November 29, 2010

Older adults need better primary care, geriatrician says

In an article published in the Nov. 3 edition of the <Journal of the American Medical Association>, Chad Boult, professor of health policy and management at the Johns Hopkins Bloomberg School of Public Health, calls for key improvements to primary care in order to improve the health of the nation’s most costly patients: older adults with multiple chronic conditions.

Boult and his co-author, G. Darryl Wieland, research director of Geriatrics Services at Palmetto Health Richland Hospital in Columbia, S.C., evaluated studies of new primary care models to determine the best way to improve care and outcomes for the more than 10 million older adults living with four or more chronic conditions.

“Today’s primary care physicians are often overwhelmed by the complex needs of patients with multiple chronic health challenges, such as diabetes, high blood pressure, arthritis and more,” Boult said. “Current medical training often does not prepare physicians to provide the comprehensive support that these patients require. Through our research, we identified four processes that can improve how we care for these patients, and three models that include these critical processes.”

Boult and Wieland examined all peer-reviewed studies published between 1999 and 2010 of comprehensive primary care models for older adults with multiple conditions. From this review, they identified four processes that are present in most successful models of primary care for these patients: a comprehensive patient assessment that includes a complete review of all medical, psychosocial, lifestyle and values issues; creation and implementation of an evidence-based plan of care that addresses all the patient’s health-related needs; communication and coordination with all who provide care for the patient; and promotion of the patients’ (and their family caregivers’) engagement in their own health care.

“Most of today’s primary care does not include these four processes, so patients receive fragmented and inefficient care that is further undermined by a lack of family and community support,” Wieland said. “However, new models of primary care that include these processes have improved health outcomes, and patient and physician satisfaction, and have in some cases lowered the cost of care.”

Boult and Wieland identified three models of care that have the greatest potential to improve effectiveness and efficiency of complex primary health care. All include a team-based approach to primary care, and they provide many of the same services to complex older patients, beginning with a comprehensive assessment and an evidence-based care plan. All these models include proactive monitoring and coaching, coordination of care across all sites of care, support of a patient’s transitions from acute to post-acute settings and access to community-based agencies.

GRACE (Geriatric Resources for Assessment and Care of Elders) is a team-based intervention developed by researchers from Indiana University and the Regenstrief Institute. In a large clinical trial, GRACE improved quality of care, decreased emergency department visits and lowered hospital admission rates and costs in a group at high risk for hospital admission.

PACE (Program of All-inclusive Care for the Elderly) provides comprehensive, interdisciplinary team care to low-income frail elders. Based in an adult day health center, PACE professionals provide (or contract for) primary, specialty, emergency, hospital, home and long-term care. PACE has been found to increase health screenings, reduce hospital admissions, increase nursing home stays and reduce mortality among participants at high risk of dying.

Guided Care, a multidisciplinary model of comprehensive primary care for people with multiple chronic conditions, was developed by Johns Hopkins researchers. Early results from a multisite randomized controlled trial indicate that Guided Care improves the quality of a patient’s care, improves physician’s satisfaction with some aspects of chronic care and tends to reduce the use and cost of expensive health-related services.

Of the three models, only PACE is currently reimbursable through Medicare and state Medicaid programs.

“While most of the programs noted here are not yet widely available, we are hopeful that new initiatives launched by the Patient Protection and Affordable Care Act of 2010 will provide new opportunities for primary care physicians to care for their chronically ill patients more effectively and efficiently,” Boult said. “More research is needed to define the optimal methods for identifying the patients who will benefit most, for providing the essential clinical processes, for disseminating and expanding the reach of these models and for paying for excellent chronic care.”