Successful Models of Comprehensive Care for Older Adults with Chronic Conditions: Evidence for the Institute of Medicine's “Retooling for an Aging America” Report

Abstract

The quality of chronic care in America is low, and the cost is high. To help inform efforts to overhaul the ailing U.S. healthcare system, including those related to the "medical home," models of comprehensive health care that have shown the potential to improve the quality, efficiency, or health-related outcomes of care for chronically ill older persons were identified. Using multiple indexing terms, the MEDLINE database was searched for articles published in English between January 1, 1987, and May 30, 2008, that reported statistically significant positive outcomes from high-quality research on models of comprehensive health care for older persons with chronic conditions. Each selected study addressed a model of comprehensive health care; was a meta-analysis, systematic review, or trial with an equivalent concurrent control group; included an adequate number of representative, chronically ill participants aged 65 and older; used valid measures; used reliable methods of data collection; analyzed data rigorously; and reported significantly positive effects on the quality, efficiency, or health-related outcomes of care. Of 2,714 identified articles, 123 (4.5%) met these criteria. Fifteen models have improved at least one outcome: interdisciplinary primary care (1), models that supplement primary care (8), transitional care (1), models of acute care in patients' homes (2), nurse-physician teams for residents of nursing homes (1), and models of comprehensive care in hospitals (2). Policy makers and healthcare leaders should consider including these 15 models of health care in plans to reform the U.S. healthcare system. The Centers for Medicare and Medicaid Services would need new statutory flexibility to pay for care by the nurses, social workers, pharmacists, and physicians who staff these promising models.

A Matched-Pair Cluster-Randomized Trial of Guided Care for High-Risk Older Patients

“…7,8 Similarly, recent studies of other primary care-based interventions for high-risk patients have reported significant improvement in one or two, but not all three, of the components of "the triple aim:" quality of care, health, and health care costs. 12,33 High-quality studies of various versions of the "patient-centered medical home" have shown improvement in the quality of care or in some clinical outcomes, but none has shown a significant reduction in net health care costs. 33 The national Medicare Care Coordination Demonstration 34 showed few improvements in the quality of care; 13 four of its 15 demonstration sites showed significant reductions in hospital admissions for high-risk patients, but the costs of the interventions at these sites were equal to the savings generated by the reductions in admissions over six years.…”

“…In the meantime, however, as millions of baby-boomers are reaching retirement age each year, near-term improvements may be achievable by developing and adopting clinical models that improve outcomes for high-risk people with multiple chronic conditions. Some such models have shown promise, [7][8][9][10][11][12] while others have either failed 13 or have not yet been tested rigorously. 14 Guided Care is a new model of comprehensive, interdisciplinary care that comprises primary care-based care management, transitional care, and support for self-management and family caregiving.…”

Integrated multiple sclerosis care: New approaches and paradigm shifts

“…Fifteen care models were found to improve at least one outcome in chronically ill adults. These models fall within the following broad topical areas: interdisciplinary primary care, models that supplement primary care, transitional care, models of acute care in patients' homes, nursephysician teams for residents of nursing homes, and models of comprehensive care in hospitals [10].…”

“…While there is no consensus on a specific model, an expert panel has recently advocated reforms that would strengthen the primary care system, encourage care coordination, and promote care management of patients with complex conditions who have high medical costs [9]. The Institute of Medicine commissioned a study to identify evidence-based successful models of comprehensive care for adults with chronic disease [10]. Fifteen care models were found to improve at least one outcome in chronically ill adults.…”

Primary Care Clinicians’ Recognition and Management of Depression: A Model of Depression Care in Real-World Primary Care Practice

“…[25][26][27][28][29][30][31][32][33][34][35][36][37][38][39][40] Research aligned with still-developing PCMH concepts attempt to address patients as whole persons and make changes in systems that support the capacity of clinicians to provide care more consistent with PC core concepts. [41][42][43][44][45][46][47][48] Results of interventions to date suggest that more comprehensive interventions are more effective, but they tend to be costly and conducted mostly in large health care systems. [49][50][51] In addition, although Veterans Affairs systems have begun to see early positive results, 33,40 even more comprehensive interventions have yielded limited enduring effects in real-world practices.…”