If our work at the John A. Hartford Foundation has taught us one thing, it's this: In the quest to transform primary care for older adults, a huge part of the answer is deploying more geriatrically expert primary care teams that can coordinate and deliver care designed around the patient's needs. You could call this the low-hanging fruit of health care reform, because, if there is a population in which we have the biggest opportunity to see improvements in both cost and quality of care outcomes, it is older Americans.
The debate on how best to deliver effective primary care has gone on a long time, sometimes frustratingly so, but it has almost never included a crucial constituency: older adults. Today we are pleased to help change that.
We believe that listening to older adults is essential if we are ever going to transform our primary care system so it can and does deliver well-coordinated, comprehensive, accessible care centered on their needs and goals. This belief has already led the Hartford Foundation to conduct two previous public opinion polls, focused exclusively on adults 65 and older, examining serious gaps in geriatric primary care and mental health care.
And today it feels like Christmas morning because, after more than six months designing and planning our latest poll, "On Your Team," we finally get to release the results. (For complete information, including the press release, topline poll results, poll memo, and more, please visit our Learning Center Public Poll page.)
"On Your Team" explodes several tired stereotypes about older adults and health care innovation (e.g. they distrust and will reflexively resist it, and don't want to see anyone but their own physician), by providing a huge vote of confidence for team care and the key services of the patient-centered medical home (PCMH).
We asked older adults whether they received a number of key services of the patient-centered medical home. Unsurprisingly, only about 27 percent said they did. Then things got interesting. In most cases, the effectiveness of a health care innovation is determined by the willingness of people to participate in it. Even among the many respondents who don't receive team care now, a significant majority (73 percent) say they would like to. And 61 percent also said they believed this type of care would improve their health.
Among the lucky few already in a medical home type of practice, a whopping 83 percent said they felt the care they were getting had already improved their health. And the more specific PCMH services they reported receiving, the higher their reported satisfaction with their care.
This standard – improving health – is a high bar. Virtually all of our respondents are Medicare beneficiaries, fully insured, with a regular primary care provider, so it was actually somewhat surprising (pleasantly so) to discover that they believe some fairly simple steps would help them become healthier.
When patients feel engaged, supported, and in control of their health, physicians and other health care researchers and providers consider it a strong and valuable predictor of improved future health and decreased use of such costly clinical outcomes as future hospitalizations, emergency department visits, and intensive care. Most improvements in health don't come from receiving more care – they happen when the patient and his or her family feel involved in their care in meaningful ways, empowering positive behavioral changes. Happiness and satisfaction with care are also important factors.
We know that, for all of the incredible capacities of the United States health care system – which make it perhaps the best place for cutting-edge, high-tech care – it is a bad place to try to age safely and in good health. Study after study has shown that geriatric conditions such as dementia and incontinence are strong predictors of decline (and increased costs of care). Yet, older adults receive only a fraction (~30 percent) of indicated care. (See RAND's Assessing Care of Vulnerable Elders [ACOVE] Project.)
We know that part of the problem of hospital readmissions results from a system failure at the border of acute and primary care: 20 percent of older adults discharged from the hospital are readmitted within 30 days. But half of those people never see an outpatient provider for follow-up, much less their own primary care provider – a missed opportunity.
Even worse, we know that many people are hospitalized for conditions that should be handled outside the hospital, and that this is especially common among older adults.
To address these needs, we have supported training of primary care practitioners (e.g., the Practicing Physician Education in Geriatrics project) and the development and dissemination of many models of improved primary care, such as IMPACT and Care Management Plus.
But the road has been a hard one. For every successful effort, there have been two models that failed the critical tests of improving health and reducing costs. And for each model that got some traction in the market, another with just-as-good clinical and financial results has failed to spread, often for very unfair and unpredictable reasons.
The PCMH and primary care reinvention has had lots of ups and downs and is a complex process to get right. I wrote about failed demonstrations reported in the press recently and we feel that the needs and interest of older patients are particularly important to inform course corrections as we move forward (as we must).
Medical homes seeking to improve their rapport with, and service to, older patients would do well to note that older adults are open to change. About half (48 percent) of respondents who do not currently receive team care said they would change providers if it meant they could get easier access to care, more reminders about needed care, and more follow-up and coordination when they needed it.
It turns out that including the patient in the design and practice of patient-centered care may be just what the doctor ordered.
This post originally appeared on the Hartford Foundation's HealthAGEnda blog on April 3, 2014.