I’m just back from a two day conference sponsored by the Catholic Health Association on ways we can do a better job integrating both medical and personal care for chronically-ill seniors. There may be no more important issue for the delivery of care to this population. If you don’t believe me, ask Don Berwick, who runs the Medicare and Medicaid programs for the federal government, Dr. Berwick, the administrator for the Centers for Medicare and Medicaid Services, recently said, “If there is one hallmark, centering idea to achieve better care, better health, and lower cost…it is through integrated care.”

CHA asked me to write a paper for this conference and gave me the opportunity to visit providers around the country who are leading the effort to meet this challenge. And the conference allowed about 100 of the nation’s top faith-based care providers to get together and exchange ideas. To read my paper, and to see presentations of other participants, go here.   

The idea of integrated care is simple to describe: Ideally, it is a seamless system that provides seniors with medical treatment for chronic and acute disease even as it meets their personal care, social, and spiritual needs. The description may fit on a (long) bumper sticker, but it is not easy to implement. Building such a system requires hospitals, doctors, nursing facilities, home health agencies, assisted living facilities, care managers, families, and communites to work together. And for many reasons, including a perverse payment and regulatory system and the inability of health providers to talk to one another, this rarely happens today.

But some providers are making it work. In researching this paper I learned about projects such as:

The Congregational Health Network: Methodist LeBonheur Health Care in Memphis–a 7 hospital, 1,000-bed system– is working with 250 churches to improve care for chronically-ill congregants. The keys to this program: hospital-based patient navigators and church-based volunteer liaisons who work together to help patients while they are hospitalized and build a care plan and follow-up after they are discharged.

Schervier Nursing Center’s Cardio-Pulmonary Program: Schervier, a Bronx (N.Y.) skilled nursing facility operated by the Bon Secours health system, has dedictated a 39-bed unit to providing sub-acute and post-acute care to patients who have undergone major heart surgery at local hospitals. Rather than recovering in the hospital, where care is extremely expensive and risks of infection and delerium are high for elderly patients, they can recover and undergo rehab at Schervier.

Guided Care at Kaiser Permanente focuses on elderly patients at high-risk of hospitalization. Designed by Dr. Chad Boult at Johns Hopkins University, the Guided Care model is built around an RN who is fully integrated into primary care practices. She visits patients at home, reponds to their telephone calls, and works with families, physicians, and patients to build an easy-to-follow care plan. Kaiser is now deciding whether to make this experimental program a regular part of its healh delivery system.    

Making these creative solutions work today is a huge challenge. But the new health law includes some important incentives, such as accountable care organizations, that mayl encourage more providers to find innovative ways to deliver integrated care.

After spending two days with CHA’s health system members, I am optimistic. I was really impressed with their commitment to turn the concept of integrated care into a reality that can both improve the health of chronically ill seniors and be financially sustainable for providers.