James T Pacala

Predictive Validity of the Pra Instrument Among Older Recipients of Managed Care

OBJECTIVE: to determine the validity of the Pra instrument in predicting the use of health‐related services by older enrollees in a managed care plan.

The Association Between Geriatric Syndromes and Survival

To ascertain the effect on survival of eight common geriatric syndromes (multiple comorbidities, cognitive impairment, frailty, disability, sarcopenia, malnutrition, homeostenosis, and chronic inflammation), identified by an expert panel of academic geriatricians.

Systems of care for older populations of the future

rganized health care of oldcr Americans is becoming 0 more common. As of December 1,1997, the number of Medicare beneficiaries enrolled in health plans operated under Tax Equity and Fiscal Responsibility Act (TEFRA) risk contracts with the Health Care Financing Administration (HCFA) was 5.2 million, and was growing by about 200,000 each month, To cover the costs of their care, MCFA was making capitation payments of more than

Hearing Deficits in the Older Patient: “I Didn't Notice Anything”

2.4 billion per month to managed care organizations. The rapidly increasing number of risk contracts stood a t 307; 89 other applications for new or expanded contracts were pending. The rccent 35% annual increasc in total enrollment, projected to continue into the near future, appears likely to catapult Medicare managed care into the center of the US health care industry within a few years. Already 14% of the Medicare beneficiaries in the United States and more than 25% of those in Arizona, California, Colorado, Florida, Nevada and Oregon are receiving capitated managed care.’ The likely effects of the deepening penetration by managed care organizations (MCOs) into the Medicare market are controversial. Skeptics worry that thcse organizations will underserve older enrollees: especially if HCFA ratchets down its capitation payments. Optimists stress that MCOs will have opportunities to develop comprehensive, integrated systems capable of providing health care that is both more effective and less costly than today’s fragmented fee-forservice care.3 In this paper we do not attempt to rcsolve this debate; rather we describe how the more progressive organizations, both within and outside the world of managed care, have experimented with creative methods for caring for their senior members. We present the early outcomes of such approaches, make recommendations for the implementation of the more promising interventions and comment on some of the changes in infrastructure that will be necessary in order to implement improved systems of care in thc future.

Ten years' experience conducting the aging game workshop: Was it worth it?

Hearing loss is common in older adults. Patients, clinicians, and health care staff often do not recognize hearing loss, particularly in its early stages, and it is undertreated. Age-related hearing loss or presbycusis, the most common type of hearing loss in older adults, is a multifactorial sensorineural loss that frequently includes a component of impaired speech discrimination. Simple office-based screening and evaluation procedures can identify potential hearing disorders, which should prompt audiologic referral to confirm the diagnosis with audiometric testing. The mainstay of treatment is amplification. For many older adults, accepting the need for amplification, selecting and purchasing a hearing aid, and getting accustomed to its use is a daunting and often frustrating process. There are numerous barriers to hearing aid use, the most common of which is dissatisfaction with its performance across a range of sonic environments. Newer digital hearing aids have many features that improve performance, making them potentially more acceptable to users, but they are expensive and are not covered by Medicare. Hearing aids have been demonstrated to improve hearing function and hearing-related quality of life (QOL), but evidence is less robust for improving overall QOL. Depending upon the etiology of the hearing loss, other medical and surgical procedures, including cochlear implantation, may benefit older adults. Older adults with multiple morbidities and who are frail pose specific challenges for the management of hearing loss. These patients may require integration of hearing assessment and treatment as part of functional assessment in an interdisciplinary, team-based approach to care.

Targeting elders for geriatric evaluation and management: Reliability, validity, and practicality of a questionnaire

In the Aging Game, medical students experience simulated physical, sensory, and cognitive deficits that are associated with disability from chronic diseases. Since 1994, the University of Minnesota has presented an innovative version of the Aging Game as part of the curriculum in a required clinical clerkship. The experiences conducting the Aging Game over the past decade were reviewed, focusing on the resources necessary to produce it and on its worth as an educational tool. Because many of the reusable props were obtained free as donations, start‐up material costs were calculated at

Factors Affecting Sample Selection in a Randomized Trial of Balance Enhancement: The FICSIT Study

530. Personnel necessary for each half‐day presentation of the Aging Game included two faculty and a minimum of five nonfaculty serving as facilitators; a staff coordinator was also essential. Quantitative student evaluations (N=673) exhibited mean ratings of 1.41, 1.35, and 1.40 (1=excellent) for overall value, teaching effectiveness, and quality of a postsimulation discussion. Written student comments regarding the strengths of the Aging Game centered on three major themes: mode of learning, especially using role playing and simulating deficits (total of 192 comments); attitudinal change, specifically raising awareness and stimulating reflection on the experiences of disabled older adults (121 comments); and educational value, particularly the Aging Games capacity for creating a memorable impression (56 comments). Despite consuming significant personnel resources, the Minnesota version of the Aging Game is an effective tool for stimulating long‐lasting awareness and understanding of key issues related to aging and geriatrics.

Using Structured Implicit Review to Assess Quality of Care in the Program of All-inclusive Care for the Elderly (PACE)

Geriatric evaluation and management (GEM) is most cost-effective when provided to persons at high risk for functional decline or heavy use of health services. Identifying high-risk members of elderly populations is, therefore, the first step in conducting successful GEM programs. We have developed and tested a mailed, self-administered, eight-item questionnaire to identify home-dwelling elders at risk for heavy use of hospitals. Scored by a logistic formula, this questionnaire estimates each respondent’s probability of repeated admission (Pra) to a hospital within four years. Its primary purpose is to help select elders who are likely to benefit from outpatient GEM. We created this instrument by analyzing data from half the subjects in the Longitudinal Study of Aging (LSOA); its test-retest reliability is high (r=0.78). In a preliminary test of its predictive validity among the other half of the LSOA subjects, the instrument prospectively identified high-risk elders who went on to use hospitals at twice the rate of their lower-risk peers. In a separate study of its predictive validity among low-income urban elders, the instrument again identified a high-risk group that went on to use hospital days at twice the rate of its lower-risk counterpart. In a pilot study, we used the questionnaire to identify potential recipients of outpatient GEM. The identified elders appeared to be appropriate candidates for GEM. They averaged 9.6 significant medical problems, 6.7 significant prescription medications, and two IADL limitations. We are now using this instrument to identify subjects for a randomized clinical trial of outpatient GEM. (Aging Clin. Exp. Res. 7: 159-164, 1995)

Using self-reported data to predict expenditures for the health care of older people

OBJECTIVE: To determine demographic, functional, and health‐related factors that may have influenced the selection of older adults for a randomized trial of balance enhancement.

Is Palliative Care the “New” Geriatrics? Wrong Question—We're Better Together

OBJECTIVE: To develop a quality assessment tool for care rendered to enrollees in the Program for All‐inclusive Care of the Elderly (PACE) that can discriminate care quality ratings across PACE sites.