Is the impossible dream possible?

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.

So, what are we doing about it? Not much, as it turns out. No question there have been projects, lots of projects. And, I guess, as an academic, I should be happy about this, since it has mostly been research and dem-onstrations. You’ve heard of many of them. I’ve even written about a number. They include PACE (Program of All-inclusive Care for the Elderly), SHMOs (social health maintenance organizations), GEM (Geriatric Evaluation and Management). And, while limited in scope, some of them have shown promising results. No question that some models of integrated health and social care for the elderly can result in improved outcomes, client satisfaction, and/or cost savings or cost-effectiveness. But there are caveats. One is that, as suggested by a recent Canadian study, “integration costs before it pays.” And some innovators, wearied by the prospect of ongoing and heavy investments prior to profits, give up the ghost. This can be particularly true of research projects which, when the funding agency’s resources dry up, recognize that the concept of “sustainability” has been overlooked. Under the best of circumstances, changing systems of care requires a major and lasting commitment as well as a willingness to take risks. What new and innovative programs really require is a product champion willing to accept a run-in period that might be plagued with difficulty and expense. We also discover that what worked in the laboratory doesn’t always translate in the real world.

Results promising

That said, results remain promising with an increasing understanding of what it takes to succeed. In that same Canadian study, (which analyzed systems across the world, not just in Canada), four prerequisites for success stand out. They include:

  • an umbrella organizational structure designed to guide the integration of strategic, managerial, and service delivery levels, to encourage and support effective joint/collaborative work, to ensure efficient operations, and to maintain overall accountability for service, quality, and cost outcomes

  • multidisciplinary case management for effectively evaluating and planning for client needs, providing a single entry point into the healthcare system, and packaging and coordinating services

  • organized provider networks joined by standardized procedures, service agreements, joint training, shared information systems, and even common ownership of resources so as to enhance access to services, provide seamless care, and maintain quality

  • financial incentives to promote prevention, rehabilitation, and the downward substitution of services, as well as to enable service integration and efficiency

So, why this laborious discussion of the problem and potential pathways for its resolution? Because at least one geriatric service provider is about to launch a private-sector (not a research) project which is designed both to recognize the caveats while embracing the prerequisites. The provider’s name is Erickson Retirement Communities. The location is the Lorien Health Campus in Howard County, Maryland. Erickson is one of the leading national developers of full-service retirement communities. Headquartered near Baltimore, Erickson has built an innovative network of 23 communities from the eastern seaboard to Colorado that combine a maintenance-free active lifestyle with an ever-expanding host of amenities, social activities, and wellness and medical centers, proven to improve both physical and mental health. More importantly, Erickson offers a sterling example of how best to deliver comprehensive healthcare to seniors. In each of its communities (which can be comprised of more than 1,500 individual apartments as well as assisted living and nursing facilities), is housed a medical practice, highly integrated with an on-campus multidisciplinary team, which provides all essential geriatric health services. But that’s only part of the story.

The company’s founder, John Erickson, is well aware that the continuum of services for seniors is multifaceted, from physical to mental, from social to psychological, from environmental to cultural. To be sure, all Erickson communities have their own geriatric medical practices, rehabilitation therapists, and home care agencies. But how many CCRCs have their own television studios? Banks? Multiple restaurants?

For its entire history, Erickson has been facility-based. It is now venturing into Howard County to take the concept of a seamless services continuum “beyond the gates.” The program’s cornerstone will be the Erickson Health medical practice and model, which will now collaborate with complementary service providers in the community. To create a sustainable model, Erickson has partnered with Evercare, a division of United Health, to offer Evercare’s Medicare Advantage plan. In a Medicare Advantage Special Needs Plan, nurse practitioners and care managers work with primary care physicians, facilities, social support service providers, and families to provide intensive primary and preventive services to people who have long-term or advanced illness, are older, or have disabilities. The model combines benefit design, the creation of a provider network, and clinical management programs. (Medicare Advantage plans were first known as “Medicare+Choice” plans.)

In this initiative, Erickson providers and employees will be directing and managing all aspects of care delivery to patients enrolled in the practice, which will provide care across the entire continuum. The business partnership of Erickson with Evercare is a natural as it reflects the commitment and high alignment of the two entities to clinical best practices and coordinated care. While the venture in Howard County will be managed in close cooperation with Evercare, the services coordinated will not be limited to those provided through the Medicare Advantage plan. Someone once said, “It takes a village.” Well, the village in Howard County is already in place. Erickson’s partners span the entire breadth of senior services in the county. From the county’s own network of senior centers, its community hospital, the local nursing facility, the county’s transportation system, even a new exercise center—all will become part of the continuum of service and care.

Critical component

But, wait. There’s more. Involvement of nontraditional community-based services are a critical component of this venture. Nursing home placement, for example, can often be traced back to the absence of familial, social, and environmental support structures. Once totally implemented, the plan will cover the entire array of services which make up the continuum. But, of equal importance, those services will be part of an existing county infrastructure with great care directed toward the orientation to and management of that infrastructure with seniors in mind. Even the county’s system of higher education (Howard Community College, for example) is being looked to as one means of providing family caregivers some of the basic competencies crucial to the provision of services to their loved ones. When the project developers in this venture say “community,” they include family as perhaps the most critical element of community. They also see services to family members as of equal importance to those offered to the senior. If successful, that concept might just become the prototype for similar undertakings across the country.

While the project is still in the development phase, the physician practice is already up and running with not only a board-certified geriatrician in charge, but a nurse coordinator and a member services representative also in place. But plans for the future go far beyond that. Given the Erickson reputation for embracing the entire continuum and the enthusiasm of its partners in Howard County, the project will eventually extend across the entire gamut of senior services and care, starting with the more traditional healthcare providers. Both Lorien Health Systems, the county’s primary nursing and assisted living provider, and Howard County General Hospital have demonstrated an interest in becoming partners. The county executive, Ken Ulman, has expressed his own enthusiasm, which will lend itself to incorporating both the county’s transportation system as well as its eight senior centers.

How does it stack up?

And just how does the project stack up with respect to the ideal system? Well, let’s go back to the four prerequisites cited in the Canadian study. The first is an umbrella organizational structure designed to guide the integration of strategic, managerial, and service delivery levels. We certainly have that in Erickson Retirement Communities and Evercare. No healthcare provider is more experienced and successful in delivering coordinated services to seniors.

And how about multidisciplinary case management for effectively evaluating and planning for client needs? It’s instructive that, among the first staff hired for the physician practice, is a registered nurse care coordinator. It’s not enough for services to be available and providers to be in place to deliver them. Someone has to put it all together, person by person; someone to determine what is the right service, at the right time, in the right place. That’s the job of the care coordinator, a position as important as that of the provider herself. And an organized provider network joined together by standardized procedures, service agreements, joint training, shared information systems? This might just be the most exciting aspect of the new venture.

I wrote just a few months back that it’s all but impossible to have a seamless transition across the respective “silos” of long-term care as long as there is no electronic and portable health record to facilitate that transition. The partners in this enterprise are well aware of that fact. Erickson is a leader in the development and implementation of electronic health records, and both Lorien Health Systems and Howard County General Hospital are on record as being capable and willing to accommodate to that record. That, in and of itself, is worth celebrating.

And, finally, there are financial incentives to promote prevention, rehabilitation, and the downward substitution of services, as well as to enable service integration and efficiency. That’s really what Medicare Advantage plans are all about. And the fact that the partners engaged in this project are all successful business entities, with bottom lines to worry about, makes for a much higher likelihood of success. That, along with the fact that the project has the full support of county government, suggests a partnership that goes even beyond the four prerequisites suggested in the Canadian study. The public and private sectors, proprietary and nonproprietary partners—all working together to fulfill a dream that has long eluded most communities. It’s exciting, to say the least. Stay tuned for further developments.

To send your comments to Dr. Willging and the editors, e-mail

Long-Term Living 2008 October;57(10):16-24

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