DM and Chronic Care (Part 2 of 2)
Chronic care will need to play catch-up to serve boom’-ing elder market
Using the acute care model just doesn’t work
If the past 10 years were about outcomes improvement and cost containment, the next 10 will be about service delivery for the 100 million people who have chronic conditions. By 2010, that number will increase 30%, according to U.S. Census Bureau projections.
Although the demographics long ago forecast the need to redesign systems to serve steadily aging consumers, not many paid attention. Between 1960 and 1994, the age 85-plus population alone mushroomed 274%. "Yet, the entire health care system — from medical schools to primary care clinics — is skewed to acute care. We are trained to care for one disease in 10- to 20-minute appointments," observes John Scott, MD, staff internist and geriatrician with Kaiser Permanente in Westminster, CO.
However, he adds, the typical person over 65 has four diseases and takes nine medications. Scott insists that "you can’t isolate diabetes from arthritis or from depression. Elderly people need multiple issues-based care."
The disease management approach, which we described in Part 1 of this series, shows some promise, but not enough for providers to settle on it, chronic care leaders say. Chad Boult, MD, MPH, associate professor at the University of Minnesota Medical School in Minneapolis, explains that it works well when a person has one condition such as diabetes or congestive heart failure. "But it becomes top-heavy when the person has several problems. Are they going to be in a separate program for each condition?" he asks.
Time to retrain and redesign
Our current attempts to deliver chronic care through the acute care model are disintegrated and expensive, Boult notes. Health care providers rely on the same methods to treat a 20-year-old with a broken arm or a 50-year-old with hypertension. But such methods fall apart when the patient is a 90-year-old who has congestive heart failure, arthritis, and incontinence, and lives alone in an apartment. It’s time to retrain present providers and redesign academic programs to prepare the new professionals for chronic care delivery. "It’s still going to be expensive," warns Boult, "but at least it will use resources to better advantage."
The necessary changes are multifaceted, Boult notes. He adds optimistically that some building blocks are in place:
• We know how to monitor patient groups to proactively identify those with high-risk conditions before they show up in the emergency room.
• Case management techniques are refined to the point that providers can incorporate them into care plans and shepherd patients through the health care delivery system.
• Information technology is capable of providing a rudimentary patient record, including medications lists and current advance directives. With at least that much to go on, clinicians would have some clue how to proceed when an elderly person goes to the emergency room at night. "We also need information systems to share between doctors’ offices and hospitals for our elderly patients," Boult stresses. "Confidentiality is an issue, but we can find ways to uphold it and have the background we need on our patients. Now most of it is on paper. We send it back and forth on faxes and letters. It’s inefficient, costly, and archaic."
References
1. Beck A, Scott J, Williams P, et al. A randomized trial of group outpatient visits for chronically ill older HMO members: The cooperative health care clinic. J Am Geriatr Soc 1997; 45:543-549.
2. Scott J, Gade G, McKenzie M, et al. Cooperative health care clinics: A group approach to individual care. Geriatrics 1998; 53:68-81.
Related articles in this issue
• Instead of further detailing the statistics of graying America, we’ve highlighted those that impinge on health services in "Demographics Mandate Better Chronic Care," at left.
• We’ve profiled two models that epitomize excellence in "Group clinics fold elder care into new model," p. 16; and "Nurse-driven model gains elder lifestyle changes," p. 17.
• Finally, you’ll find a guide to crafting a quality measurement system for chronic care in "Chronic care measurement: A study in complexity," p. 18.
Need More Information?
For chronic care delivery systems, contact:
- Marlene McKenzie, Research Project Coordinator for Senior Programs, Kaiser Permanente, 10350 E. Dakota Ave., Denver, CO 80231. Telephone: (303) 344-7740.
- Linda Leimer, Institute for Research and Education, HealthSystem Minnesota, 3800 Park Nicollet Blvd., St. Louis Park, MN 55416. Telephone: (612) 993-3453.
- Institute for Healthcare Improvement, 135 Francis St., Boston, MA 02215. Telephone: (617) 754-4800. Web site: www.ihi.org.
For quality measurement of chronic care delivery systems, contact:
- Mark Splaine, MD, Department of Quality Education, Measurement and Research, Dartmouth Hitchcock Clinic, Lebanon, NH. E-mail: [email protected].
You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
- Award-winning Medical Content
- Latest Advances & Development in Medicine
- Unbiased Content