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- Report of a Forum of the Council on Heady Care Technology Care of the Elderly Patient: Policy Issues and Research Opportunities Jeremiah A. Barondess, David E. Rogers, and Kathleen N. Lohr, editors l Institute of Medicine NATIONAL ACADEMY PRESS WASHINGTON, D.C. 1989

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TO INSllTlTrE OF MEDICINE was chartered in 1970 by the National Academy of Sciences to enlist distinguished members of appropriate professions in the examination of policy matters pertaining to the health of the public. In this, the Institute acts under both the Academy's 1863 congressional charter responsi- bility to be an adviser to the federal government, and its own initiative in identifying issues of medical care, research, and education. THE COUNCIL ON HEALTH CARE TECHNOLOGY was established in 1986 by the Institute of Medicine of the National Academy of Sciences as a public-private entity to address issues of health care technology and technology assessment. The council is committed to the well-being of patients as the fundamental purpose of technology assessment. In pursuing that goal, the council draws on the services of the nation's experts in medicine, health policy, science, engineering, and industry. The Forum and this monograph were supported in part by a grant to the Council on Health Care Technology of the Institute of Medicine from the Na- tional Center for Health Services Research of the U.S. Department of Health and Human Services (grant 5 R09 HS055 26 02~. The opinions and conclusions expressed here are those of the authors and do not necessarily represent the views of the Department of Health and Human Senices, the National Academy of Sciences, or any of their constituent parts. Library of Congress Catalog Card Number 89~2106 International Standard Book Number ~309-04097-3 Additional copies of this report are available from: National Academy Press 2101 Constitution Avenue, NW Washington, DC 20418 Printed in the United States of America S031

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ACKNOWLEDGMENTS . - The Forum on Care of the Elderly Patient: Policy Issues and Research Opportunities would not have been possible without the dedi- cated efforts of Leslie Hardy, who, as a staff officer of the Council on Health Care Technology at the time, devoted long hours to the logistics of the meeting. Sunilarly, the publication of this monograph would not have been possible without the many hours of skinny and cheerful preparation of several drafts~of this manuscript by Brenda Patterson of the council staff. The original version of these papers was most competently edited by Heather Wiley. On behalf of He members of the~council and the authors in this volume, the editors thank them aD for their contributions. The editors wish to thank Enriqueta Bond, former Director of the Division of Heals Promotion and Disease Prevention, for her substantial contributions to the council~and-its activities. They are grateful as wed to Samuel O. Thier, President of He Institute of Medicine, for inspired leadership and support of the council initiatives. Finally, they acknowI- edge a considerable debt to William N. Hubbard, Ir., chairman of the council, and to Jeremiah A. Barondess, co-chairman; their blend of guid- ance and support through the past year has made this form and the entire forum series possible. . ~ 111

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Council on Health Care Technology Chairman WILLIAM N. HUBBARD, JR., M.D. Former President, The Upjohn Company Co-Chairman JEREMIAH A. BARONDESS, M.D. Irene F. and I. Roy Psaty Distinguished Professor of Clinical Medicine, Cornell University Medical College Members HERBERT E. ABRAMS, M.D. Professor of Radiology, Stanford University School of Medicine ~ RICHARD E. BEHRMAN, M.D. Dean, School of Medicine, Case Western Reserve University PAUL A. EBERT, M.D. Director, American College of Surgeons PAUL S. ENTMACBR, M.D. Senior Vice President and Chief Medical Director, Metropolitan Life Insurance Company MELVIN A. GLASSER Director, Health Security Action Council BENJAMIN L. HOLMES Vice President and General Manager, Medical Products Group, Hewlett-Packard Company 1V GERALD D. LAUBACH, Ph.D. President, Pfizer Inc. . . WALTER B. MAZIER Director, Employee Benefits, Chrysler Motors Corporation WAYNE R. MOON Executive Vice President and Operations Manager, Kaiser Foundation Health Plan, Inc. LAWRENCE C. MORRIS, JR. Senior Vice President, Health BeneSts Management, Blue Cross and Blue Shield Association C. FREDERICK MOSTELLER, Ph.D. Roger I. Lee Professor (Ementus), Director, Technology Assessment Program, Harvard School of Public Health MARY O. MUNDINGER, Dr.P.H. Dean, School of Nursing, Columbia University ANNE A. SCITOVSKY Chief, Health Economics Department, Palo Alto Medical Foundation GAIL L. WARDEN President, Henry Ford Health Care Corporation

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PREFACE In the recent past, the interests of different groups concerned with health care have focused on the use of medical technologies~heir safety, efficacy, and effectiveness; their cost-effectiveness and cost-benefit; their impacts on quality of care; and their social, legal, and ethical implications. The sum of these varied interests is the field of health care technology assessment. The Council on Health Care Technology was created to promote He development and application of technology assessment in health care and the review of health care technologies for their appropriate use. The council was established as a public-private enterprise at the Institute of Medicine, a component of the National Academy of Sciences, Hugh the Health Promotion and Disease Prevention Amendments of 1984 (P.L. 9~55l, later amended by P.L. 9~171. In 1987 the U.S. Congress extended support for the council as a public-private venture for an addi- tional three years (by P.L. 10~1771. The goals and objectives of the council, as stated in the report of its first two years of operations, are "to promote the development and appli- cation of technology assessment in medicine and to review medical tech- nologies for their appropriate use. The council is guided in its efforts by the belief that the fundamental purpose of technology assessment is to improve patient wet/-being and the quality of care." In pursuing these goals, the council seeks to improve the use of medical technology by developing and evaluating the measurement criteria and the methods used for assessment; to promote education and training in assessment methods; and to provide technical assistance in the use of data from published assessments. The council conducts its activities through several working and liaison panels. Members of these panels reflect a broad set of interested constituencies physicians and other health professionals, patients and their families, payers for care, biomedical and health services researchers, manufacturers of health-related products, managers and administrators throughout the health care system, and public policymakers. In addition, the council carries out activities of interest to more than one panel.

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V1 PREFACE The Forum Series is one of the councilwide activities. The Forum Series seeks to facilitate an exchange of views among the many and diverse groups concemed with health care technology. Themes addressed by these symposia include He interdependence among medical technol- ogy assessment, quality assessment, and assurance of the quality of pa- tient care; the performance of existing technology assessment activities; the appropriate use of technology to minimize risks posed to special or vulnerable patient populations; and He development, application, and appropriate use of technology. A guiding principle of the council is a special focus on outcome measures that coincide with patient wet/-being, quality of health care, and quality of life. In keeping with this pnnciple, a forum conducted in October 1987 dealt win care of the elderly patient. This report is the record of that symposium. William N. Hubbard, Ir., Chairman Jeremiah A. Barondess, Co-Chairman

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CONTENTS Introduction to He Council on Health Care Technology William N. Hubbard, Jr. Quality of Care and He Health Needs of the Elderly Patient 3 Avedis Don~bedian Home and Community Care of the Elderly: Introduction Mary 0. Mundinger ....... ~4 Home and Community Care of the Elderly: Framing the Issues 16 Robert L. Kane Framing the Issues of Home and Community Care: Response 28 Earl M. Collier, Jr. Special Perspectives on Home land Community Care 32 Patricia P. Barry Special Perspectives on Home and Community Care 36 Eileen M. Quinlan Special Perspectives on Home and Community Care Susan A. Walker Special Perspectives on Home and Community Care Charlotte K. Flynn 44 .48 Special Perspectives on Home and Community Care 52 Lynn M. Etheredge Home and Community Care of the Elderly: System Resources and Constraints ~ a~ en e Susan L. Hughes Home and Community Care of the Elderly: System Resources and Constraints John H. Mather Home and Community Care of the Elderly: Research and Policy Issues ................................................................................... Bruce C. Viadeck V11 ........ 65

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~ ~ V111 CONTENTS Home and Community Care of the Elderly: Research and Policy Issues e~ e-~-e~ e~eeeeeeeeee~eeeeaeeeee-eeeeeeee~eieeae~-eee~ Lisa V. Rubenstein 71 The Acute Care Hospital and the Elderly: Introduction .~ eee.~ 77 Jeremiah A. Barondess The Acute Care Hospital and the Elderly: Framing the Issues Mitchell T. Rakkin 80 Special Perspectives on Acute Hospital Care 87 William R. Hazzard Special Perspectives on Acute Hospital Care Carol ]. Gray ............ ...94 Special Perspectives on Acute Hospital Care 103 lack E. Christy Special Perspectives on Acute Hospital Care 109 Joseph W. Westbrook Acute Hospital Care of the Elderly: System Resources and Constraints 1 ]. Alexander McMahon Acute Hospital Care of the Elderly: System Resources and Constraints L. Gregory Pawlson Acute Hospital Care of the Elderly: Research and Policy Issues Jerome Kowal Acute Hospital Care of the Elderly: Research and Policy Issues . Stephen R. McConnell ,14 124 ....... 132 Care of the Elderly Patient: Summation of He Forum 136 David E. Rogers List of Authors