The New Health Dialogue

(This post first appeared on the Altarum Health Policy Forum. In a future post I'll tie it into advanced medical homes and other aspects of health reform  that address the needs of  the chronically ill and the elderly.)

Transitions are one of the weak points in the U.S. health care system. Poor coordination and inadequate communication around transitions is particularly pronounced in the care of frail elderly people with multiple chronic diseases -- or maybe an acute illness or injury on top of a whole big bunch of chronic diseases.

Wishard Memorial Hospital in Indianapolis is a large urban safety net hospital serving largely low-income people, many of whom are “dually eligible” for Medicaid and Medicare. Led by geriatrician Dr. Steve Counsell, the hospital has been developing a multi-pronged strategy to improve care and care coordination for this at-risk population. The programs have a smart approach to the shortage of geriatricians, leveraging the skills of geriatricians and geriatric nurse practitioners to support, not supplant, hospitalists (inpatient) and the primary care doctors (outpatient) caring for at-risk patients.

In the hospital, for instance, under a program called acute care for elders, or ACE, hospitalists focus on the acute crisis that landed the patient in the hospital, while the geriatric team unpacks all the other conditions that are going on which could undermine recovery or lead to functional decline. In the outpatient world, Geriatric Resources for Assessment and Care of Elders, or GRACE, supports the primary care team or clinic -- which is still the primary care. GRACE patients fall under the ACE umbrella when they are admitted to the hospital; ACE patients may get connected to GRACE when they leave.

In addition, Counsell and colleagues aim to increase coordination between these medical teams and Aging and Disability Resource Centers, so that medical and community-based social services working in tandem with disability caseworkers will be “embedded” in the hospital, to get home and community based services in place before the patient is discharged. Those first few days after the hospital are very high risk. ACE and GRACE differ from some of the other care transition programs that have gotten national attention (some of which do show good results). ACE and GRACE aren’t a separate set of caregivers -- and a separate set of transitions -- serving as a bridge between inpatient and outpatient care. They are part of the continuum of ongoing care -- more like a lane of ongoing traffic than a bridge between two types of care. Counsell strives for established relationships over the long-run, building relationships not only between patient and care providers, but amongst the care providers.

Counsell gives the following ACE scenario: “In a standard setting, a patient comes in to the ER, coughing, short of breath, abnormal chest X-ray … The hospitalists run tests and do the diagnosis -- is it cancer, TB, pneumonia? Let’s say its pneumonia. The hospitalist can handle that -- admit to the hospital, three days of IV antibiotics, then send the patient home. And they’re off to the next patient.”

But if ACE is consulted, the team looks at the patient differently -- not focusing on the pneumonia but on everything else. Counsell says, “They’ll say, ‘Oh you were found down in your home after two days. You live by yourself. You take eight medications -- and two of them are duplicates, and one can cause falls. Your pneumonia might be OK in three days, but not the rest of you.’”

The ACE team might help the patient get to a short-stay rehab facility, because although they have recovered from the pneumonia, they really shouldn’t be going home alone. ACE teams can streamline medications, reduce the fall risk, identify community resources, and get them in place fast.

At first there was a bit of resistance, but now the hospitalists have come to love the program. Counsell also sees hospitalists growing more perceptive in dealing with geriatric patients; the interaction with the ACE team has sensitized them to the red flags that might not have registered before.

GRACE supplements the outpatient experience, particularly the coordination of care and services, using nurse practitioners and social workers, and interdisciplinary geriatric teams, which collaborate with primary care doctors. Patients get in-home assessments and are followed-up, at least by telephone, once a month or more, depending on the intensity of needs. GRACE targets 12 geriatric conditions, including medication management, deterioration of hearing or vision, pain, incontinence, depression, nutrition, dementia, helping the family caregiver, and advanced care planning.

These patients often see eight different doctors, and have multiple medications but without a program like GRACE, “no one is steering the ship,” Counsell said. When patients -- or the grown kids in California -- try to manage the care coordination themselves, “a lot falls through the cracks.”

“GRACE looks to bring the geriatric eye,” he explained. The teams can diagnose the depression, figure out if a drug is causing falls, and identify therapeutic needs that can allow the patient greater mobility and independence.

A study in JAMA found that patients in the GRACE program did better, and that they were in the emergency room less often. By the second year, both ER and hospital admissions dropped in the sickest group of patients (More savings were documented in the third year, beyond the data on years one and two in JAMA.)

In the current fee-for-service Medicare system, only about 10 percent of GRACE’s costs are covered, and it’s not always in a hospital’s self-interest to keep people from being admitted. In an integrated care system or an accountable care organization, like the models that will be encouraged under health reform, the incentives are different. In some ways GRACE resembles an “advanced medical home,” which pays for care coordination for people with serious or multiple illnesses.

Counsell is still fine-tuning his programs, but he sees encouraging signs of change in his own community and beyond. His model is spreading. The Indianapolis VA, an integrated system, is beginning a variant of GRACE, as is HealthCare Partners in Los Angeles.

And caregivers love it. He read me a letter from one woman, whose 89 year old mother-in-law is under GRACE’s watchful eye. “It means so much for me,” the woman wrote, “to have doctors and nurses who listen. They make her feel so comfortable and well-cared for.”