery system.

Over the last 2 decades, a variety of models have been developed and tested to improve the care of older persons.^{3 - 4} The sum of this research is an emerging vision of optimal health care delivery for older persons with chronic diseases.

First, care must be personalized to meet each patient's goals, values, and resources. These are often influenced by the patient's age, health, function, economic and social situations, ethnicity, and culture. Clinicians must then provide information on the realities of the patient's medical conditions to formulate, with the patient, a plan that best meets the patient's goals. Sometimes this means eschewing more intensive services and accepting clinical outcomes that are less than the best possible health and function. For example, after a stroke, a patient may choose to remain wheelchair bound rather than participate in physical therapy to attempt to regain mobility—the key is that the outcome meets the patient's goals.

Second, care should be provided in accordance with best practices. Care should be evidence-based, when evidence is available. When evidence is unavailable, care should be provided according to some consensus, such as from expert panels. The basic approach to clinical management is that patients with the same conditions should receive the same care. However, particularly in geriatrics, care must then depart from rigid guidelines and be tailored to patients' individual needs. A principle of quality improvement is to reduce variation across clinicians but retain variation across patients as needed.⁵ The implementation of evidence-based care frequently involves protocols or guidelines and requires systems to ensure that they are followed.

In practice, implementation of recommended care has been difficult for many reasons. Physician barriers to adhering to guidelines include lack of awareness of guidelines, disagreement with specific guidelines or guidelines in general, disbelief that the performance of guideline-specified care processes will lead to desired outcomes, and inability to overcome existing practice habits.⁶ Additional obstacles include patient factors (eg, preferences, adherence) and environmental factors (eg, lack of resources, reimbursement).⁶ Perhaps most important, clinicians commonly believe that evidence-based care takes more time. For most clinicians and health care systems, adding time to each encounter is not a viable option.

Third, physicians cannot do the job alone. Team care, which has been a hallmark of geriatrics, is essential for providing high-quality care for patients of all ages who have chronic diseases.⁷ Many aspects of chronic disease management and care coordination are managed better by other health professionals and office staff.^{8 - 12} Moreover, team care is more efficient as members expand their roles to their highest levels of competence. However, this care needs physician oversight and must be integrated within the practice. The adoption of team care has been impeded by the lack of financing and physician barriers. Physicians are poorly trained to work with teams and are frequently reluctant to delegate components of care.¹³

Fourth, care must be coordinated among those caring for patients. All necessary information should be available at the time of decision making. A necessary, but not the sole, requirement for coordination is an electronic health record. This record should span across health care systems and between clinicians and community agencies. Such bridges are possible and have been integral to providing higher-quality care for older persons.⁹ In addition to information linkages, coordination requires discussion, exploration of available resources, negotiation, and compromises.

Fifth, care must consider the resources and environment of the person. With aging, the social support system becomes much more tenuous and the individual's interaction with the environment and nonmedical resources assumes increasing importance. Herein lies the value of home visits for many interventions^{11 - 12 ,14} and assessment of social support in all successful models of care.

Sixth, older persons must be included as active partners in their care except when they are too frail, mentally or physically. This partnership includes adoption of healthful lifestyles, self-management of chronic conditions,¹⁵ and participation in decision making. Frequently, patients' families and friends are also part of this partnership,

These principles fit well within the chronic care model,¹⁶ a construct that espouses better health care linked to community- based services. If the chronic care model is followed, patients become more informed and activated and practice teams are more prepared to be proactive, which should result in improved clinical and functional outcomes. Implementing this type of care requires staff, support systems, and a payment mechanism.

In this issue of JAMA, Counsell and colleagues¹⁴ report the findings of a clinical trial assessing the effectiveness of the Geriatric Resources for Assessment and Care of Elders (GRACE) model of primary care for low-income seniors. The GRACE model embraces each of the core principles of this emerging vision and results in better health and health care of patients. However, the findings of the GRACE trial are probably not as convincing as the investigators had hoped. Most of the differences in outcomes between intervention and control groups involved social and mental health measures. In contrast, functional status, as measured by activities of daily living or the physical functioning scale of the Medical Outcomes 36-Item Short-Form (SF-36), did not differ between groups, and the effects on utilization were not compelling. Although intervention group patients had fewer emergency department visits over 2 years, the hospital admission rates were not different between groups except among the subgroup of participants at high risk of hospitalization.

There are a variety of potential explanations for the findings. Despite numerous structural (eg, team composition), process (eg, quality indicators), and outcome (eg, functional status, health-related quality of life) measures, it has been exceptionally difficult to quantify the comprehensiveness, coordination, and patient-centeredness of care that is so important to older persons. In other words, better patient-centered care provided by GRACE may not have been adequately captured by the measures used in the study. Moreover, the inclusion of a relatively unselected and young (mean age, 72 years) population in the study may have diluted the effect by applying the intervention to those who may not have needed it. Supporting this explanation and the value of targeting specific patients is the finding that participants at high risk of repeated hospitalizations who received GRACE care had fewer hospital admissions during the second year of the intervention. In addition, the window of measurement may have been too short. The authors rightly conclude that there was a “period of engagement” that may cause a lag in the health care utilization benefits. The noted differences between groups on process of care measures provide optimism that there will be more striking health dividends in the future.

Unfortunately, most of the services provided by the GRACE intervention are not reimbursed under current fee-for-service payment systems. These services would be available only within managed care Medicare systems, which have the flexibility to provide needed services that do not have Current Procedural Terminology (CPT) codes. Thus, the GRACE model may suffer the fate of other successful models that have not been disseminated widely or even sustained at the institutions where they were developed.^{3 - 4} Diffusion of new health delivery innovations requires a relative advantage over current care and a business case.

Nevertheless, as health care reform gathers momentum, there may be hope for payment changes that facilitate better health care of older persons. The Patient-Centered Medical Home advocated by internists, family physicians, and pediatricians¹⁷ promotes many of these principles and may offer a means for implementing innovative models on a wider scale. At the moment, however, the Patient-Centered Medical Home is only a concept and lacks details about implementation. However, if this approach is to accomplish what is needed for older persons, it must incorporate the principles of optimal geriatric care that have been established through years of rigorous research. The proof will be whether the Patient-Centered Medical Home will be able to sustain valuable programs like GRACE.