Q: What are the key challenges in our current health care system when it comes to meeting the needs of frail older adults?
A: The challenges are the same for every patient in the system, but if someone is frail, a small disturbance can have a big negative impact. First, there is fragmentation, when you have multiple clinicians in multiple settings and not enough communication or coordination among them. Second, is the bias towards acute care. Without alternatives in the community, if a frail older person has a need that could be addressed in acute care, that is where they go, without a search for alternatives. Third, hospitalizations are very hard on frail older people. Their routines, sleep, response to medications, nutrition, activity, safety, and even sense-making are disturbed. They need to be cared for with extra everything: skill, protection, thoughtfulness, and patience. Lastly, the health care system is on auto-pilot when it comes to which care decisions are made and who makes them. These are not necessarily correct for frail older people.
Q: The current system is clearly inadequate. What are the opportunities for making care better for frail older adults?
A: The three biggest opportunities are:
• Identification and assessment—know who is frail and what they need;
• Individualized care planning; and
• Tailoring services to meet the needs of frail older adults.
The first opportunity is to have a very good understanding of who needs a special level of care, and making that visible to everyone who cares for them. Anyone who touches these people should know current conditions, special needs, and anticipated needs. Simple but thorough assessments then lead to a smarter and more customized plan of care. Finally, by knowing the needs of the frail elders being served, care delivery can be built to protect and benefit frail elders. Geriatric emergency rooms, geriatric units in hospitals, specially designed programs in primary care are all being used to good effect both in the US and internationally, but they are not yet commonplace.
Q: How is the approach you’re taking with the upcoming Improving Care for Frail Older Adults with Complex Needs Expedition different from a more general focus on reducing avoidable readmissions?
A: Reducing readmissions is very important, but it is only one focus, and for the frail older adult, it is a little like closing the barn door after the horse has run off. There is so much more to do before any admission that would improve outcomes and reduce unwanted care.
Before any hospitalization, anticipating likely events like falls and preventing them, seeking alternatives for care that do not involve a hospital, and making contingency plans are all useful “upstream” changes. These will be an important part of the Expedition. We’ll also address post-acute care interventions, including 1) assuring communication and care planning; 2) securing contact with the “receiving” clinicians; and 3) focusing on social supports as well as medical supports. These will be covered with very practical applications.
Q: A study recently published in Health Affairs found nearly one in five older adults who have a number of common operations will end up in the emergency department within a month of their hospital stay. The study’s authors suggest that understanding why ED visits occur (and how to help patients avoid their necessity) may be more helpful than focusing solely on readmissions since not all these patients get readmitted. How does addressing the needs of this population complement the work already being done on reducing readmissions?
A: Care for frail older patients is not a single-dimension issue. It requires an understanding of the system of care and what makes systems work better. High rates of readmission have drawn attention because they indicate defects in care and waste. Thanks to outstanding research, we have learned both causes and solutions. As we get better at addressing readmissions, we will find other defects like unwanted and unneeded ED visits, and these also warrant attention and perhaps different solutions. What do they have in common? They involve transitions and hand-overs, when the risk to frail people rises. If you focus on better care for frail elders, you will make progress on the defects that cause readmissions and you will find and be able to fix many other system problems beneficial to the frail and older population. We are learning that it would be useful to consider not just readmissions but ED visits, and not just these but other events like duplicate procedures and diagnostic tests, and frequent transfers among doctors or settings.
Q: The New York Times recently reported on a study in the Journal of the American Geriatrics Society that found that older adults benefited from having a primary care physician and a nurse practitioner co-managing their care. How do you see a more team-based approach being helpful for older adults?
A: The kinds of things that come up for older adults are both medical and not medical, so relying only on a physician to provide all the needed support is a poor use of his or her time. The “co-manager” is someone who has time to focus on the broader spectrum of needs and services, and can connect with other resources like nutritionists or social workers. A team-based approach provides the opportunity to consider all aspects of care and to coordinate them to deliver the best individualized care plan.
I had been looking after my father when he was very sick and many of the challenges were not medical. We did not need a doctor’s time, but we did need others who understood my father’s condition and what kinds of non-medical supports would be helpful. Having someone else who could suggest and connect us to these other resources was a blessing.
Q: Why is this work so personally compelling to you?
A: I have been working on improving care for people with chronic conditions for many years. It became personal to me when my father was hospitalized, and suffered a heparin overdose. Overnight, he became a frail older person. I observed wonderful nurses trapped in a system that was not equipped to be reliable for frail people. Communication, monitoring, and prevention failed over and over because the system was not designed to, for instance, assure that he had food after insulin, detect when his level of consciousness dropped, or help him with the activity he needed to stave off delirium. The caregivers did their very best, but they did it without the system to deliver on their good intentions, and the result was one avoidable harm after another.
So, I went from being interested in improving care for this population to being a crusader. Both for moral and practical reasons, we cannot accept the system we have now. And, while it is not easy to make the care better, as Joanne Lynn says, almost anything we do will be an improvement. It is not hard at all to take the first steps and make a big difference. That is what we at IHI want to bring to health care providers, frail older people, and their families and friends.