Peter A. Boling

Care transitions and home health care.

Transitions of care are becoming recognized as an important area for improvement in health care quality and patient safety. Yet there remains consistent evidence from multiple studies in varied settings of failures to complete safe, effective hand-offs from one location of care to the next. Major lapses include absent or limited clinical information and care plan content, plus errors related to medications. There are identifiable problems with half or more of the transitions that occur between care settings, and adverse consequences occur in 15 to 25 percent of patients. Undoubtedly these lapses contribute to the rates of re-hospitalization in post-acute care which affect 20 to 30 percent of patients within 60 days after hospital discharge. This article reviews models of transitional care intervention that have been tested and shown to be effective including less intensive coaching or guided care approaches, and more intensive case management strategies. Effective transitional care processes, linked with strong home care programs can reduce re-hospitalization by a third in some less intensive models and by half or more in some more intensive models.

Opportunities for Improving Post-Hospital Home Medication Management Among Older Adults

SUMMARY Effective post-hospital home medication management among older adults is a convoluted, error-prone process. Older adults, whose complex medication regimens are often changed at hospital discharge, are susceptible to medication-related problems (e.g., Adverse Drug Events or ADEs) as they resume responsibility for managing their medications at home. Human error theory frames the discussion of multi-faceted, interacting factors including care system functions, like discharge medication teaching that contribute to post-hospital ADEs. The taxonomy and causes of post-hospital ADEs and related risk factors are reviewed, as we describe in high-risk older adults a population that may benefit from targeted interventions. Potential solutions and future research possibilities highlight the importance of interdisciplinary teams, involvement of clinical pharmacists, use of transitional care models, and improved use of informational technologies.

Independence at Home: Community-Based Care for Older Adults with Severe Chronic Illness

By most clinical and economic measures, our health care system is not providing effective or affordable care to Medicare beneficiaries with severe chronic illness. Two million elders, constituting most of the 5% who account for nearly half of Medicare costs, have multiple chronic conditions, functional disability, and average per capita costs of over

Multimorbidity and a comprehensive medicare care-coordination benefit

50,000 per year. Prior reforms aimed at this population did not change the flawed delivery system, which remains centered in the doctors office, hospitals, and nursing homes. This article describes a model of coordinated home-based medical care, called Independence at Home (IAH), which operates on a limited basis in many US communities and in the Veterans Affairs system. IAH-type teams deliver a full range of medical and social services at home to seriously ill elders and thereby reduce overall health care costs. We review the evidence that this approach can lower total costs by 25 percent or more while improving patient satisfaction and outcomes. We discuss funding for the new model, which also produces net savings for Medicare. A Medicare reform bill, called the Independence at Home Act, was introduced in the US House and Senate in 2008 to promote replication of this mobile elder care model.

Workforce Development in Geriatric Home Care

Many articles in this Journal share a common theme: the exponential growth in the number of older persons (Medicare enrollees), of which a small fraction has serious illness and needs substantial care. This subset contains a large and rapidly growing number of individuals who consume the majority of healthcare resources. Geriatricians are inured to this information, because we read it so much. We live it. We know who populates the ‘‘small fraction’’Fthe very subset of older persons most likely to be referred to geriatricians. We take care of them every dayFthe very old with multiple competing illnesses, who face pervasive polypharmacy, impaired access, and a fragmented, silo-like care-delivery system that synergize to threaten our favorite patients. The currency of our daily existence is the phone calls to home care agencies, ‘‘potentially avoidable’’ emergency department visits and attendant hospitalizations, nursing home rounds, drives to house calls, piles of forms to sign, and lengthy family conferences with the care team and worried relatives on speaker-phone from a thousand miles away, discussing complex rehabilitation or end-of-life care. We experience simultaneously frustration and deep satisfaction every day caring for these people. We think: if only we had the resources to do simple medical case management with low-tech evaluation and hands-on helpers, we could save Medicare billions. We err in assuming that others truly comprehend the reality we experience and what we mean when we say how we intend to fix things. When policy-makers see these words, they see different issues and experience their own angst. Like us, they are intelligent and altruistic, but they have a different currencyF influential lobbying groups with competing interests, complex legislation with enormous budgetary implications that are impossible to fully comprehend now much less in the future, and a pressing constituency (in which we are one small voice). Many policy-makers have an abiding interest in the care of older persons, sometimes fueled by personal experience. But they are not clinicians and do not view our issues with a clinical gaze. As a society (both the U.S. citizenry and the American Geriatrics variety), we confront a big issueFcare of very ill older personsFand we need to speak a simple common language when designing solutions. Some progress has been made in designing eligibility schemes and benefits for the ‘‘small fraction.’’ Notable examples include Program for All-inclusive Care for the Elderly (PACE) for dually eligible, dependent older persons and the Hospice Medicare Benefit. This important legacy shows that care coordination can work for subgroups of Medicare enrollees, enabling comprehensive, high-quality services without breaking the bankFindeed even mitigating the overall economic effect of care. In these models low-tech, service-intensive care for small numbers of patients, either brought to the home (hospice) or delivered at a central location (PACE), actually improves quality of life in a costneutral and often cost-saving manner. Efforts continue to build on these examples, leading to a comprehensive carecoordination benefit to all Medicare enrollees with complex illnesses. Cigolle et al. help us move forward in this issue of the Journal with their study ‘‘Setting Eligibility Criteria for a Care-Coordination Benefit.’’ They engage in a cross-sectional analysis of data from the Health and Retirement Study to explore various ‘‘cutpoints’’ to define eligibility for a comprehensive Medicare care coordination and case management benefit directed to people with advanced chronic illness and debility. The authors start with a reasonable, although restrictive, framework: four or more severe, complex medical conditions with one functional dependency, which would apply to about half a million Medicare beneficiaries. Using cognitive impairment plus functional dependency as criteria would include about 1.5 million, and combining medical complexity, cognitive impairment, and functional dependency takes us to 2 million, or about 6% of beneficiaries. Geriatricians and gerontologists certainly recognize the importance of cognitive impairment as a driver of work effort for case managers. Although the exact description of what constitutes ‘‘severe, complex medical conditions’’ could not be addressed with the available data, this definition should be relatively easy to create by consensus. These numbers are manageable and are similar to previous estimates based solely on activity of daily living criteria of the frail, immobile elder population that might need home care services; up to 1.3 million qualifying for home-based care and at least 1 million older people needing chronic medical home care. From a policy and planning perspective, it is vital to understand the size and characteristics of the population most likely to benefit from more-intensive comprehensive care coordination. The current analysis adds the dimension of medical illness to a framework previously limited to functional status parameters. A parallel effort is underway at the National Institutes of Health (NIH). Several excellent thinkers and investigators are working together on the concept of ‘‘multiple DOI: 10.1111/j.1532-5415.2005.00504.x

Elderly patients have an altered gut-brain axis regardless of the presence of cirrhosis

With the rapidly aging population, it is anticipated that within two decades several million more individuals in the United States with functional impairment and serious ill health will need home health care. This article discusses workforce development, which is a critical issue for future planning, as recently highlighted by the Institute of Medicine (IOM). Key aspects of recruitment, training, and retention of home care workers are discussed, including those who provide basic support for activities of daily living as well as a variety of skilled professionals: therapists, nurses, pharmacists, and physicians. Although the geriatric workforce shortage affects all care settings, it is especially critical in home health care, in part because we are starting with far too few clinicians to meet the medical needs of homebound elderly. A combination of actions is needed, including educational programs, such as those developed by the American Academy of Home Care Physicians (AAHCP), changes in financial incentives, and changes in the culture and practice of health care, to make the home the primary focus of care for these vulnerable, underserved individuals rather than an afterthought.

Comprehensive longitudinal health care in the home for high-cost beneficiaries: a critical strategy for population health management

Cognitive difficulties manifested by the growing elderly population with cirrhosis could be amnestic (memory-related) or non-amnestic (memory-unrelated). The underlying neuro-biological and gut-brain changes are unclear in this population. We aimed to define gut-brain axis alterations in elderly cirrhotics compared to non-cirrhotic individuals based on presence of cirrhosis and on neuropsychological performance. Age-matched outpatients with/without cirrhosis underwent cognitive testing (amnestic/non-amnestic domains), quality of life (HRQOL), multi-modal MRI (fMRI go/no-go task, volumetry and MR spectroscopy), blood (inflammatory cytokines) and stool collection (for microbiota). Groups were studied based on cirrhosis/not and also based on neuropsychological performance (amnestic-type, amnestic/non-amnestic-type and unimpaired). Cirrhotics were impaired on non-amnestic and selected amnestic tests, HRQOL and systemic inflammation compared to non-cirrhotics. Cirrhotics demonstrated significant changes on MR spectroscopy but not on fMRI or volumetry. Correlation networks showed that Lactobacillales members were positively while Enterobacteriaceae and Porphyromonadaceae were negatively linked with cognition. Using the neuropsychological classification amnestic/non-amnestic-type individuals were majority cirrhosis and had worse HRQOL, higher inflammation and decreased autochthonous taxa relative abundance compared to the rest. This classification also predicted fMRI, MR spectroscopy and volumetry changes between groups. We conclude that gut-brain axis alterations may be associated with the type of neurobehavioral decline or inflamm-aging in elderly cirrhotic subjects.

Transitions of care: the next major quality improvement challenge

In this issue of the Journal of the American Geriatrics Society are two welcome reports of substantial financial and clinical success resulting from deploying two similar, although not identical, models of interprofessional homebased primary care to more than 10,000 high-risk individuals across the United States. Home care is an inclusive term with many meanings. Clinical service models are heterogeneous, as are patients, who have multiple chronic conditions, functional limitations, social vulnerabilities, and high mortality. The need for an appropriate comparison group and for measuring many variables over time challenges researchers and limits the number of robust evaluations and large-scale studies. In particular, randomized controlled clinical trials are difficult and expensive to organize, and because studies of this model must last for years, whereas health care itself is changing rapidly, they may also have inherent design weaknesses. Studying 9,425 individuals newly enrolled in the Department of Veterans Affairs (VA) Home-Based Primary Care (HBPC) programs in 2006, Edes and colleagues found high beneficiary satisfaction while reducing total costs by 11.7% and hospital admissions by 25%. They included Medicare costs because many veterans concurrently use Medicare services, raising the possibility that earlier positive HBPC studies could have benefitted from cost shifting. In this study, VA and Medicare costs were reduced. Previous recent VA HBPC reports relied on preand postenrollment costs to estimate savings, a method with important limitations. Here the cost analysis used concurrent modeled costs based on hierarchical condition categories (HCCs), which is similar to the method that the Centers for Medicare and Medicaid Services uses for Medicare Advantage plans and for the Program of AllInclusive Care of the Elderly, with additional risk adjustment appropriate to the studied population, and created a predictive model for expected costs in the absence of HBPC. The model was pretested on a large sample in the VA and proved highly accurate. DeJonge and colleagues report findings of a case– control analysis of costs and savings from delivering longitudinal team-based in-home care to 722 frail persons over 5 years in the MedStar Washington Hospital Center House Calls Program, which serves people in Washington, District of Columbia who are insured through the standard Medicare and Medicaid programs. Their cost analysis relied on carefully matching three Medicare beneficiaries who were not receiving home-based team care to each of the enrolled beneficiaries. The method used to determine similarity of controls and study subjects incorporated important medical conditions, including 57% prevalence of dementia or chronic mental illness, functional status, and patterns of prior service use. Despite using more home health and hospital services than controls in the baseline preenrollment period, which suggests that they were sicker, participants receiving house calls had 17% lower overall Medicare costs than controls, and there was no indication of poorer quality of care, greater mortality, or underservice. Hospital admissions were 9% lower, and there were 27% fewer nursing home bed days. Cost savings were concentrated in the frailest subset. In both cases, the care models feature a longitudinal, continuous team approach that included physician and nurse practitioner house calls with social work support and was comprehensive and truly patient-centered, managing medical and social circumstances. In both cases, the enrolled individuals were relatively old and sick, with high mortality, frailty, and medical comorbidity. The VA HBPC model has a larger core team on staff, whereas the MedStar Washington Hospital Center team drew in comparable community services in most cases. Although one step short of randomized clinical trials in reducing the chance of random error based on their design, these two studies used robust, accepted methods to control for potential confounders, and they reported similar and strongly positive findings. It is important to place these two studies in context. In the past 15 years, randomized controlled trials have shown benefit from short-term in-home care models, with better quality and lower cost. Among short-term interventions are Hospital at Home, an acute care model providing hospital-level care in the home; intensive short-term transitional care from a nurse practitioner team based at hospitals; and a less-intensive short-term transitional care model, all of which improved quality and substantially reduced costs. The Global Registry of Acute Coronary Events (GRACE) study consultative intervention model lasted for 3 years, adding quarterly in-home geriatric assessments by nurse practitioners supported by hospital-based geriatricians who made recommendations to office-based primary care DOI: 10.1111/jgs.13049

Professional Development in Geriatrics for Community-Based Generalist Faculty

This review and discussion outline domains and a research agenda leading to improvements in the quality of transitions of care between health‐care settings. Over the past two decades changes in health care financing have restructured the organization and delivery of health care. Health‐care plans and insurers have shifted to provision of health care in less expensive settings and growing concerns about the quality of health care have arisen – continuity may be lost, errors may occur, and patients may end up deeply dissatisfied. To improve the quality across the continuum of care, providers will need to reconceptualize from an intra‐organizational to an inter‐organizational viewpoint and will have to focus on transitions of care across settings. Services, such as case management, must effectively bridge gaps in the continuity of care. Improved measurement of outcomes, such as satisfaction with the transition, will be necessary.

Patterns of Emergency Care Use in Residential Care Settings: Opportunities to Improve Quality of Transitional Care in the Elderly

Generalist physicians provide most primary care for older people. Increasingly, undergraduate clinical education occurs in community sites. Hence, community‐based generalist faculty members need continuing education in geriatrics to support clinical practice and teaching. The Geriatrics Scholars Program provided continuing medical education (CME) in geriatrics over a 3‐year period to 88 participants. Sixty physicians completed 30 or more hours of education and were designated Geriatrics Scholars. On an anonymous exit survey, Scholars reported being better equipped to care for elderly patients and to teach geriatrics and improved patient care in specific aspects of geriatrics, including medication use, cognition, and functional assessment. In summary, community‐based generalist faculty who participated in a substantial, 3‐year program of geriatrics CME reported that their care of older people and their teaching of geriatrics were enhanced.