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Is the impossible dream possible?

October 1, 2008
by root
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Little doubt in the minds of most that geriatric care is broken. In fact, to even speak of a “continuum” of care is a blatant misnomer. There is no continuum of care for seniors. There are multiple silos, with movement from one silo to the other fraught with difficulty and inefficiency—even danger. Today's geriatric system is fundamentally hampered by a structure that has evolved, to a great extent, in response to the needs, demands, and availability of funding sources. Senior care suffers from a structural failure which puts payers—not customers—first.

In short, the failure to place customers at the center of decision-making, financing, and care-related processes is a central weakness of the current system, and this weakness has generated a cascade of woes. It is the lack of consumer choice that is one of the current system's most fatal flaws. The current care model was built around Medicare and Medicaid entitlement programs and is driven mostly by financial concerns. This priority affects the structure of eligibility, level of care determinations and, ultimately, the ability to access community services. Clearly consumers not only want greater choice than the current system allows, they want the ability to drive the healthcare system, including control of healthcare dollars.

Fraught with fragmentation

Absent the unifying and coordinative focus on the customer, we end up with fragmentation. As customers move through the “continuum,” they experience a disjointed system, which does little to promote communication, cooperation, or seamless delivery among providers. In its acclaimed report, “Crossing the Quality Chasm,” the Institute of Medicine underscored the existing healthcare system's poor organization. “Care delivery processes are often overly complex, requiring steps and handoffs that slow down the care process and decrease rather than improve safety,” the report said. “These processes waste resources, leave unaccountable gaps in coverage, result in loss of information, and fail to build on the strengths of all health professionals involved to ensure that care is timely, safe, and appropriate.” Well, for geriatric care, that goes in spades.

Clearly, the fragmented care system in place for seniors today fails to effectively integrate or target services to the populations it ostensibly serves. And that fragmentation, a function of disparate funding sources, is also reflected in the absence of meaningful and coordinated data. Data collection is limited and data sharing virtually nonexistent among providers. This impedes their ability to leverage data for the purpose of clinical, disease, and quality management. Databases in long-term care vary in adequacy from one setting to another, and do not interact or intersect. The minimum data set (MDS) used by nursing homes, for example, is wholly separate from the OASIS database used by home health agencies. This perpetuates the silos that fragment the long-term care continuum. As a result, when patients move from one sector to another, data collection continually begins frustratingly anew.

Forget the system's unstable financing. True, neither Medicare nor Medicaid can sustain projected program growth. However, even absent a resolution of the financing issue, the burden on funding is only exacerbated by the inefficiencies in the delivery system itself. And those inefficiencies are compounded by the increasing importance of chronic conditions as descriptors of health status among American citizens. The Institute of Medicine, in its sentinel publication, graphically described the growing prevalence of chronic disease to a point where it now accounts for most healthcare in the United States. The delivery of appropriate care for those with chronic conditions requires a paradigm shift from episodic, short-term interventions, which characterize care for acute conditions, to long-term comprehensive care for those with continuous care needs. And our current system simply cannot provide such care without, as the Institute's report made abundantly clear, major steps toward improved coordination, cooperation, and integration.

It is also clear that, with the attention devoted to chronic care needs, a parallel focus has to be on the elderly. Forty-eight percent of Medicare recipients experience three or more chronic conditions and consume 89% of the Medicare budget. Similar data exist for Medicaid's aged population. With age comes, not just frailty, but chronic disease. And, so contends the Institute, any system designed to deal with the healthcare needs of seniors must be customer-focused, timely, safe, effective, equitable, and cooperative.