Global Roadmap for Healthy Longevity (2022) / Chapter Skim
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6 Health Systems
6 Health Systems
Pages 173-220
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From page 173... ...
Few countries are well positioned to provide the prevention and care required to decrease the prevalence of chronic conditions and associated symptom burden and functional decline. Public health is chronically underfunded and lacks influence in other government departments that influence health, limiting its ability to improve population health.
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Shift health care systems to focus on healthy longevity 6-3. Make available culturally sensitive, person-centered, and equitable long-term care Supporting Structures All Health Systems Integration across public health, health care, long-term care, and social services Public Health Interventions at population and individual level to reduce underlying risk factors for aging and chronic conditions Close collaboration with social service providers, workplaces, and other entities that can promote health Data and analytics systems for surveillance, precision public health, and assessment of the efficacy of interventions Health Care Integrated person-centered care, including care coordination 2022 - 2050 Primary care Comprehensive and shared health records and a goal-based care plan Collaboration with social services to address social determinants of health Primary care systems that provide preventive screening, address risk factors for chronic conditions, and promote positive health behaviors Geriatrics workforce that can adequately care for older people globally Palliative and hospice care Long-Term Care Policy and funding prioritizes care delivery in the setting the person chooses, to the extent possible; respects individual autonomy and maintains dignity; and attends to care quality and the risk of abuse, neglect, and exploitation Care and social supports addressing all needs, including meaning and purpose Supports for families and family caregivers when providing long-term care while making formal care available when needed Technology to support caregivers and people needing care by providing monitoring that allows privacy Goals 7.
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The chapter concludes with an overview of related international efforts calling for similar actions, metrics that stakeholders can use to gauge progress toward achieving healthy longevity, and areas needing more research. As with earlier chapters, commissioners selected key targets for action beginning in 2022 from the many factors affecting healthy longevity.
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Since the early 1990s, WHO has sought to measure the burden of poor health using two related measures: years of healthy life lost due to disability (YLDs) and disability-adjusted life years (DALYs)
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The Health of Older People One myth about older people as a group is that most are in poor health and frail. The reality is that the health of older adults is heterogeneous, although at a population level it declines with age.
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A 2019 analysis calculated global health care spending to be USD8 trillion in 2016 and predicted it to climb to USD15 trillion in 2050. The authors describe 6 4 Staff calculated unhealthy life expectancy GLOBAL using data ROADMAP from WHO FOR HEALTHY by subtracting LONGEVITY healthy life expectancy at age 60 from life expectancy at age 60.
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This chapter aligns with UN SDG 3, Good Health and Well-being. All of the targets within SDG 3 would promote healthy longevity (UN DESA, 2022)
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Four health behaviors (tobacco and unhealthy alcohol consumption, unhealthy diet, and physical inactivity) are major contributors to the development of the four conditions responsible for 80 percent of chronic disease deaths ("cardiovascular disease, cancer, chronic obstructive pulmonary disease, and diabetes")
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over the period 2011–2030 is estimated at nearly USD47 trillion" • Value of a statistical life approach: "the economic burden of life lost due to all noncommunicable diseases ranges from USD22.8 trillion in 2010 to USD43.3 trillion in 2030" SOURCE: Bloom et al., 2012, p.
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It minimizes threats to health that can be averted or lessened only through collective actions aimed at the community." Creating healthy longevity will require a "new public health" that works to prevent chronic conditions at the societal, community, and individual levels (Halpin et al., 2010) .7 6 Public health systems have different functions in different countries.
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The top three tiers, which comprise efforts to improve population health one person at a time, are addressed in the next section, on the role of person-centered integrated health care in preventing and managing chronic conditions. Although the pyramid was developed in the United States, a 2019 review article emphasizes the need for low- and middle-income countries to shift away from a focus on identifying individual risk factors and screening to a focus on the interventions at the bottom of the pyramid (Miranda et al., 2019)
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To address social and economic risk factors successfully will require col laboration between public health and other government agencies and private-sector stakeholders that can influence health behaviors, such as unions and employers. Changing the Context Interventions at the next level of the health impact pyramid change the context in which health behaviors occur.
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Investment in and Return on Investment from Public Health Prevention Despite its importance, public health is chronically underfunded in countries around the world. Even as the threat of increasing numbers of older people with chronic conditions and more years of poor health has grown, public health spending patterns have largely remained unchanged in higher-income countries.
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The absence of these data makes it difficult to monitor progress toward health-related SDGs or toward healthy longevity at the national and subnational levels.
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The government also analyzes economic decisions from the perspective of their impacts on health. The result is that Costa Rica, which is ranked by the United Nations Development Programme as "High" development driven in part by national income, has results consistent with countries ranked as "Very High" in life expectancy, mortality rate of children under age 5, and expected years of schooling.
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will be necessary at the national and community levels to understand the most important contributors to health and healthy longevity. Capturing data on social determinants of health globally is critically important and more difficult relative to data on age and gender, requiring data collection methods not currently in use.
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First, they have limited ability to influence other government agencies with authority for addressing social determinants of health, including availability of social services, clean air and water, safe housing, and walkable communities, among others. Public health also needs to be involved in decisions about health care and long-term care, and the three systems need to work in concert on prevention efforts, coordinating across the full health impact pyramid -- something that is not yet a reality in most places.
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age bands and by sex, will be necessary to understand the impacts of public health interventions and progress toward healthy longevity. The commission also emphasized the need to collect data on social determinants of health at the individual level.
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KEY TARGET: HEALTH CARE DELIVERY The health care delivery system has multiple roles to play in promoting healthy longevity and reducing the burden of chronic conditions and their impacts at the individual and societal levels. Prevention roles for the health system include individual-level screening, preventive measures (e.g., vaccinations)
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. By following clinical guidelines for discrete medical conditions without taking the whole person and multiple conditions and context into account, providers can harm people with multiple chronic conditions, who represent the majority of older people.
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Farrell, MD, American Geriatrics Society Fellow, February 7, 2022.
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. High-quality primary care is critical for health, and requires functional partnerships across systems to maximize the capacity of individuals by addressing social determinants of health (Kruk et al., 2010)
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The local primary health care teams were first assigned to rural communities, which were most likely to experience health care inequities, an approach that led to a rapid increase in coverage. Additionally, community health workers play a vital role in developing relationships with their patients, allowing for early diagnosis of diseases and con ditions while promoting nutrition, physical activity, family planning services, and more.
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Because most older people with complex care needs prioritize goals that require a threshold level of physical and cognitive function, geriatric care typically prioritizes improvement in or maintenance of cognitive and physical function over medical goals. That said, because decisions about care goals among older patients with chronic conditions are complicated by a lack of clinical guidelines and the challenge of polypharmacy, some geriatricians are encouraging goal-based care, which includes using the person's
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Multiple geriatric care models have emerged in the United States in recent years, some of which have been exported to other countries. A review article written in 2009 for the Institute of Medicine (IOM)
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According to WHO, integrated, person-centered care (including behavioral health care) is the most effective and appropriate care delivery model for maximizing health, function, and well-being across the life course (WHO, 2015b)
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. Components Needed for Integrated, Person-Centered Care WHO's Global Strategy on People-Centred and Integrated Health Services builds on its earlier strategies to promote universal health care, primary health care, action on chronic conditions, action on social determinants of health, and enhanced health security through resilient health systems (WHO, 2015a)
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. Research Questions Research is needed to investigate the following questions: • effective interventions for real-world older people -- not just clinical trials that include real-world conditions, such as cognitive function; • how to promote self-management among people with multimorbidity and barriers to self-management; • development and testing of value-based care outcome measures; • effective priority setting between clinician and patient; • development of consensus for evaluating the quality and efficacy of geriatric care models;
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b. Governments should develop plans to align health care payment and reimbursement systems with healthy longevity outcomes.
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KEY TARGET: LONG-TERM CARE Long-term care is crucial to enable people with significant loss of capacity to experience lives of meaning and dignity. Even if the health span increases and healthy longevity is achieved at higher rates than today, some people will still need long-term care.
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104–105. Caregiving experts agree that family caregivers need training to provide adequate care for older people; support for the emotional strain caregiving can bring; and, when possible, financial support, particularly for those who must forego paid work to provide care for a family member (NASEM, 2016)
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. FIGURE 6-4 Percentage of older people living in nursing homes.
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In the United States, nursing homes that serve the poor are often underresourced, limiting such aspects of care as nurse-to-patient ratios. Research has found that nursing homes in the United States with higher percentages of Black residents are more often understaffed and receive deficient care and mistreatment ratings than nursing homes with lower percentages of Black residents (Harrington et al., 2017)
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. At the same time, the adverse experiences with COVID-19 in nursing homes globally may generate increased interest and investment in nursing home alternatives, such as hospital-based extended care units, home care, and other community-based care models.
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Finding 6-12: Family caregivers provide the majority of long-term care globally, but most have inadequate training and experience to provide quality care, especially for people with dementia. BOX 6-10 Case Study: Wraparound Services in Canada's Senior Villages Senior villages are campuses that include four colocated components: hous ing options, community supports, and a long-term care facility.
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Needed as well are data on the quality of family caregiving and paid home care providers, and on the needs of family and paid caregivers. The International Long-Term Care Policy Network captures and makes available data on long-term care, which have been critical to understanding the challenges posed by COVID-19 to long-term care systems and policy responses from countries.9 Research on the following questions also is needed: 9 See https://www.ilpnetwork.org.
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Other health care workers, especially those who provide direct services in low- and middleincome countries, also lack the training needed to provide high-quality care for this population. A critical component of the care workforce for older people consists of those who provide personal care and other supports to people needing long-term care within and outside of facilities.
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Although geroscience has the potential to extend the life span, the commission chose to emphasize the "healthy" part of "healthy longevity"; thus, the goal is to improve the percentage of life in good health, not to further prolong the life span, recognizing that major disparities in life span exist globally. In its focus on the underlying drivers of aging, geroscience differs from traditional biomedical research, which focuses on one disease at a time and often is conducted with carefully constructed study samples that are not representative of the larger population.
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Care Delivery Technology Digital technologies have the potential to play an important role in integrated care delivery for older people by enabling early detection and management of chronic diseases and functional impairments. Digital care technology is most effective when experts across sectors, such as engineers, medical professionals, and scientists, use human-centered design techniques to engage older adults throughout the design process.
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Older adults thereby have a visible reminder to increase physical activity that supports healthy longevity and enables self-monitoring and feedback (Kononova et al., 2019)
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A combination of unstructured AI and hypothesis-driven research is expected to enable the precision medicine and precision public health described earlier in this chapter. Unstructured AI detects patterns and clusters that are complex, multidimensional, and subtle, and that would be very difficult to identify using hypothesis-driven quantitative research methods.
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Research Questions In addition to the efficacy and acceptability of AI use and interventions across health systems, Kennedy and colleagues (2014) suggest the following research goals for geroscience: • "Continuum from psychological to molecular stresses • Differentiate hormesis from toxic stress • Better align human and animal studies • Biomarker development: chronologic versus biologic aging • Link age-related environmental inputs to epigenetic signatures • Test small molecules that regulate enzymes controlling epigenetic events • Differentiate adaptive and maladaptive inflammatory responses • Define age-related inflammatory sources and their systemic effects • Determine how obesity and metabolic dysfunction alter inflammation with age • Generate systems-level understanding of the types of macromolecular damage and their roles in chronic disease states • Understand how stochastic damage influences the variability of aging • Define role of signal transduction pathways linked to metabolism in the aging process • Understand contribution of circadian clocks to aging and metabolism • Connect metabolic dysfunction with tissue-specific decline in aging • Identify proteostatic pathways that are overwhelmed in specific chronic disease states • Examine crosstalk between proteostasis machineries • Understand non-cell-autonomous signaling and activation of proteosta sis pathways • Determine whether declining adult stem cell function drives aging and chronic disease • Examine how aging and associated disease impair adult stem cell function
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2020. Characteristics of US nursing homes with COVID‐19 cases.
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2018. The global burden of multiple chronic conditions: A narrative review.
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2020. The intersection of genomics and big data with public health: Opportunities for precision public health.
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2021. Voices of paid and family caregivers for Medicaid enrollees receiving HCBS.
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2011. International Association of Gerontology and Geriatrics: A global agenda for clinical research and quality of care in nursing homes.
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2019. Life expectancy and healthy life expectancy by World Bank Income Group.
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