Tuesday, November 12, 2013

Reliable and Sustainable Comprehensive Care for Frail Elderly People

“The United States needs arrangements that allow elderly people to live with confidence, comfort, and meaningfulness at a cost that families can afford and the nation can sustain … Without significant structural changes in service delivery, an aging nation faces a future of substantial costs and needless pain and distress among those who are old...”

writes Joanne Lynn, M.D., M.A., M.S., of the Center for Elder Care and Advanced Illness, Altarum Institute, Washington, D.C., in a Viewpoint appearing in the November 13 issue of JAMA, a theme issue on critical issues in U.S. health care.


Dr. Lynn presented the article at a JAMA media briefing at the National Press Club in Washington, D.C.

The current "care system" for an elderly person with self-care disability and numerous diagnoses “provides disjointed specialty services, ignores the challenges of living with disabilities, tolerates routine errors in medications and transitions, disdains individual preferences, and provides little support for paid or volunteer caregivers. This maladapted service delivery system now generates about half of the person's lifetime costs for health care services, yet patients and families are left fearful and disoriented, with pain, discomfort, and distress.”

Dr. Lynn provides specific changes she contends are critical for improving care for this population, an approach she calls “MediCaring”. She writes that discussions about living with frailty now are virtually absent from popular media, political discussion, and professional education.
“To counteract this shortcoming, reformers will need to generate discussion about the challenges of aging, disability, and death, along with the continuing opportunities to live meaningfully and comfortably. Medical professionals, political leaders, and popular culture must generate vigorous discussion about how people live well with frailty and how best to die.”
“Each frail elderly person has unique resources, priorities, fears, medical issues, and aspirations, and each should be given an opportunity to evaluate his or her potential futures and to have an individualized plan for services. A multidisciplinary team should conduct an appropriately comprehensive assessment and work with the patient and family to generate a care plan that documents the patient's goals and the chosen service strategies.”
“The service delivery system should encompass health care and long-term services and supports as equal partners,” Dr. Lynn writes. “A balanced system would give integrated multidisciplinary teams the tools and authority to match services with each frail person's priority needs. … Today, a physician can order any drug for any Medicare patient at any cost—but that physician cannot order a substitute caregiver or adequate housing, except perhaps by arranging nursing home admission. The mismatch of service availability with the priorities of frail elderly people engenders high costs as well as frustration and heightened fear of decline and death for frail elders.”

Dr. Lynn also suggests that “by allowing localities to take a role in monitoring and managing their arrangements for supporting frail elders, the services could become more reliable and appropriate, and most or all of the funding for supplementing social services for people who cannot afford them could come from sharing in the savings from better health care.”

“Essential reforms include requiring development and use of comprehensive care plans; modifying medical care to ensure continuity, comprehensiveness, honesty about treatment goals, and comfort; bringing health care and long-term services and supports together into stable funding and management arrangements; and enabling some degree of local monitoring and control. Meeting the challenges of long lives requires substantial changes, quickly, in how people in the United States envision health care, community obligations, and the lives of frail older adults.”

doi:10.l001/jama.2013.281923;

Editor’s Note: The author has completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest and none were reported.


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