Long-Term Care Policy Should Aim to Keep More Elderly in Their Homes

Seventy percent of Americans over age 65 are expected to require some kind of long-term care. We can’t build enough facilities or leave that responsibility to family members.

Dr. Michael Fleming is the former president of the American Academy Of Family Physicians and Chief medical Officer at Amedisys Home Health and Hospice.
National Journal
Dr. Michael Fleming
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Dr. Michael Fleming
July 22, 2014, 6:21 a.m.

Let’s say you’re a primary-care phys­i­cian. Your pa­tient — call her Sally — is 82 years old. Sally suf­fers from a few chron­ic ill­nesses. She reg­u­larly sees sev­er­al med­ic­al spe­cial­ists and takes mul­tiple med­ic­a­tions.

Where does Sally be­long? What set­ting will best serve her per­son­al needs clin­ic­ally, so­cially, and eco­nom­ic­ally? Should she be ad­mit­ted to a hos­pit­al? Enter a nurs­ing home or as­sisted-liv­ing fa­cil­ity?

The con­sensus in­creas­ingly emer­ging is that Sally should stay at whatever loc­a­tion best meets her needs, and in this case it’s at home. An es­tim­ated 7 mil­lion eld­erly Amer­ic­ans already re­quire long-term care, with more ex­pec­ted to fol­low. In­deed, over the next 40 years, the call for long-term care is ex­pec­ted to double, ac­cord­ing to the Health and Hu­man Ser­vices De­part­ment.

study re­leased by AARP in late June found that “home care gen­er­ally is more af­ford­able than nurs­ing home care, al­low­ing con­sumers to stretch their dol­lars fur­ther.” Its au­thors poin­ted out, “Once people ac­cess Medi­caid, shift­ing ser­vice de­liv­ery to­ward home- and com­munity-based ser­vices is crit­ic­al.” In prac­tic­al, hu­man terms, the re­port ad­ded, “Hir­ing the people who will help you bathe, dress, eat, use the toi­let, and move from one place to an­oth­er is fun­da­ment­al to hav­ing more per­son­al con­trol over what hap­pens to you on a daily basis.”

The grow­ing de­mand for long-term home care is the res­ult of a seis­mic shift in demo­graph­ics. Amer­ic­ans are liv­ing longer than ever be­fore. People 80 or older rep­res­ent the na­tion’s fast­est-grow­ing age group. Baby boomers are turn­ing age 65 at the rate of roughly 10,000 per day, the Pew Re­search Cen­ter re­por­ted in 2010. And by 2030, adults 65 and older will make up 19 per­cent of the pop­u­la­tion.

Age is hardly the only factor, though. Most older Amer­ic­ans face spe­cial health care chal­lenges, par­tic­u­larly com­mon chron­ic dis­eases such as dia­betes, high blood pres­sure, heart fail­ure, and Alzheimer’s. About three out of four Amer­ic­ans age 65 or older suf­fer from more than one chron­ic con­di­tion, ac­cord­ing to the Cen­ters for Dis­ease Con­trol and Pre­ven­tion.

Un­for­tu­nately, chron­ic dis­ease is the single biggest and fast­est-grow­ing con­trib­ut­or to health care costs. About half of the na­tion’s col­lect­ive health care spend­ing provides for the care of just 5 per­cent of Medi­care be­ne­fi­ciar­ies. Most of this group live with chron­ic dis­ease.

That’s why pa­tients like Sally have be­come the sub­ject of a seem­ingly nev­er-end­ing de­bate. Should we in­vest in what’s best for pa­tients or in what is most cost-ef­fect­ive for the coun­try?

Right now, health care de­liv­ery for eld­erly Amer­ic­ans re­mains largely frag­men­ted, in­ef­fi­cient, and ex­pens­ive. Most older Amer­ic­ans who are at home and in need of long-term care get only un­paid help, mainly from fam­ily, friends, and vo­lun­teers. That’s a prob­lem. About 70 per­cent of Amer­ic­ans over age 65 are ex­pec­ted even­tu­ally to re­quire some kind of long-term care. But some fam­il­ies and friends must shoulder those re­spons­ib­il­it­ies them­selves rather than hire and pay pro­fes­sion­als.

This pre­dic­a­ment will take a par­tic­u­larly heavy toll on eld­erly Amer­ic­ans who are mem­bers of ra­cial and eth­nic minor­ity groups. Afric­an-Amer­ic­an and His­pan­ic seni­or cit­izens have dis­pro­por­tion­ately small life­time earn­ings and on av­er­age have less money saved for re­tire­ment. Some live in rur­al set­tings and are mem­bers of fam­il­ies in which fin­an­cial struggle is com­mon. Des­pite the Af­ford­able Care Act and rising rates of health in­sur­ance cov­er­age, ra­cial and eth­nic minor­it­ies also re­main more likely than oth­er Amer­ic­ans to live without health in­sur­ance and the reg­u­lar health care it provides.

Already, re­search shows that ra­cial and eth­nic minor­it­ies over age 65 of­ten lack ad­equate ac­cess to health care and re­ceive lower-qual­ity health care than their white coun­ter­parts. Older minor­ity Amer­ic­ans have also, on av­er­age, con­sist­ently lived in worse health, as meas­ured by dis­ease and dis­ab­il­ity, than whites the same age.

Be­ware the loom­ing omens: By the year 2050, minor­it­ies are ex­pec­ted to ac­count for 50 per­cent of the eld­erly pop­u­la­tion. The state of their health and health care will in­creas­ingly char­ac­ter­ize what grow­ing old and ill in the United States will mean.

Even so, evid­ence is mount­ing that health care de­livered at home can con­trib­ute to the over­all solu­tion. In health care, just as in real es­tate, loc­a­tion just might turn out to be everything. After all, man­aging chron­ic dis­ease should in­volve con­tinu­ous care, com­plete with daily mon­it­or­ing of vi­tal health cri­ter­ia, in­clud­ing blood pres­sure, diet, and phys­ic­al activ­ity. Only un­der such reg­u­lar over­sight can chron­ic­ally ill pa­tients ex­pect to func­tion well. No single ap­proach can do this bet­ter, I be­lieve, than home care. It can shorten the length of a hos­pit­al stay and re­duce the num­ber of pa­tients sent home and later re­ad­mit­ted. It can en­able pa­tients to live health­i­er, longer lives, all at lower cost.

How can we — mean­ing mainly phys­i­cians, hos­pit­als, poli­cy­makers, and tax­pay­ers — do bet­ter by our eld­erly pop­u­la­tion? Well, the Af­ford­able Care Act is already mov­ing the coun­try in the right dir­ec­tion. One of the law’s pro­vi­sions es­tab­lished a pro­gram to im­prove care for seni­ors after they leave a hos­pit­al. Right now, nearly one in five Medi­care pa­tients dis­charged from a hos­pit­al are re­ad­mit­ted with­in 30 days. The Com­munity-based Care Trans­itions Pro­gram is de­signed to con­nect seni­ors to com­munity ser­vices such as home health agen­cies that can help keep them healthy at home.

Still, more has to be done to nar­row and even elim­in­ate the dis­par­it­ies in health and health care so widely evid­ent among older Amer­ic­ans. For starters, Con­gress and all fed­er­al and state health agen­cies should take fresh ac­tion to safe­guard such at-risk Amer­ic­ans. They should, for ex­ample, cre­ate a more ef­fect­ive in­fra­struc­ture, broadly de­ploy­ing in­nov­at­ive mod­els of care such as ac­count­able care or­gan­iz­a­tionspa­tient-centered med­ic­al homes and bundled-pay­ment pro­grams.

They should im­ple­ment long-over­due re­form of the Medi­care pay­ment for­mula to en­sure that phys­i­cians are fairly re­im­bursed. Law­makers should also cre­ate in­cent­ives that urge all the play­ers in the health care sys­tem to bet­ter co­ordin­ate care, im­prove pa­tient health out­comes, and, above all, unite with a sense of shared re­spons­ib­il­ity.

Our na­tion should move ahead more ag­gress­ively than ever to des­ig­nate older adults, as well as eth­nic and ra­cial minor­it­ies, as a high-pri­or­ity pop­u­la­tion, as the Agency for Health­care Re­search Qual­ity re­com­men­ded back in 1999. The Health and Hu­man Ser­vices De­part­ment and the Na­tion­al In­sti­tutes of Health, among oth­ers, should un­der­take ma­jor new ini­ti­at­ives to im­prove the health and health care of older Amer­ic­ans.

The dia­logue be­gun in earn­est years ago between fed­er­al agen­cies and re­search­ers to re­fine our na­tion­al agenda for re­search on the eld­erly should be ac­cel­er­ated. Today, we should meas­ure the ex­tent to which the needs of the eld­erly for long-term health care are be­ing met — or go­ing un­met — as well as how and why. New stud­ies should as­sess how we can best en­sure that our rap­idly di­ver­si­fy­ing eld­erly pop­u­la­tion gains ac­cess to geri­at­ric ex­pert­ise and equit­able treat­ment. Med­ic­al school cur­ricula must be de­veloped to train the next gen­er­a­tion of health care pro­viders to bet­ter meet the needs of these par­tic­u­lar demo­graph­ics.

But why stop there? Primary care phys­i­cians should col­lab­or­ate and com­mu­nic­ate more ef­fect­ively and more of­ten with home-care clini­cians to co­ordin­ate care, es­pe­cially dur­ing and im­me­di­ately after the cru­cial trans­ition from hos­pit­al to home. More home-care com­pan­ies should in­vest in tech­no­logy — such as In­ter­net portals that share a pa­tient’s vi­tal signs and oth­er in­form­a­tion with oth­er health care pro­viders. The true value of home care should be re­flec­ted in what Medi­care and private in­surers pay health care pro­viders. Fi­nally, poli­cy­makers should es­tab­lish a pay­ment mod­el that re­cog­nizes — and re­wards — the be­ne­fits of good pa­tient out­comes.

If we are to im­prove qual­ity and rein in health care costs, we need to, in ef­fect, bring back the house call.

In the ideal scen­ario, then, Sally would get to re­main in the home where she and her hus­band raised three chil­dren, next door to the neigh­bors who of­ten look in on her. A nurse, a ther­ap­ist, and a so­cial work­er would vis­it her reg­u­larly. They would keep her eat­ing, speak­ing, mov­ing, dress­ing, and bathing. She would take her med­ic­a­tions as pre­scribed. Tele­m­on­it­or­ing devices would track her vi­tal signs. Sally would stay health­i­er at lower cost.

But best of all, Sally would ac­com­plish much more than aging well. She would re­tain cer­tain in­valu­able qual­ity-of-life staples — her pride, her in­de­pend­ence, and her dig­nity.

Dr. Mi­chael Flem­ing is the former pres­id­ent of the Amer­ic­an Academy of Fam­ily Phys­i­cians and chief med­ic­al of­ficer at Amedisys Home Health and Hos­pice.

HAVE AN OPIN­ION ON POLICY AND CHAN­GING DEMO­GRAPH­ICS? The Next Amer­ica wel­comes op-ed pieces that ex­plore the polit­ic­al, eco­nom­ic, and so­cial im­pacts of the pro­found ra­cial and cul­tur­al changes fa­cing our na­tion, par­tic­u­larly rel­ev­ant to edu­ca­tion, eco­nomy, the work­force, and health. In­ter­ested in sub­mit­ting a piece? Email Jan­ell Ross at jross@na­tion­al­journ­al.com with a brief pitch. Please fol­low us on Twit­ter and Face­book.

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