Our fragile elders are often forced to navigate the ever-widening gaps in a fragmented health care system, without the support and tools they need.
70 million Americans 50 and up (four out of five) suffer from one chronic illness. More than half of older adults have more than one chronic illness and 11 million live with five or more chronic conditions. Most of these people will need intensive health care the last few years of their lives, yet the health system is ill-equipped to provide the kind of chronic disease management these elders will need.
According to a U.S. Department of Health and Human Services report in 2010, there were 40.4 million adults 65 or over. The same report says that by 2030 there will be almost twice that amount at 72.1 million adults 65 years or over. That represents 19.3% of the population.
This anticipated growth rate will impact the delivery of health care services significantly. With health care services being strained across the spectrum and the discontinuity of care between hospital and home, fragile elder adults with multiple chronic illness find themselves in ever-increasing danger.
What are some of the “danger zones” for elders in our health system? Discharges from hospitals and nursing homes are a great place to start. It’s become widely known that some of the most vulnerable areas for elder adults are transitions in care from one care setting to another.
A 2012 article in “Health Policy Briefs” has this definition of care transitions:
“The term care transition describes a continuous process in which a patient’s care shifts from being provided in one setting of care to another, such as from a hospital to a patient’s home or to a skilled nursing facility and sometimes back to the hospital. Poorly managed transitions can diminish health and increase costs. Researchers have estimated that inadequate care coordination, including inadequate management of care transitions, was responsible for $25 to $45 billion in wasteful spending in 2011 through avoidable complications and unnecessary hospital readmissions.”
These transitions in care, especially for those frail elderly who are often somewhat confused and overwhelmed, present opportunity for miscommunication, misunderstanding, and resultant discontinuity of care.
There are many emergent models providing frameworks for better continuity of care across settings. One of the most well-known models is Eric Coleman’s “Care Transition Program.” A key concept in Coleman’s model is called “the four pillars.” The four pillars identify the core components of care management common to all age groups. Here they are:
1. Medication Self-Management: Patient is knowledgeable about medications and has a medication management system.
2. Use of a Dynamic Patient-Centered Record: Patient understands and utilizes the Personal Health Record (PHR) to facilitate communication and ensure continuity of the care plan across providers and settings. The patient or informal caregiver manages the PHR.
3. Primary Care and Specialist Follow-Up: Patient schedules and completes a follow-up visit with the primary care physician or specialist physician, and is empowered to be an active participant in these interactions.
4. Knowledge of Red Flags: Patient is knowledgeable about indications that their condition is worsening and how to respond.
In my many years of experience in elder care and general care management, most chronically ill patients and frail elders are not able to self-manage these core components. Because of this, I feel strongly that Geriatric Care Managers are critical to the successful navigation of these elements of care.
In the real unfunded and underfunded world between now and 2030, when we are predicted to have 72.1 million chronically ill and homebound patients, there will be few providers available to guide care in the synaptic gaps between acute/post-acute systems and the patient home. Clearly, Geriatric Care Manager’s are uniquely positioned to make sure there is continuity of care in the interface between care settings and in patient-centered care at home.
