Patients, family caregivers, clinicians and health care systems each play a significant role in achieving high value healthcare. The path to this goal is most challenging for vulnerable patient populations with complex health and social needs. Prominent among these groups are older adults coping with multiple chronic conditions (MCCs). Findings from multiple studies have demonstrated that the health needs of this patient group are often poorly managed, commonly resulting in devastating human and economic consequences. As the number of chronically ill older adults continues to grow, what research-based solutions are available to better respond to their needs? What can be done to prepare the current and emerging health care workforce to address their complex challenges? What are the responsibilities of health care systems in assuring person-centered, effective and equitable care for vulnerable older adults and their family caregivers, while enabling wiser use of society’s finite resources?
Research-Based Solutions. A robust body of science has uncovered the dimensions of care management for vulnerable older adults that are essential to achieve high value health care and positive health and quality of life outcomes. In brief, effective care management is a process that engages older adults, family caregivers and clinicians in collaboratively identifying patients’ needs and in implementing individualized care plans aligned with patients’ preferences and goals. We are fortunate to have a number of research-based interventions that have demonstrated better care and outcomes for hospitalized, community-based older adults as well as those receiving care in residential settings. In a few weeks, I look forward to joining you at the 2016 Annual NICHE Conference when I will describe to you the work of a multidisciplinary team of clinical scholars and health services researchers based at the University of Pennsylvania and our efforts to generate, disseminate and translate one such approach known as the Transitional Care Model. I hope to explore with you how together we can promote and accelerate widespread adoption of high value, rigorously evidence-based interventions.
Workforce Development. Successful implementation of evidence-based care management strategies will only be achieved with simultaneous efforts to redesign the workforce. Competencies in areas such as patient and family caregiver engagement, complexity management, palliative care, cultural diversity, team-based care, population health and performance improvement are essential. Based on available evidence, patients, family caregivers, and nurses are and will continue to assume expanded roles and will require additional investment. At the NICHE meeting, I look forward to discussing with you the competencies essential for the existing and emerging workforce to assure high value care for older adults with MCCs.
Health Systems’ Accountability. Health systems and their community partners are ultimately accountable for creating the environment essential for high value health care of chronically ill older adults and their family caregivers. The following are a few examples of how systems can support effective care management of older adults with MCCs across the care continuum:
Adopting or adapting evidence-based interventions targeting vulnerable older adults and their family caregivers.
- Employing system for monitoring and providing feedback on the effects of care management processes and outcomes at individual and population levels.
- Supporting ongoing competency development of health team members to promote continuity (relational, management and informational) between and among patients, family caregivers and clinicians within and across health care delivery and community-based organizations.
- Investing in the infrastructure needed to assure informational continuity.
- Establishing an advisory committee representing stakeholders (patients, family caregivers, hospitals, post-acute, primary care, community-based agencies, payers) to guide the health care system’s ongoing efforts to improve care management for the patients, family caregivers and community it serves.
We have much to discuss when we get together at the NICHE conference in April and I look forward to this terrific opportunity.