Retooling for an Aging America Building the Health Care Workforce (2008) / Chapter Skim
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3 New Models of Care
3 New Models of Care
Pages 75-122
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From page 75... ...
The nation faces major challenges as it prepares for the growing number of older adults. There is a pressing need to develop a health care workforce that is sufficient in size and ability to meet the needs of this group.
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From page 76... ...
Finally, the chapter discusses shifts in the workforce that may be required to support these new models, such as new roles for providers, increased delegation of responsibilities, greater use of interdisciplinary teams, and increased involvement of patients and their families. A VISION FOR CARE IN THE FUTURE The committee identified three key principles that need to form the basis of an improved system of care delivery for older Americans (Box 3-1)
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Care needs to be seamless across various care delivery sites, and all clinicians need to have access to patients' health information, as well as population data, when needed. Health information technology, such as interoperable electronic health records and remote monitoring, needs to be used to support the health care workforce by improving communication among providers and their patients, building a record of population data, promoting interdisciplinary patient care and care coordination, facilitating patient transitions, and improving quality and safety overall.
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NEW MODELS OF CARE DELIVERY A number of new models of care have been developed with the aim of improving quality and patient outcomes, promoting cost savings, or both. The proliferation of these new models indicates not only a recognition that services for older adults need to be improved but also a willingness among providers, private foundations, and federal and state policy makers to commit resources to learning about better ways to finance and deliver care.
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The care managers (typically nurses, psychologists, and social workers) are trained as depression clinical specialists and work with the patient's
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. Results from the model indicate that evidence-based care for major depression can be successfully delivered by specially trained nurses, psychologists, and social workers in primary care settings.
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The model was based on the principles of the Eden Alternative, a movement to foster culture change within nursing homes by creating a home-like culture
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Quality of care was at least as good in the GH group as in the control group. The GH group also had a lower prevalence of residents on bed rest, fewer residents with limited activity, and a lower prevalence of depression compared with residents of traditional nursing homes.
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. The additional pay is made possible through stabilization of the direct-care workforce (i.e., lower costs due to decreased turnover rates)
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. These demonstration projects have examined mechanisms to restructure the Medicare and Medicaid programs in ways that support more efficient and more effective care delivery for older adults.
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. The benefits of PACE were even greater for the frailest older adults, whose enrollment was associated with lower rates of service utilization in hospitals and nursing homes and higher rates of ambulatory care services.
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. Under the program, nurse practitioners provide more intensive primary care services than is typical for nursing-homes residents, and they coordinate enrollees' care with the nursing-home staff (Stone, 2000)
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. Other Medicare Demonstrations In addition to the demonstration projects described above, the Medicare program has developed and implemented a number of other demonstration projects that have tested new ways of delivering care to older adults.
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Medicaid Demonstration Projects Many state Medicaid programs have developed innovative models of care to integrate services, to improve care coordination, and most notably, to allow individuals a larger role in shaping the services that they receive.
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Medicare To test whether providing Interim evaluation found increases in Coordinated Care coordinated-care services to beneficiary education but no effect on Demonstration Medicare beneficiaries with satisfaction, patient adherence, self (2001) complex chronic conditions care, or Medicare expenditures.
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Services offered under ALTCS include acute medical care, behavioral health services, and case management. Services are also covered for care delivered in nursing homes, in the home setting, and in assisted-living facilities.
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SHO offers enrollees a package of acute and long-term care services through a choice of managed care plans. The state is essentially treated like a health plan that contracts with CMS to provide services; the state then subcontracts with health plans that combine services from Medicare and Medicaid into one integrated benefit package for enrollees (CMS, 2004; Malone et al., 2004)
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. Funding from multiple programs (e.g., home- and community-based waiver services, state general-revenue-funded programs, and Medicare long-term care services)
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For example, preventive home visits may be too costly to expand to all older persons, the majority of whom may not even require that level of care. Similarly, caregiver-support programs may not be sufficient for older adults with more intensive needs.
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, quality of care, health outcome social workers, physical therapists, pharmacists, scores, and patient satisfaction. occupational therapists, recreational therapists, Some also showed lower total costs, dieticians, home-care providers, personal-care fewer hospital admissions, physician attendants, and drivers.
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psychologists, social workers, or rehabilitation therapists, these programs provide varying combinations of health information, training, access to professional and community resources, emotional support, counseling, and coping strategies. They communicate with primary care providers primarily through their clients.
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Overall, the traditional FFS system limits innovation in care delivery. Shifting the focus of care delivery away from acute care is difficult in part because of the rather complicated process that CMS must follow in order to add coverage for newer services, such as preventive home visits or care coordination.
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. Furthermore, many geriatric care models require the services of care managers, typically nurses or social workers, but these workers often do not qualify for Medicare reimbursement.
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New Financing Mechanisms Given the challenges associated with traditional FFS Medicare and MA, a new model of payment is needed to support effective models of care and the integration across various settings of service that are necessary to prevent or delay declines in functional and health status for older adults (Biles et al., 2006; Guterman and Serber, 2007)
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For example, one proposal calls for the creation of a modified home visit benefit for beneficiaries in need of extended home-nursing and personal-care services (Berenson and Horvath, 2003)
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Participating practices would be required to undergo structural and organizational changes (e.g., the adoption of interoperable electronic health records with decision support and the use of interdisciplinary teams) that follow established standards.
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use health information technology (e.g., remote monitoring and patient registries) to monitor and track the health status of patients and to provide them with enhanced and convenient access to services; and (4)
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They include • the model having an intuitive appeal; • the existence of a strong evidence base demonstrating benefits for patients; • potential cost savings; • patient dissatisfaction with existing care; and • secular trends, such as the aging of the population, recognition of the importance of managing chronic disease, and the move toward community-based care (Leff, 2007; Rogers, 2003)
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. The spread of the IMPACT model, though somewhat limited, has been aided by the IMPACT Implementation Center, which is funded by private foundations and provides resources and technical assistance to organizations seeking to adopt the IMPACT model.
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. Like IMPACT, PROSPECT provides depression-care management to older patients in primary-care settings in an effort to reduce the burden of depressive symptoms, remove suicidal ideation, and improve health-related quality of life.
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. The National PACE Association, largely funded by private foundations, offers a number of resources and technical assistance to organizations that wish to establish PACE programs.
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. Evaluations of HELP indicate that it is effective in preventing delirium and functional decline, and that it is cost effective in hospitals and long-term care settings (Inouye et al., 2006)
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Contextual factors, such as the challenges in changing the cultures of health care organizations and gaining internal support for adoption from the organization's leadership, are also critical to dissemination, but such factors are not well understood. Creating culture change in health care settings requires that organizations and individuals consider better ways to deliver care, including changing the ways that health care personnel function (Shields, 2005)
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Still, as discussed previously, the evidence base on models of care for older adults remains somewhat limited, and the information regarding which models are most suitable for dissemination needs to be improved. Considering the current relative lack of investment in research and demonstration programs for new models of care, especially in comparison to annual spending on health care services, much more funding is needed to develop this evidence base.
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. More information is needed on how the size and capabilities of the health care workforce affect patient care in terms of quality and outcomes.
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, and service-enriched housing (providing housing situations or physical environments that accommodate each patient's individual health needs or preferences, allowing greater freedom in choice of care settings)
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As more models depend on patients and informal caregivers being part of the health care team, these individuals will need to be given more education and training so that they can be more effective members of the team. Finally, as is true for the health care workforce as a whole, the development and use of new technologies will have implications for the health care workforce for older adults; the implications will arise not only from the need to train individuals in the use of these new technologies but also from their potential ability to assist existing health care workers in performing tasks and their potential for reducing the number of workers needed.
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First, as new and expanded roles are delineated, more will need to be done to assure the competence of those providing increased levels of care. Second, as more responsibilities are delegated by professionals to other members of the health care workforce, these professionals will have increased responsibility for management and supervision but will need to be taught the skills required for these roles.
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(See Chapter 6 for more on patients and informal caregivers.) Interdisciplinary Care The introduction of interdisciplinary teams into care delivery will pose a number of challenges.
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. Many new models of care strive to improve care coordination, and these efforts can affect the use and development of the health care workforce.
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The interaction between developing technologies and the health care workforce is discussed further in later chapters, and recommendations are offered for encouraging the development and use of health technologies. CONCLUSION Simply expanding the size of the workforce qualified to provide the needed health care services to older adults will not be sufficient to address the challenge that will face this country over the next two decades.
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Paper commissioned by the IOM Com mittee on the Future Health Care Workforce for Older Americans. Bowers, B
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A case study of disseminating the hospital elder life program. Journal of the American Geriatrics Society 53(9)
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Presentation at Meeting of the Com mittee on the Future Health Care Workforce for Older Americans, San Francisco, CA.
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2007. Resident outcomes in small-house nursing homes: A longitudinal evaluation of the initial Green House pro gram.
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Presentation at Meeting of the Committee on the Future Health Care Workforce for Older Americans, San Francisco, CA.
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2005. Culture change in nursing homes.
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2000. Access to palliative care and hospice in nursing homes.
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