Lisa Boult

Screening Elders for Risk of Hospital Admission

Objective: To define a set of screening criteria that identifies elders who are at high risk for repeated hospital admission in the future.

A Controlled Trial of Outpatient Geriatric Evaluation and Management

Objective: To evaluate the effects of targeted outpatient geriatric evaluation and management (GEM).

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

MODELS OF GERIATRICS PRACTICE: Outpatient Geriatric Evaluation and Management*

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.

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

OBJECTIVE: To describe the development and operation of a practical model of outpatient geriatric evaluation and management (GEM) for high‐risk, community‐dwelling older adults.

Perspective: transforming chronic care for older persons.

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)

Underuse of Physician Services by Older Asian-Americans

The size and impending morbidity of the aging baby boom generation could soon overwhelm the U.S. health care system. Transforming chronic care for older persons to avert this calamity will require rapid increases in the number of physicians who are skilled in providing chronic care and prompt adoption of new models for providing high-quality, cost-effective chronic care. The authors propose a new approach for attaining these objectives, recommending that todays leaders of academic medicine help transform geriatrics into a collaborative discipline of clinicians with advanced skills in leading educational, organizational, and research-related initiatives; that they support the collaboration of geriatrics with primary care and specialty disciplines in preparing physicians to practice effectively in new models of chronic care for older persons; and that they energetically promote rigorous training in chronic care at all levels of medical education. Implementing this strategy would require firm commitment by the Association of American Medical Colleges, specialty boards, accrediting organizations, academic institutions, the Centers for Medicare and Medicaid Services, legislators, and business leaders. Although garnering such support would be challenging and controversial, this approach could leverage the expertise of geriatric educator-leaders to help transform chronic care in the United States and to make high-quality, cost-effective chronic care accessible to most chronically ill Americans within 20 years.

Clinical practice guidelines and quality of care for older patients with multiple comorbid diseases : Implications for pay for performance

n important influence on older persons’ use of physician A services is the cultural group to which they belong. As the size and cultural diversity of America’s older population continue to increase throughout the coming decades,’ a deeper understanding of this relationship could be used to guide the evolution of systems for providing cultureappropriate, cost-effective health care. There is a long-standing controversy about whether members of minority and majority cultures share health services equitably in the United States. Employin the Andersen behavioral model of health services use?’ two large studies found that “need predicts use” more strongly in minority cultures than in the majority (white) ~ u l t u r e , ~ . ~ but the two groups of investigators drew opposite conclusions from this finding. One study deduced that members of minority groups who need health care usually receive it, and, therefore, that there is no inequity between the majority and minority The other concluded that, although minority older persons may sometimes use urgent or emergency services when they need them, they less frequently use discretionary preventive services that would allow the early diagnosis and treatment of ominous but nonurgent conditions. They regarded this as conspicuous evidence of inequity in health care.4 Other analyses have shown that uninsured, low-income, and black persons use fewer health services than other In a recent study, membership in a minority culture (Asian-, Native-, or Arab-American) emerged as the most powerful of 28 independent variables in predicting problems with access to medical care.I2 Several studies have reported unequal use by whites and blacks of angiography, angioplasty, and coronary bypass graftir~g.’~.’~-” In the National Long-Term Care Channeling Demonstration, frail older blacks and Hispanics were significantly less likely than their white counterparts to use nursing home services (odds ratios = 0.28 and 0.42, respectively); blacks were also less likely to use in-home services (odds ratio = 0.82).16 Previous investigations have not, however, compared the frequency of use of physician services by older persons of different cultural groups, nor have they focused on subgroups of older people whose need for health care services is high. The present study was designed to address both of these