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Managed Care Partners - Why geriatric care doesn't have to mean hospital care

Managed Care Partners Fall 2010

Why geriatric care doesn't have to mean hospital care

Date: October 31, 2010

Bruce Leff
Bruce Leff, who sees patients every week in the Johns Hopkins Bayview Medical Center geriatric clinic, has received a competitive appointment to the Health and Aging Policy Fellows Program to work on public policies affecting older Americans. He will focus on implementing the Independence at Home Act, part of the recently passed health care reform legislation.

Bruce Leff has never been shy about his intentions to advocate for better care for older adults. A driving force behind Johns Hopkins Elder House Care Program, the Hopkins geriatrician is now co-piloting a national program called the Medicare Innovations Collaborative (Med-IC) to improve the quality of life for hospitalized elderly patients and help hospitals’ bottom line.

Leff and his colleague Albert Siu, professor of geriatrics at Mt. Sinai School of Medicine, are co-principal investigators for Med-IC, which shares best practices for improving hospital-based geriatric care. Ideally, says Leff, that means managing patients with chronic illnesses in an outpatient setting for as long as possible. But when acute flare-ups require hospitalization, these patients would be managed humanely and efficiently so that they could return home faster.

“We want to change how services get deployed,” says Leff, who is also a professor of health policy and management at Hopkins’ Bloomberg School of Public Health. “We need to deliver care to people in their homes to avoid the nastiness of hospitals, and when they need to be admitted we need to get them through that experience safely and efficiently, and when they are discharged we need to do our best to keep them from getting readmitted to the hospital.”

Leff’s research has found that patients with multimorbid conditions who are admitted to hospitals typically experience complications from inappropriately prescribed medications, suffer from preventable medical errors and go home lacking the information and follow-up they need. As a result, one in 10 is readmitted to a hospital within 15 days, and one in five is back at the hospital within 30 days.

Three years ago, Siu and Leff received a grant from The Atlantic Philanthropies to develop a business case giving hospitals the tools—evidence-based practices—to help them provide the best possible care to older adults. Med-IC evolved from there.

Rather than establish a center, Leff and Siu are working with early adopters of the concept. They sent a letter to 40 health systems with a geriatric service asking if they would join the Med-IC Collaborative, which would include access to experts, technical assistance and training. Though no money was offered, 26 applications came in.

Med-IC selected six sites with a proven track record for excellent geriatric care to act as “learning laboratories” to test the feasibility of offering novel programs that would incorporate six models of a “geriatric portfolio” care model. These include using established geriatric assessment tools and quality improvement; palliative care; a national program to improve elder care and nurse competence; strong transitional care; and Hospital at Home, a project Leff designed, which provides hospital-level care in a patient’s home to substitute for acute hospital care.

Leff acknowledges that for hospitals, Med-IC is a hard sell. But, he and Siu argue, the return on investment would result from reducing lengths of stay and freeing beds for other admissions.

Med-IC has had ongoing collaboration with policymakers, government officials, hospital administrators, researchers and organizations with ties to older adults. “If we have 20 to 50 programs in a climate of health care reform,” says Leff, “we can really get it moving.”

One reason Leff considers Med-IC so important “is that the baby boomers are coming, and many already need services for chronic health problems.” Innovations—like more nurse practitioners to deliver care—Leff believes, will become the norm. “Geriatrics has models that don’t get delivered because they’re considered the ‘losers.’ Here are six models that work. It’s a first step.”