Better Care for Older People With Chronic Diseases

Abstract

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 thosewhohavegeriatricconditionssuch as dementia, falls, and urinary incontinence. In response to poor quality, the Institute of Medicine has called for fundamentalchanges inhowcare isprovided. Suchchangehasbeen exceptionally difficult because of an outmoded financing system,slowadoptionof informationtechnology,andoverwhelming 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. 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,careshouldbeprovidedinaccordancewithbestpractices. Care should be evidence-based, when evidence is available. When evidence is unavailable, care should be provided according to someconsensus, suchas fromexpertpanels.The basicapproachtoclinicalmanagement is thatpatientswith 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 ofquality improvement is to reducevariationacross clinicians but retainvariationacrosspatients asneeded. The implementation of evidence-based care frequently involves protocols or guidelinesandrequiressystemstoensurethattheyarefollowed. 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. Additional obstacles include patient factors (eg, preferences, adherence) and environmental factors (eg, lack of resources, reimbursement). 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 highquality care for patients of all ages who have chronic diseases. Many aspects of chronic disease management and care coordination are managed better by other health professionals and office staff. 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. 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. 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 and assessment of social support in all successful models of care.