3
New Models of Care

CHAPTER SUMMARY

This chapter presents the committee’s vision for the care of older adults in the future and describes a number of new models of care delivery that show promise for achieving this vision. Widespread implementation of new models of care will require changes in traditional staffing patterns and provider roles. Despite the evidence that patient care can be improved through the implementation of new models of care, diffusion of those models has been limited, in part due to external constraints such as insufficient funding. The committee recommends improved dissemination of models that have been shown to be effective as well as increased support for research and demonstration programs that promote the development of new models of care.

The nation faces major challenges as it prepares for the growing number of older adults. There is a pressing need to develop a health care workforce that is sufficient in size and ability to meet the needs of this group. Projections indicate that there will be significant workforce shortfalls in the coming years, but simply increasing the numbers of geriatric-trained workers will not be sufficient, as it will do nothing to fix the deficiencies in the way care is delivered to older adults or to address the inefficiencies in the current system. The care that is currently provided to older adults often falls short of acceptable levels of quality. Providers’ performance in the delivery of recommended care to older adults varies greatly (RAND, 2004), and there is limited coordination of care among providers. Expanding the capacity of the current system to meet the future needs of older adults would



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3 New Models of Care CHAPTER SUMMARY This chapter presents the committee’s ision for the care of older adults in the future and describes a number of new models of care deliery that show promise for achieing this ision. Widespread implementation of new models of care will require changes in traditional staffing patterns and proider roles. Despite the eidence that patient care can be improed through the implementation of new models of care, diffusion of those models has been limited, in part due to external constraints such as insuf- ficient funding. The committee recommends improed dissemination of models that hae been shown to be effectie as well as increased support for research and demonstration programs that promote the deelopment of new models of care. The nation faces major challenges as it prepares for the growing num- ber of older adults. There is a pressing need to develop a health care work- force that is sufficient in size and ability to meet the needs of this group. Projections indicate that there will be significant workforce shortfalls in the coming years, but simply increasing the numbers of geriatric-trained work- ers will not be sufficient, as it will do nothing to fix the deficiencies in the way care is delivered to older adults or to address the inefficiencies in the current system. The care that is currently provided to older adults often falls short of acceptable levels of quality. Providers’ performance in the delivery of recommended care to older adults varies greatly (RAND, 2004), and there is limited coordination of care among providers. Expanding the ca- pacity of the current system to meet the future needs of older adults would 

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 RETOOLING FOR AN AGING AMERICA be a wasted opportunity. Instead, the current care delivery system requires significant reform in order to improve the care of this population. This chapter begins with the committee’s vision of how best to deliver health services to older adults in the future. The vision represents a major departure from the current system, and its implementation will require shifts in the way that services are organized, financed, and delivered. After this vision has been detailed, the chapter continues with a discussion of models of health care delivery that hold promise for moving closer toward the committee’s vision. The chapter examines the evidence on several mod- els as well as the challenges that will likely be encountered in disseminating these models. Although better models can lead to better care, dissemination of improved models has generally proved to be limited, in part due to finan- cial disincentives to implementing these better models. Thus the committee offers its recommendation for how to foster dissemination of new models. Finally, the chapter discusses shifts in the workforce that may be required to support these new models, such as new roles for providers, increased delegation of responsibilities, greater use of interdisciplinary teams, and increased involvement of patients and their families. A VISION FOR CARE IN THE FUTURE The committee identified three key principles that need to form the basis of an improved system of care delivery for older Americans (Box 3-1). These principles are in alignment with the six aims of quality defined in Crossing the Quality Chasm (IOM, 2001). First and foremost, the health needs of the older population need to be comprehensively addressed, and care needs to be patient-centered. For most older adults care needs to include preventive services (including life- style modification) and coordinated treatment of chronic and acute health conditions. For frail older adults social services may also be needed in order to maintain or improve health. These social services need to be integrated with health care services in their delivery and financing. Furthermore, ef- BOX 3-1 Principles of Care • The health needs of the older population need to be addressed comprehensively. • Services need to be provided efficiently. • Older persons need to be active partners in their own care.

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 NEW MODELS OF CARE forts need to be made to reduce the wide variation in practice protocols among providers, which should further enhance the quality of care for older adults. The principle of comprehensive care also includes taking into account the increasing socio-demographic diversity of older adults. The number and percent of ethnic minorities in the older population is increasing dramati- cally, and even within ethnic groups there is tremendous cultural diversity. Health care providers need to be sensitive to the wide variety of languages, cultures, and health beliefs among older adults. Other segments of the older population face additional challenges. For example, older adults in rural areas often face isolation and barriers to access for some services. The second principle underlying the vision of care in the future is that services need to be provided efficiently. Providers will need to be trained to work in interdisciplinary teams, and financing and delivery systems need to support this interdisciplinary approach. Care needs to be seamless across various care delivery sites, and all clinicians need to have access to patients’ health information, as well as population data, when needed. Health infor- mation technology, such as interoperable electronic health records and re- mote monitoring, needs to be used to support the health care workforce by improving communication among providers and their patients, building a record of population data, promoting interdisciplinary patient care and care coordination, facilitating patient transitions, and improving quality and safety overall. Giving providers immediate access to patient information, especially for patients who are cognitively impaired and unable to provide their own clinical history, may reduce the likelihood of errors, lower costs, and increase efficiency in care delivery. Efficiency can be further improved by ensuring that health care person- nel are used in a way that makes the most of their capabilities. Expanding the scope of practice or responsibility for providers has the potential to increase the overall productivity of the workforce and at the same time promote retention by providing greater opportunities for specialization (e.g., through career lattices) and professional advancement. Specifically, this would involve a cascading of responsibilities, giving additional duties to personnel with more limited training in order to increase the amount of time that more highly trained personnel have to carry out the work that they alone are able to perform. While the necessary regulatory changes would likely be controversial in some cases, the projected shortfall in workforce supply requires an urgent response. This response will most likely have to involve expansions in the scope of practice at all levels, while at the same time ensuring that these changes are consistent with high-quality care. The third principle is that older persons need to be active partners in their own care, except when they are too frail, mentally or physically, to do so. Such partnerships need to include the adoption of healthy lifestyles,

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 RETOOLING FOR AN AGING AMERICA self-management of chronic conditions, and increased participation by the patient in decision making. By becoming participants in their own care, pa- tients can improve their health, reduce unnecessary treatments, and reduce the need for reliance on formal or informal caregivers. Putting this vision into effect will require changes in policy and a re- structuring of the health care financing and delivery systems. The purposes of this chapter are to highlight those models of care delivery that hold promise for providing high-quality and cost-effective care for older adults and for promoting the committee’s vision for the future of care delivery; to discuss the dissemination of new models of care; and to explore the changes to the workforce that would best support those models. NEW MODELS OF CARE DELIVERY A number of new models of care have been developed with the aim of improving quality and patient outcomes, promoting cost savings, or both. The proliferation of these new models indicates not only a recognition that services for older adults need to be improved but also a willingness among providers, private foundations, and federal and state policy makers to com- mit resources to learning about better ways to finance and deliver care. Nonetheless, while it is widely accepted that the current way of car- ing for older adults can be improved, there is little guidance available to provider organizations about which interventions are most effective. Ob- taining information on the effectiveness of various models is challenging for two reasons. First, a general information gap exists. Many promising approaches have not yet generated reliable or complete findings, and some may never undergo rigorous evaluation because the resources required to systematically collect data on a program can be prohibitive. Second, evalu- ations often come up with conflicting results. Many models have elements in common (e.g., interdisciplinary teams, care coordination, disease man- agement), and some evaluations of particular elements may indicate success while others find no effect. It can be difficult to explain such discrepancies because evaluations rarely provide information about key inputs, such as staffing and training, or about the effects that these inputs have on program outcomes. In order to obtain a better understanding of the models that hold the most promise, the committee commissioned a paper to identify those ap- proaches to comprehensive health care delivery for older adults that have the strongest evidence base. The review focused on frail older persons and was limited to models that have been shown, in high-quality controlled trials, to produce significant improvements in quality or efficiency (i.e., uti- lization and cost). The threshold for inclusion was the existence of one meta- analysis or at least three randomized controlled trials or quasi-experimental

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 NEW MODELS OF CARE studies showing positive results. Undoubtedly these constraints led to the exclusion of a number of approaches that may actually show promise in the future, but a full analysis of every approach ever devised is beyond the scope of this report. The scope of the review was limited to articles published between January 1987 and May 2007 on care models that were staffed primarily by health care professionals and that in some way involved comprehensive care (that is, were related to treatment for several chronic conditions, to treatment for several aspects of one condition, or to treatment from mul- tiple providers). Altogether, the authors of the commissioned paper reviewed 128 ar- ticles reporting positive results. Because the number of new models of care that have been developed is so large, it is not possible to discuss each one. The models of care described here offer a few examples of the innovative ways in which care is being provided to older adults at several points along the care continuum and in a variety of settings. Notably, many of the mod- els strive to provide care in a manner that is consistent with the committee’s vision—in a more comprehensive way (e.g., by providing services beyond those normally available), more efficiently (e.g., through the coordination of medical and social services and the shifting of traditional provider re- sponsibilities), and with encouragement for older adults to take on more active roles in their own care. Private-Sector Models Improing Mood: Promoting Access to Collaboratie Treatment for Late Life Depression (IMPACT) Depression in older adults is common, particularly among individu- als with chronic illness (Katon, 2003). Because of the importance of this disease to the older adult population, the John A. Hartford Foundation as- sembled a panel of national experts to design a program to treat depression in the primary care setting. The result was the IMPACT program, a care model that builds upon evidence-based treatment for depression and that incorporates approaches used in managing other chronic diseases, such as diabetes. Those approaches include collaboration among patients, primary care providers, and specialists (including the use of targeted consultations); development of a personalized treatment plan; proactive follow-up and monitoring; and protocols for stepped care (Unutzer et al., 2002). Patients participating in IMPACT receive educational materials about late-life depression and visit a depression-care manager at a primary care clinic. The care managers (typically nurses, psychologists, and social work- ers) are trained as depression clinical specialists and work with the patient’s

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0 RETOOLING FOR AN AGING AMERICA regular primary care provider to establish a treatment plan. These care man- agers are supervised by a team psychiatrist and a primary care physician. Under the IMPACT program, the care managers monitor patients in person or by telephone and have contact with each patient at least once every other week. They encourage patients to engage in social events, and they refer them for additional health or social services as necessary. If a pa- tient recovers from depression, a relapse-prevention plan is developed, and the care manager continues to follow up with the patient. If a patient does not respond to treatment, the patient’s case is discussed by the IMPACT team, the patient receives a consultation with a psychiatrist at the primary care clinic, and the patient’s medications may be altered. The IMPACT program has reported successes according to a vari- ety of measures. Participants had higher rates of depression treatment, for example, and greater reductions in depressive symptoms compared to nonparticipants (Unutzer et al., 2002). Participants were also more satis- fied with their care and reported less functional impairment and greater quality of life. They experienced an average of 107 more depression-free days over a 2-year period than did patients receiving usual care (Katon et al., 2005). Positive results also held over time. One year after IMPACT activities ended, participants maintained improvements with respect to antidepressant treatment, depressive symptoms, remission of depression, physical functioning, quality of life, self efficacy, and satisfaction with care as compared with a control group (Hunkeler et al., 2006). Results from the model indicate that evidence-based care for major depression can be successfully delivered by specially trained nurses, psy- chologists, and social workers in primary care settings. Total outpatient costs were $295 higher for participants during the course of the program, or an average of $2.76 for each additional depression-free day. Another evaluation of IMPACT, limited to older adults with depression and dia- betes, found that the incremental outpatient cost for each depression-free day was 25 cents (Katon et al., 2006). It is difficult to know, however, the degree of cost savings that may have been realized through the prevention of unnecessary hospitalizations or other treatments associated with unman- aged depression. Geriatric Resources for Assessment and Care of Elders (GRACE) Providing health care for low-income older adults is challenging for a number of reasons, including their high incidence of chronic illness, limited access to care, low health literacy, and socioeconomic stressors (Counsell et al., 2007). To improve the care provided to these patients, the GRACE model was developed by researchers from the Indiana University School of Medicine, the Indiana University Center for Aging Research, and the

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 NEW MODELS OF CARE Regenstrief Institute. The GRACE intervention provides home-based, in- tegrated geriatric care by a team consisting of a nurse practitioner and a social worker that visits patients at their homes for an initial assessment and then follows up with the patients at least once a month, either by phone or face to face. The team also visits the patients at home after any emergency-department or hospital visit. This two-person team is supported by a larger interdisciplinary team which is led by a geriatrician and which also includes a pharmacist, physical therapist, mental health social worker, and community-based services liaison. This group, using input from the patient’s primary care physician, establishes a care plan for the patient which incorporates protocols that have been developed for the treatment of 12 targeted geriatric conditions. The GRACE interdisciplinary team meets weekly to discuss the patient’s progress with the smaller team. The team’s efforts are also supported by an electronic medical record and web-based tracking system. In a controlled clinical trial, Counsell and colleagues found that the GRACE program resulted in improved quality of care and reduced acute- care utilization among a group of high-risk, low-income seniors. However, improvements in health-related quality of life were mixed, and physical functional outcomes did not differ from the control group (Counsell et al., 2007). These somewhat mixed results may be explained by several factors, including the difficulty of quantifying the comprehensiveness, coordination, and patient-centeredness of the care. Furthermore, the study duration may have been too short to allow a complete assessment of the intervention (Reuben, 2007). The Green House Model Historically, residents’ quality of life in nursing homes has received insufficient attention (Bowers, 2006). For example, nursing home residents often have little choice in their schedules or daily activities. Over the past decade, however, a small but growing movement has developed whose goal is to change the culture of traditional nursing-home care both to im- prove workers’ job satisfaction and to improve the residents’ quality of life through transformed environments, greater choice, and more empowerment of the direct-care staff. Several new models of nursing-home care have been developed that move away from a medical model of care toward a more patient-centered approach. One such model is the Green House (GH), which is designed to make residents feel at home (March, 2007). The GH model emphasizes residents living their lives under normal, rather than therapeutic, circumstances. The model was based on the principles of the Eden Alternative, a movement to foster culture change within nursing homes by creating a home-like culture

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 RETOOLING FOR AN AGING AMERICA with plants, pets, and visits by children (Hamilton and Tesh, 2002). The Eden Alternative also decentralizes the organizational structure of nursing homes to empower certified nursing assistants (CNAs) to develop their own schedules and daily assignments and to provide companionship to the residents. GHs take the concept one step further by creating a more residential social setting. The initial development and implementation of the GH model was sup- ported by grants from private foundations. The model involves three key elements. First, the environment is composed of a small, technologically sophisticated house that functions as a home for eight to ten residents. Each resident has a private room and bathroom, and the residents’ individual rooms are clustered around a central area with a shared kitchen, dining room, and living room. GHs serve as real homes in appearance and func- tion and, as such, do not have nurses’ stations, medication carts, or public address systems (Kane et al., 2007). Second, the frontline caregivers have broad roles that include personal care, cooking, housekeeping, and assuring that residents spend time accord- ing to their preferences. These direct-care workers, referred to as shahbazim, receive 120 hours of training above those required to be a CNA. This level of training is significantly beyond federal and state requirements and reflects the CNAs’ expanded role in a GH. In addition, there are “sages,” older adults who serve as coaches or mentors to the shahbazim, and “guides,” who are supervisors and serve as liaisons between the shahbazim and other staff. This system of support is the basis of the care team. Third, professional healthcare providers (e.g., nurses, physicians, social workers, and pharmacists) form visiting clinical support teams that provide specialized assessments for residents. Licensed nurses are available and responsible for the clinical care in the GH. A nurse is available to shahba- zim whenever needed, 24 hours a day, by emergency pager (NCB Capital Impact, 2007). While information on the effectiveness of GHs is preliminary, a recent evaluation of the model showed that GH residents reported better quality of life on several measures, higher satisfaction with their place of residence, and better emotional health than a comparison group (Kane et al., 2007). No difference in self-reported health was noted. Quality of care was at least as good in the GH group as in the control group. The GH group also had a lower prevalence of residents on bed rest, fewer residents with limited activity, and a lower prevalence of depression compared with residents of traditional nursing homes. In addition to its potential to promote patient-centered care, the GH model also holds promise for improved recruitment of direct-care workers. The first GH site received only two responses to advertisements for a CNA but received more than 70 when the ad was for a shahbaz (Angelelli, 2006).

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 NEW MODELS OF CARE Shahbazim are paid approximately 10 percent more than CNAs for their additional responsibilities and training hours (NCB Capital Impact, 2007). The additional pay is made possible through stabilization of the direct-care workforce (i.e., lower costs due to decreased turnover rates), operational efficiencies, and diminished need for middle-management positions. How- ever, GHs do require providers to adapt to new roles. For example, attend- ing physicians and medical directors provide care in disaggregated homes where shahbazim are central to the care of residents and are responsible for monitoring their status based on the direction of physicians (Kane et al., 2007). This is different from the situation in the typical nursing home setting, where physicians have traditionally had little communication with direct-care staff. The Adanced Illness Management (AIM) Program Numerous studies have shown deficiencies in the quality of care at the end of life. Many older adults die with inadequate palliative care (Zerzan et al., 2000), and often patient preferences are not assessed, communicated, or followed (Haidet et al., 1998; Hofmann et al., 1997). Most patients prefer to die at home, yet most deaths occur in the hospital (Brumley et al., 2007; Grande et al., 1999). And although hospice care can lead to higher patient and family satisfaction at a lower cost (Brumley et al., 2007), many individuals do not receive hospice care (NHPCO, 2005), and those who do receive it rarely use the full Medicare hospice benefits (Ciemins et al., 2006). In an effort to bridge the gap between curative care and hospice care, Sutter Visiting Nurse Association and Hospice created the Advanced Illness Management (AIM) program, which provides both disease-modifying care and comfort care in the home setting to those with advanced illnesses who are eligible for home care but not yet eligible for hospice care (Ciemins et al., 2006). Patients are included regardless of Medicare eligibility or insur- ance coverage. The program coordinates hospital services, home health care, and, when needed, hospice services. The goals of the program are to provide seriously ill patients with an array of home-based services, to ease their transition from home health care to hospice care, and to avoid un- necessary hospitalizations. The program uses a combination of home care and hospice staff. Nurse case managers (known as AIM nurses) are the primary providers for AIM patients. They educate patients on disease process and prognosis, treat- ment alternatives, advance care planning, avoidance of unnecessary hos- pitalization, management of pain and symptoms, and hospice enrollment. Additionally, AIM nurses receive training classes that cover such topics as palliative care definition and philosophy, insurance coverage, home care

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 RETOOLING FOR AN AGING AMERICA and hospice regulations, and facilitating difficult conversations. They also attend biweekly patient-centered conferences. An early evaluation of the program found that AIM program patients had higher rates of hospice utilization (Ciemins et al., 2006). Notably, the program was successful in increasing hospice utilization by African Ameri- cans, a group that has traditionally had very low rates of hospice use. Medicare Research and Demonstration Projects In addition to private-sector initiatives, a number of models have been tested by the Centers for Medicare and Medicaid Services (CMS). These demonstration projects have examined mechanisms to restructure the Medi- care and Medicaid programs in ways that support more efficient and more effective care delivery for older adults. For example, older adults with long-term health care needs often face fragmentation in their care because the Medicare program finances acute care at the national level while state- administered Medicaid programs are the predominant payers for long-term care services (Kaiser Family Foundation, 2006). Discontinuities between the two programs can translate into discontinuities in care as well as into higher costs, as the two programs often seek to shift costs to each other (National Commission for Quality Long Term Care, 2006). CMS demonstration projects have tested a number of ways to improve quality in Medicare (and often Medicaid as well). Several of these projects are described below. Programs of All-Inclusie Care for the Elderly (PACE) PACE is a managed-care program that was developed to address the spectrum of needs for adults aged 55 and older with disability levels that make them eligible for nursing-home care (Tritz, 2005). The program is based on the belief that the well-being of older adults can be improved by serving them in the community (Mukamel et al., 2007). PACE was modeled after an innovative initiative in San Francisco, On Lok, that was designed to help the Asian American community care for older adults in their homes (Greenwood, 2001). Start-up funds for PACE were provided by private foundations, and its implementation was supported by congressional authorization of Medicare and Medicaid waivers (Gross et al., 2004). The PACE model funds a com- prehensive set of services by combining federal Medicare dollars, state and federal Medicaid funds, and the individuals’ own contributions (National PACE Association, 2007). The PACE service package includes all Medicare and Medicaid covered services plus additional services, including adult day care, nutritional counseling, recreational therapy, transportation, and personal-care services, such as meals at home (CMS, 2005). PACE also pays for nursing-home care, if appropriate.

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 NEW MODELS OF CARE PACE services are provided by an interdisciplinary team composed of at least the following members: a primary care physician, a registered nurse, a social worker, a physical therapist, a pharmacist, an occupational therapist, a recreational therapist, a dietician, a PACE center manager, a home-care coordinator, personal-care attendants, and drivers (Mukamel et al., 2007). The team approach in PACE is innovative in its inclusion of both profes- sionals and direct-care workers as part of the care team. Each member of the team performs an initial assessment of each patient, and then the group works together to create a single care plan that takes the different assess- ments into account. The team holds weekly care-planning meetings during which the care plans are reassessed. The services, which are provided primarily at an adult day-care center, are also highly coordinated (Cooper and Fishman, 2003; Mukamel et al., 2006). The center includes a health clinic and at least one common room for social and recreational activities. PACE enrollees attend the day center approximately three days per week, enabling team members to identify subtle changes in health status or mood and to address them quickly. Team members regularly reassess the medical, functional and psychosocial condi- tions of patients and document any changes in the medical record. An evaluation of the PACE demonstration program found that enroll- ment was associated with higher patient satisfaction, improved health status and physical functioning, an increased number of days in the community, improved quality of life, and lower mortality (Chatterji et al., 1998). The benefits of PACE were even greater for the frailest older adults, whose en- rollment was associated with lower rates of service utilization in hospitals and nursing homes and higher rates of ambulatory care services. An analysis showed that capitated payments under PACE were about 10 percent higher than the payments that would have been likely under the fee-for-service (FFS) program. The analysis found savings for Medi- care but higher costs for Medicaid. Capitated Medicare payments were 42 percent lower than projected Medicare FFS expenditures, but capitated Medicaid payments were 86 percent higher than projected FFS expenditures (Grabowski, 2006; White et al., 2000). It is also notable that PACE programs have achieved some success in the recruitment of direct-care workers (Hansen, 2007). The program has a 12 percent annual turnover rate among aides, well below rates reported nationally. Aides at PACE sites are given opportunities for career advance- ment, and PACE provides financial support to direct-care workers seeking additional training. Eercare The Evercare program, originally developed by United Health Care Corporation, assigns nursing-home residents to a risk-bearing health main-

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 RETOOLING FOR AN AGING AMERICA are responsible for the majority of patient care and monitoring (Sibbald and Roland, 1998). Many of these new roles and responsibilities require additional train- ing, although the training in some cases can be provided by the hiring organization and may not require a higher educational degree. IMPACT’s depression-care managers, for example, underwent a 2-day orientation session and 2-day training meetings (Wagner et al., 2001). Some models of care also require the professional providers to serve as the instructors to patients or informal caregivers. Overall, new models of care often require all members of the care team—whether they are health care professionals, formal direct-care work- ers, informal caregivers, or patients—to take on added responsibilities. Cascading various patient-care responsibilities—shifting them from one type of worker to another—will be an essential tool in efforts to alleviate the projected shortages in the numbers of providers available to meet the care needs of an aging society. In some cases, the assumption of these new responsibilities will require regulatory changes, most often through the expansion of state-based definitions of scopes of work. Recommendation 3-3: Health care disciplines, state regulators, and employers should look to expand the roles of individuals who care for older adults with complex clinical needs at different levels of the health care system beyond the traditional scope of practice. Critical elements of this include • development of an evidence base that informs the establishment of new provider designations reflecting rising levels of responsi- bility and improved efficiency; • measurement of additional competence to attain these designa- tions; and • greater professional recognition and salary commensurate with these responsibilities. These new roles and responsibilities have implications for the work- force beyond the need for more training. First, as new and expanded roles are delineated, more will need to be done to assure the competence of those providing increased levels of care. Second, as more responsibilities are delegated by professionals to other members of the health care workforce, these professionals will have increased responsibility for management and supervision but will need to be taught the skills required for these roles. Finally, the assumption of increased responsibility, especially for direct-care workers, has been associated with greater job satisfaction, and ultimately,

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 NEW MODELS OF CARE higher retention and potential improvement in patient outcomes. Specific examples of changing roles, delegation of responsibilities, and expanded scopes of work are discussed later in this report as they relate to each seg- ment of the workforce. Patients and Informal Caregivers Some models of care introduce new and expanded roles for patients and informal caregivers and integrate those individuals into the care team. An important element of the chronic-care model is engaging patients in their health and providing them with the education and tools to make decisions about their own care and to manage it (Arehart-Treichel, 2006; Unutzer et al., 2001). As more services are delivered in home- and community-based settings, patients and informal caregivers will become even more important to the delivery of care. And, as models of care recognize the contributions needed by these individuals to improve care, more will need to be done to educate and train them in principles of self-management, proper methods of service provision (e.g., wound care and medication administration), and use of new technologies. (See Chapter 6 for more on patients and informal caregivers.) Interdisciplinary Care The introduction of interdisciplinary teams into care delivery will pose a number of challenges. Although in the long run the use of such teams has the potential to reduce the use of intensive health services such as hospitalization, these teams are not adequately reimbursed at this time. Furthermore, since team care requires greater effort with respect to primary care and patient monitoring, the introduction of interdisciplinary teams to manage patients may strain the existing capacity of primary care providers even further. An additional challenge is that team training is not a focus of the curriculum for many providers, so that they may be unfamiliar with this practice style (see Chapter 4). Finally, effective teams also require a certain level of respect, comfort, and trust among members, which in some cases may not be present (Boult et al., 2001; Sommers et al., 2000). Care Coordination As discussed in Chapter 2, the coordination of care among provid- ers and across settings, especially during transitions, can greatly influence patient outcomes. Older adults often see multiple providers—on average, Medicare beneficiaries are treated by five physicians annually, and beneficia-

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 RETOOLING FOR AN AGING AMERICA ries with chronic conditions (e.g., heart failure, coronary artery disease, or diabetes) see an average of 13 physicians annually (IOM, 2007). As a result, the care that these beneficiaries receive from physicians and other health care providers is often fragmented and not well coordinated. The lack of coordination stems from a variety of factors, including poor definitions of accountability, misaligned financial incentives (including the inability to reimburse for care coordination under FFS), lack of connection among information systems, and minimal training of providers in cross-site col- laboration (Coleman, 2003; Coleman and Berenson, 2004; IOM, 2006b). In the 2007 IOM report Rewarding Proider Performance, the committee recommended that Medicare, in order to reduce fragmentation of services, encourage beneficiaries to identify a primary accountable source of care to act as that patient’s care coordinator and guide the patient through the health care (IOM, 2007). Many new models of care strive to improve care coordination, and these efforts can affect the use and development of the health care work- force. Some models, for example, require a geriatric care manager who helps patients navigate the health care system (see Chapter 4). Addition- ally, many efforts to improve care coordination call for enhancing com- munication among providers; this enhancement of communication among providers—and also between caregivers and patients—will require provid- ers to change their practice patterns in a variety of ways. Furthermore, as patients and their families assume more responsibility in care delivery, it will be essential to involve these individuals in the coordination of care, which in turn will make it necessary to recognize the barriers to effec- tive communication that some older adults experience, including hearing and vision deficiencies. (See next section for more on self-management.) Finally, one of the easiest ways to improve the coordination of care will be to enhance the use of those information technologies that help to share important patient information. Health Technology Many models of care require an increased use of health information technology (HIT), such as electronic health records and personal health records, to facilitate the sharing of information among providers and to improve their ability to coordinate the complex care of older patients. Health information technologies may also be used to build databases on the health of older populations which may be very useful to practitioners and researchers in aging. Other technologies used in new models may reduce the need for certain types of workers. For example, remote-monitoring tech- nologies can extend the reach of health care professionals into the home.

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 NEW MODELS OF CARE As a result, many members of the health care workforce will need to be trained in the proper use of all of these technologies. Technologies that assist in performing activities of daily living may reduce the demands placed on direct-care workers and informal caregiv- ers, effectively shifting these responsibilities back to the patient’s level. The interaction between developing technologies and the health care workforce is discussed further in later chapters, and recommendations are offered for encouraging the development and use of health technologies. CONCLUSION Simply expanding the size of the workforce qualified to provide the needed health care services to older adults will not be sufficient to address the challenge that will face this country over the next two decades. It will be necessary to develop new models of financing and care delivery in order to promote greater efficiencies in the use of the existing workforce while at the same time promoting improvements in care quality. Although a number of innovative models have already been developed, few have been widely adopted, and in large part this is because no adequate financing mechanism is in place to encourage the promotion of these models. Given that no single model of care will be sufficient to meet the needs of all older adults in all settings of care across the health care continuum, the committee recom- mends both an improved dissemination of models that have been shown to be effective and the development of new models of care that address specific settings or populations that have largely been overlooked and that encourage more effective use of the health care workforce. The adaptation of these new models of care will have important im- plications for the development of a better health care workforce for older adults. Common features of new models include expanding the roles of workers (including expansion of the involvement of patients and their families), creating new provider roles, using interdisciplinary care teams, and improving the coordination of care through improvements in commu- nication. Today’s health care workforce is not properly prepared to perform its work in the ways that these new models demand, so all segments of the health care workforce will need to be educated and trained in the new care principles that underlie these models. The remainder of this report discusses the education, training, recruitment, and retention of the various segments of the health care workforce, with a particular emphasis on how the roles of health care providers will need to change in order to provide high-quality and cost-effective care to older Americans.

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