Published in UAB Insight, Summer 2008
Reshaping Models of Care to Serve an Aging Population
At the intersection of geriatrics and palliative care is the common goal of improving quality of life for people with chronic medical conditions and advanced illness. Finding ways to address the health care needs of these individuals grows more imperative as the date edges closer to 2011, the year 78 million baby boomers become eligible for Medicare.
Current US health care systems are not designed or prepared to meet the needs of an older adult population with multiple chronic illnesses, says Christine S. Ritchie, MD, MSPH, director of UAB's Center for Palliative Care. "About 20% of current Medicare beneficiaries have five or more coexisting chronic conditions. This situation, which is likely to increase in scope as our population ages, creates many challenges for patients and health care providers, including complex symptom and medication management and coordination of care in a fragmented system."
The costs of long-term care for older adults will overwhelm current programs that are already struggling to address critical gaps in care delivery. Despite annual health-care spending of nearly $1 trillion, at least one-half of patients do not receive optimal chronic illness care, according to the Institute of Medicine (IOM). "At current spending levels Medicare Part A will be out of money by 2019. Thus, Medicare will increasingly need to focus on care that optimizes the quality and cost of chronic disease management," Ritchie says.
To address issues associated with caring for complex patients, UAB's Division of Gerontology, Geriatrics, and Palliative Care is supporting the development of initiatives that will integrate current services and add innovative programs that reach across the continuum of care.
"Our vision is to offer person-centered care that focuses on quality of life and relief of suffering and allows patients and their loved ones to make informed decisions that are consistent with their values and goals of care," she says.
Care Transitions Program
The division seeks to assist in the development of innovative models of care delivery that provide a system-level framework to support rational growth of existing services and new initiatives. To improve quality of care when patients move from one health care setting or practitioner to another, UAB is exploring implementation of a Care Transitions Program, a model developed by University of Colorado at Denver Health Sciences Center geriatrician Eric Coleman, MD, MPH, and colleagues; The John A. Hartford Foundation; and The Robert Wood Johnson Foundation. A number of organizations, including the Centers for Medicare and Medicaid Services, the IOM, and The Joint Commission identify care transitions, particularly those after hospital discharge, as a high-priority area for improvement.
The transitional period between sites of care is an especially vulnerable time for patients. Conflicting and misinterpreted medical advice, medication errors, and a lack of follow-up care create a host of problems for patients and result in costly treatments and hospital readmissions.
"The Care Transitions Program is based on patients taking an active role to enhance the safety and quality of their care," Ritchie says. "The program focuses on four pillars of care, all designed to inform patients about their condition and empower them to make decisions that align with their desired outcomes."
Care transition coaches work with patients and their caregivers to implement the pillars of care, teaching them skills to manage medications, create and maintain a personal health record, obtain timely follow-up care, and recognize red flags that indicate a worsening condition.
Results of a randomized controlled trial found that patients participating in the Care Transitions Program were significantly less likely to require rehospitalization in the first 30 days after discharge compared with the group receiving standard care (Arch Intern Med. 2006;166:1822-1828).
Participants were aged ≥65 years and had 1 of 11 diagnoses that typically result in a stay in a skilled nursing facility or in the need for home health care. The intervention's effects were strongest at 30 and 90 days, but even after 6 months, patients had significantly reduced rates of rehospitalization.
"These programs and others are aimed at improving communication and filling critical gaps in care, a focus lacking in current systems," Ritchie says.
Chronic Care Model
Accomplishing system-wide changes and enhancements in the care of patients with chronic illness requires an innovative strategic framework, Ritchie says.
The Chronic Care Model (CCM), designed to encourage evidence-based chronic disease management, incorporates interventions at the patient, provider, and system level. "It emphasizes a prepared, proactive team of providers with the resources to implement evidence-based practices, negotiate patient preferences, and provide high-quality follow-up care," she says. The CCM, promoted by Director of The W.A. MacColl Institute for Healthcare Innovation Edward H. Wagner, MD, MPH, and colleagues at the Rand Corporation, has six distinct components identified as modifiable aspects of current health care systems:
Organizational support: leadership commits to change and evidence-based management of chronic illness;
Clinical information systems: providers track trends in the health and care of
individual patients and populations of
patients. This facilitates efficient, effective care by tracking provider performance and patient-specific needs;
Delivery system design: system emphasizes effective delivery of care through the best of use of all health care team members, planned patient interactions, regular follow-up, and case management;
Decision support: providers have increased access to evidence-based guidelines and appropriate specialists;
Self-management support: system emphasizes patient-centered interventions and patient-provider collaboration to define problems, set priorities, establish goals, identify barriers, create treatment plans, and solve problems;
Community resources: system promotes community linkages for patient support, care coordination, and community based interventions.
The Center for Palliative Care is attempting to put this model into practice with development of a Holistic Care Coordination Program, which will involve a close partnership between the Division of Gerontology, Geriatrics, and Palliative Care and UAB's Comprehensive Cancer Center. "We need to develop systems of care that are responsive to the reality that most of our patients will spend the majority of their illness trajectory self-managing advanced conditions in outpatient settings," says Elizabeth A. Kvale, MD, director of the division's outpatient palliative care clinics.
The Holistic Care Coordination Program, in addition to investigating methods to optimize coordination of services, will look at ways to offer or coordinate the provision of complementary forms of care. "Baby-boomers operate from a consumer-driven perspective," Ritchie says, "looking at an array of options before making decisions. Many older patients and individuals with cancer and other chronic conditions show significant interest in alternative therapies. Our challenge as health care providers is to be aware of these options, understand the evidence, and help connect patients with high-quality providers."
Compassionate, Comprehensive Care
These initiatives will enhance UAB's considerable existing resources for older adults and those with complex conditions.
The Geriatric Clinic, the Geriatric Consult Clinic, the Geriatric Heart Failure Clinic, and other primary care and specialty services are available at the William Clifford and Margaret Spain McDonald Clinic. Other programs for older adults focus on continence, driving assessment, low vision care, memory disorders, osteoporosis, and Parkinson disease.
UAB will soon open a 15-bed Acute Care for Elders (ACE) inpatient unit that promotes mobility and cognitive stimulation. "The ACE unit will be ‘geriatric friendly' and is designed to emphasize active therapy and interactions among patients," explains UAB geriatrician Kellie L. Flood, MD, who is directing development of the unit. "Hospitalists and a geriatric care team will work together to provide quality care for frail older adults. This approach allows us to address geriatric syndromes as well as patients' acute illnesses."
The Center for Palliative Care already offers many specialty inpatient and outpatient services that reflect UAB's innovative, patient-centered approach. The Supportive and Palliative Care outpatient clinics provide expert, interdisciplinary guidance on symptom management, goal setting, and other issues.
The 12-bed Palliative and Comfort Care unit offers comprehensive symptom management and maximizes patients' dignity and comfort when they are in advanced stages of illness, says Rodney O. Tucker, MD, the unit's medical director. The staff, which includes specialists in psychology and social work, pain management, nutrition, bereavement counseling, and end-of-life planning, focuses on holistic relief of suffering.
"Healing involves more than the medical-disease process. It involves the mind, body, and spirit," Tucker says. "Patients can die healed even though their disease cannot be cured. To die healed and whole means you have had conflict resolution, dignity maintained, symptoms controlled, and have died humanely."
Programs for Patients With Chronic Conditions and Advanced Illness:
Geriatric Clinic: 205.996.2770
Geriatric Health Center at Fair Haven: 205.975.2322
Continence Clinic: 205.801.8705
Geriatric Heart Failure Clinic: 205.996.2770
Palliative Medicine/Supportive Care Clinic: 205.975.8190
Palliative and Comfort Care Unit: 205.996.6870
Alzheimer Family Program: 205.934.2178
Geriatric Psychiatric Services: 205.934.7008
Geriatric Psychiatry Clinic: 205.934.6054
Center for Low Vision Rehabilitation: 205.488.0736
Osteoporosis Prevention and Treatment Clinic: 205.801.8187
Prostate Center: 205.801.8940
Driving Assessment Clinic: 205.325.8646
Glaucoma Service: 205.325.8110
Center for Research on Applied Gerontology: 205.934.2610
Memory Disorders Clinic: 205.934.3847
For more information on these programs and others visit www.uabhealth.org/12800.
FOR MORE INFORMATION:
Dr. Christine Ritchie
Dr. Richard Allman
Dr. Kellie Flood
Dr. Elizabeth Kvale
Dr. Rodney Tucker
1.800.UAB.MIST
mist@uabmc.edu