Older adults are among the biggest victims of our often disorganized, uncoordinated, and impersonal system of medical care. Backwards financial incentives encourage useless tests and dangerous hospital admissions and discourage important social support, personal assistance, and preventive care. The result is that Medicare pays hundreds of billions of dollars for treatment that not only fails to improve the quality of life of older adults, it often needlessly harms them.
Can this be fixed? Yes it can. But it will require fundamentally rethinking the way we care for seniors. In many cases, it will mean shifting from hospital- and skilled nursing facility-based treatment for acute episodes to a mix of medical and social care aimed at a better life for seniors with chronic conditions and their family caregivers. Hard as it is for doctors and hospitals to hear, much of this care is outside of what they do and best left to others.
We need to start thinking about a true system of care that is largely aimed at keeping older adults out of a hospital bed. I chair a hospital board, yet I can’t help but look at many of our older patients and see the result of a failed health care system. People end up in hospitals because of infections or falls that didn’t have to happen, because they took the wrong pills, because of high blood pressure that should have been treated but wasn’t, or because they missed an important medical appointment simply because they couldn’t get a ride.
None of those things should happen. Yet they do, all the time.
Last year, the influential John A. Hartford Foundation, the Institute for Healthcare Improvement, and the American Hospital Association kicked off an initiative called Age-Friendly Health Systems. Their aim is to install a very different model of care in 1,000 hospitals by 2020.
In a Health Affairs blog post last November, Terry Fulmer and Amy Berman of Hartford described seven elements of an age-friendly health system. They include: clinical staff specially trained in the care of older adults, high-performing teams that improve care for seniors, a strategy to support and coordinate with family caregivers, a process to include patient goals in a care plan, and the use of proven geriatric care models to address specific issues. Hartford has also included a systematic approach for coordinating care with other organizations as part of its model.
These care models could include specially trained nurses, tools to reduce the confusion that often occurs in hospitalized older patients and to identify and treat depression, better management of medications, improved transitions from hospital to home, better primary care for seniors, and even use of intensive home-based care to replace some hospital stays.
Hartford’s definition of an age-friendly health system is quite general and thus leaves a lot of blanks to fill in. But it is much more specific about the outcomes it expects from such a system. Since we all need our elevator speech, Hartford has boiled it down to what it calls the Four Ms: Getting medication right, improving mobility, enhanced mentation (improving care for patients with depression, dementia and delirium), and focusing on what matters to patients and their families.
On one level, this all sounds pretty obvious: Isn’t providing care that meets a patient’s goals what hospitals and health systems are supposed to do? Well it is, but often they don’t. Instead, they provide intense medical treatment that meets the goals of the physician (one more round of chemo may knock down that tumor) or the hospital (keep the patient alive for another day). The may never ask the patient what she wants (it simply may be to be kept comfortable in her last days of life).
My one concern about what Hartford, AHA, and IHI are doing is that it is so medically-oriented. Their age-friendly system remains very clinical—a comfortable place for hospital and health system executives perhaps but often inappropriate for seniors and their families. For them, a high-quality health system may include transportation, personal care, social supports, and even safe and affordable housing. That’s implied in what Hartford and IHI are saying, but I wish it were more explicit. And it is why it is so important for medical providers to partner with community-based organizations that know how to do these things.
Still, kudos to Hartford, IHI, and AHA for this initiative. It promises to raise the profile of a critical issue in an aging America.
Full disclosure: I am an unpaid board member of Suburban Hospital and Johns Hopkins Medicine and of the Jewish Council for the Aging of Greater Washington. The views in this blog are mine alone.