Study examines models to improve care and reduce the high cost for Medicare beneficiaries

It's well known that a relatively small percentage of chronically ill patients accounts for a disproportionate amount of health care dollars. Now, a multicenter study led by Johns Hopkins researcher Bruce Leff, M.D., might provide insights into how to cut Medicare costs while improving health care for older adults suffering from chronic health conditions.

Results of the study, published in the June issue of the journal Affairs, highlight the early efforts of the Medicare Innovations Collaborative, a joint program involving six health care-related organizations around the country that focused on the simultaneous implementation of six geriatric models.

"We all agree that it is critical to improve health service delivery for , especially those with complex ," says Leff. "Understanding the issues around implementing and adopting effective health service delivery is critical to Medicare's efforts to provide value-based care."

The collaborative organizations in the study varied from a solo hospital (Crouse Hospital in Syracuse, N.Y.) to hospitals that owned or operated nursing facilities, hospices and a home health agency (Lehigh Valley Health Network in Pennsylvania). Other participants included Aurora (Milwaukee), Carolinas HealthCare System (Charlotte, N.C.), Geisinger Health System (Danville, Pa.) and University Hospitals Case Medical Center (Cleveland, Ohio).

Each of the participating organizations already had one of the models in place, and each was required to plan the implementation of one additional of the six different geriatric service models. The models included: The Nurses Improving Care to Healthsystem Elders (NICHE), a patient-centered model to improve hospital care processes for older adults, with oversight by a nursing team; Acute Care for Elders (ACE), which concentrates on helping hospitalized older adults maintain or achieve functional independence in basic activities of daily life; the Hospital Elder Life Program (HELP), designed to prevent delirium among hospitalized older patients; Care Transitions Intervention Model (Care Trans.), which provides chronically ill patients with "transition coaches" who helps them effectively move from hospital to home; the Palliative Care Consultation Model (Pall. Care), which focuses on averting unwanted medical interventions for adults with life-limiting illnesses; and Hospital at Home, a model that was developed by Dr. Leff at Johns Hopkins and that provides acute hospital-level care in the home as a substitute for inpatient hospital admission.

Aurora Health Care adopted the NICHE model, along with the ACE and Pall. Care models that they subsequently expanded as part of the study. Carolinas Health Care Systems added NICHE, ACE and Care Trans to their already in-use Pall Care model. Crouse Hospital, already using the NICHE, Pall. Care and HELP models, also added ACE and the Care Trans. models, which they focused heavily on during the study. Geisinger added NICHE but, expanded its use of Pall. Care and Care Trans. Lehigh Valley added NICHE and Care Trans and University Hospitals Case Medical Center added Care Trans but focused primarily on NICHE, ACE and Pall. Care as part of the study.

"Over the years, many evidence-based models of geriatric care have been developed, but few have been widely implemented. Our study developed the theory that putting multiple geriatric models into a geriatric service line or "portfolio" and providing technical assistance to adopting organization in a learning collaborative, would make these models attractive for adoption by health systems from both a clinical and economic standpoint," adds Leff.

The study showed that NICHE, which facilitates a more effective communication and collaboration in elderly care, was seen as a model on which organizations could build a foundation for improving a hospital's culture of quality and safety for older adults. Other organizations found the Pall. Care effective in delivering patient-centered care to those suffering from terminal illnesses and in reducing medical costs.

"Organizations learned from each other and reduced adoption time and costs through structured support and voluntary exchange, since the main goal of the collaborative was to help participants evaluate and implement the geriatric service models," says Leff.

Leff points out that the study does have certain limitations, since there is no measure of traditional outcomes and no gauge of post-implementation results, but clinical and financial outcomes will be reported in the near future. The success of this phase of the work is to demonstrate that multiple complex health service delivery models that improve the quality of care can be implemented rapidly by health systems.

"We are hoping to turn the participating health systems involved in this study into expert centers to provide technical assistance to more health systems to adopt the models and working to expand beyond the hospital to include post-acute and ambulatory areas," adds Leff.

Currently 44 million beneficiaries -- approximately 15 percent of the U.S. population -- are enrolled in Medicare and nearly 7.3 million people receive benefits because of disability status, according to the Centers for Medicare and Medicaid Services.

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