Care Management for the Elderly Patient

An article in the Journal of the American Medical Association reviews approaches to better managing the care of older Americans, mostly covered by Medicare.  This group accounts for a large percent of Medicare and national health spending, largely because they have many chronic diseases, such as Alzheimer’s, heart failure, diabetes and high blood pressure.   There are an estimated ten million patients with four or more chronic conditions, responsible for 80% of Medicare spending.  Finding ways to both improve the health and lower the costs of these patients should be a priority.   (JAMA Article)

The article notes that the US health care workforce and infrastructure is ill-prepared to cope with these patients, for four basic reasons, lack of physician training in complex chronic care; not enough use of IT; inadequate reimbursements; and separation of payment for health and social needs.  To create a good care management program for these patients, the researchers believe four components need to be in place:  comprehensive assessment of the patient’s needs; characteristics and environment; creation and use of a comprehensive, evidence-based care plan; communication and coordination across all involved with the patient’s care and social needs; and encouraging the patient, and his or her lay caregivers, to be engaged in the patient’s  health and health care.

The authors then evaluated the evidence in regard to three programs designed to address managing the complex needs of these patient–the GRACE model, Guided Care, and PACE.  Each program has demonstrated some benefits but cost savings are not completely clear yet.  Each program needs a long-term review of its effects, particularly its overall economic effects.  But it is important for policymakers to encourage their spread even while they are being evaluated, because the usual standard of care for these patients is so bad.