How to Get Better Care with Lower Costs? See the Person, Not the Patient.

The U.S. health system perceives people as "patients" almost exclusively as they enter and exit the healthcare system, but with this emphasis on context, have we lost sight of the people who should be in the foreground of care? Does such a view impede care effectiveness and efficiency? How can we shift our frame of reference moving forward? To foster this needed conceptual shift, a group of national thought-leaders convened by the American Geriatrics Society (AGS) defined "person-centered care" to reorient the perspective toward individuals remaining in the center of pursuing high-quality care. This article explores how a person-centered care approach can improve healthcare effectiveness and efficiency, particularly for older adults with heightened health and daily living needs, and healthcare costs. The process for supporting a person-centered program is outlined, three critical indicators that define person-centered quality are highlighted, and several models that embrace the person-centered paradigm are briefly noted. Although there is no one-size-fits-all schematic, how and why overall success entails fidelity to essential elements of person-centered programs as the AGS expert panel identified is explained.

Influencing public policy to improve the lives of older Americans.

Aging of the U.S. population raises numerous public policy issues about which gerontological researchers, policy experts, and practitioners have much to contribute. However, the means by which aging-related public policy is influenced are not always apparent. Drawing on experience working in the U.S. Senate and other settings as Health and Aging Policy Fellows, the authors outline the formal and informal processes by which public policy is shaped in the U.S. Congress. Many who seek to influence public policy do so by telling legislators what they want. A less obvious path to policy influence is for gerontologists to offer their expertise to legislators and their staff. The authors provide specific recommendations for how gerontologists can establish productive and ongoing relationships with key legislative players. The authors also emphasize the importance of collaboration with advocacy groups and with local and state stakeholders to advance aging-related public policy to improve the lives of older Americans.

California Geriatric Education Center logic model: an evaluation and communication tool.

A logic model is a communications tool that graphically represents a program's resources, activities, priority target audiences for change, and the anticipated outcomes. This article describes the logic model development process undertaken by the California Geriatric Education Center in spring 2008. The CGEC is one of 48 Geriatric Education Centers across the nation, funded by the U.S. Health Resources Services Administration, Bureau of Health Professions. Engaging this diverse group of stakeholders to develop a logic model has added substantial value to program planning, implementation, and evaluation of key performance outcomes.

The role of consultant pharmacists in reducing medication problems among older adults receiving Medicaid waiver services.

OBJECTIVE: To evaluate the impact of an evidence-based, medication management intervention to reduce four targeted medication problems among older adults at risk for placement in a nursing facility. DESIGN: A pretest-posttest design. SETTING: Three sites of California's Multipurpose Senior Services Program (MSSP), a Medi-Cal waiver care management program. PARTICIPANTS: Six hundred fifteen dual-eligible, functionally impaired, community-dwelling adults, 65 years of age and older, enrolled in MSSP between June 2004 and January 2006. INTERVENTION: In collaboration with care managers, consultant pharmacists confirmed medication problems, developed individualized treatment plans, recommended changes, and communicated recommendations to prescribing physician(s), care managers, and participants/caregivers. MAIN OUTCOME MEASURES: Change in participant's medication at three-month follow-up. RESULTS: Twenty-six percent (n=162) had a confirmed medication problem, and of those, 61% had at least one medication changed at three-month follow-up. Change rates for each medication problem ranged from 46% to 68%. Thirty-seven percent had two or more confirmed medication problems, and those with multiple medication problems had greater opportunity to realize at least one medication change. Pharmacists communicated with physicians, care managers, and participants/caregivers at varying levels; however, in 22 cases where all three parties were contacted, change rate was 73%. CONCLUSION: Findings illustrate that consultant pharmacist services, in collaboration with other community-based providers, can reduce medication problems for vulnerable community-dwelling elders using well-defined criteria. There are policy implications for cost and reimbursement mechanisms that may increase identification and resolution of medication problems among older adults in Medicaid waiver services.

Characteristics associated with four potential medication problems among older adults in Medicaid waiver services.

OBJECTIVE: To identify characteristics associated with four potential medication problems among older adults at risk for nursing home placement. DESIGN: Cross-sectional survey. SETTING: Three sites of California's Multipurpose Senior Services Program (MSSP), a Medi-Cal waiver care management program. PARTICIPANTS: Six hundred fifteen dual-eligible, functionally impaired, community-dwelling adults aged 65 years and older enrolled in MSSP between June 2004 and January 2006. INTERVENTION: Medication screening using the Home Health Criteria that include medication use and clinical risk factors. MAIN OUTCOME MEASURES: Demographic and health characteristics associated with four problem types: 1) unnecessary therapeutic duplication, 2) psychotropic medication use with concurrent falls or confusion, 3) cardiovascular medication problems, and 4) use of nonsteroidal anti-inflammatory drugs (NSAIDs) with risk of peptic ulcer complications. Independent measures included age, gender, race/ethnicity, living arrangement, number of medications, health status, and utilization. RESULTS: Each problem type was associated with different characteristics, as identified by logistic regression modeling. Increased number of medications was associated with therapeutic duplication (odds ratio [OR] = 1.27; confidence interval [CI] 1.20-1.35; P < 0.001) and problematic psychotropic medication use (OR = 1.15; CI 1.08-1.22; P < 0.001). Psychotropic use was also associated with emergency department, hospital, or skilled nursing admission in the previous year (OR = 1.86; CI 1.15-3.00; P = 0.012), living with someone (OR = 0.57; CI 0.34-0.95; P = 0.032), and new care management enrollment (OR = 1.99; CI 1.22-3.24; P = 0.006). New enrollment was also associated with cardiovascular medication problems (OR = 2.15; CI 1.32-3.51; P = 0.002). There were no significant characteristics associated with NSAID problems (not shown). CONCLUSION: Unique predictors of potential medication problems highlight the need for systematic medication screening and treatment planning. These should include medication therapy management for vulnerable community-dwelling elders (upon enrollment for care management) and for those taking multiple medications. Funding mechanisms via Medicare Part D (prescription drug program) should be explored in this population to increase identification of medication problems and their resolution.

Prevalence of potential medication problems among dually eligible older adults in Medicaid waiver services.

BACKGROUND: Methods for identifying potential medication problems among older adults at risk for nursing home placement have generally not included clinical risk factors in addition to medication lists. OBJECTIVE: To assess the prevalence of potential medication problems for older adults enrolled in a Medicaid waiver service using tested Home Health Criteria that combine medication use and clinical risk factors for screening drug regimens. METHODS: A cross-sectional survey screened 615 community-dwelling, dually eligible, functionally impaired adults aged 65 years and older enrolled in a Medi-Cal (California's Medicaid) waiver care management program, California's Multipurpose Senior Services Program (MSSP). Measures included prevalence and predictors of having 1 of 4 potential medication problems: unnecessary therapeutic duplication, use of psychotropic drugs with concurrent falls or confusion, cardiovascular medication problems, and use of nonsteroidal antiinflammatory drugs with risk of peptic ulcer complications. RESULTS: Forty-nine percent of the sample had a potential medication problem, with unnecessary therapeutic duplication being most prevalent (24%). Nearly 20% of patients screened had 2 or more potential problems. Independent predictors of any potential medication problem were age (OR 1.029; 95% CI 1.01 to 1.05), new MSSP enrollment (OR 1.634; 95% CI 1.14 to 2.35), and number of medications (OR 1.183; 95% CI 1.13 to 1.24). CONCLUSIONS: Prevalence of potential medication problems in MSSP was markedly higher than reported in the original home healthcare sample used to test the Home Health Criteria. The prevalence rate for older adults at risk for nursing home placement necessitates expanded screening and medication therapy management interventions, especially upon initial enrollment and for those taking multiple medications. Interventions are needed to increase medication problem identification and resolution while promoting collaboration among physicians, consultant pharmacists, and waiver service providers.

Building an infrastructure to prevent falls in older Californians: the Fall Prevention Center of Excellence.

The Fall Prevention Center of Excellence (Center), a consortium of federal, state, and private organizations, was established in 2005 to guide the implementation of a statewide initiative to prevent falls among older Californians. The process began with the convening of a representative group of recognized leaders in California's health and human services in 2003. This group engaged in a 2-day strategic planning process that culminated in the development of the California Blueprint for Fall Prevention. The overarching goal of the Blueprint is to build a statewide infrastructure for fall prevention services and programs that will serve as a model for the rest of the country. The specific goals of the Center are to establish fall prevention as a key public health priority in California; create, test, and evaluate effective and sustainable fall prevention programs; and build a comprehensive and sustainable fall prevention system in California. To accomplish these goals, the Center is currently engaged in developing and disseminating fall prevention tools and informational resources directed at the needs of both consumer and professional audiences; linking organizations involved in fall prevention while increasing awareness of fall prevention as an important public health issue; and helping communities build their capacity to effectively address falls in older adults through the delivery of integrated fall prevention services and "best practice" programs.

Reduced mortality: the unexpected impact of a telephone-based care management intervention for older adults in managed care.

OBJECTIVE: This analysis evaluated mortality over 24 months for Medicare managed care members who participated in the Care Advocate Program (CA Program) designed to link those with high health care utilization to home- and community-based services. DATA SOURCE: Secondary data from the CA Program, part of the California HealthCare Foundation's Elders in Managed Care Initiative. STUDY DESIGN: Randomized-control trial in which participants (N=781) were randomly assigned to intent-to-treat (ITT) and control groups. ITT group received telephonic social care management and 12 months of follow-up. Various multivariate analyses were used to evaluate mortality risk throughout multiple study periods controlling for sociodemographic characteristics, health status, and health care utilization. POPULATION STUDIED: Older adults (65+) enrolled in a Medicare managed care plan who had high health care utilization in the previous year. PRINCIPAL FINDINGS: ITT group had a significantly lower odds of mortality throughout the study (OR=0.55; p=.005) and during the care management intervention (OR=0.45; p=.006), whereas differential risk in the postintervention period was not statistically significant. Other significant predictors of mortality were age, gender, three chronic conditions (cancer, heart disease, and kidney disease), and emergency room utilization. CONCLUSIONS: Findings suggest that the care advocate model of social care management affected mortality while the program was in progress, but not after completion of the intervention phase. Key model elements accounted for the findings, which include individualized targeting, assessment, and monitoring; consumer choice, control, and participant self-management; and bridging medical and social service delivery systems through direct linkages and communication.

Gerontology's future: An integrative model for disciplinary advancement.

Scholars have debated the legitimacy of gerontology as a discipline since Metchnikoff coined the term more than 100 years ago. Recent developments such as the emergence of interdisciplinary aging theories and consensus on longitudinal research methods suggest that gerontology is materializing as a unique discipline, rather than a subset of another more established disciplinary tradition. In this article we review substantive evidence from gerontological theory and scholarship to suggest orienting principles for the emerging discipline of gerontology. We offer a conceptual framework of gerontology as a discipline that integrates contributions of biopsychosocial perspectives with well-established concepts of age, aging, and aged and multiple contextual elements. We conclude with a discussion of how our model relates to gerontology's progress, including examples of successful interdisciplinary research, and offer questions for gerontologists to consider for further advancement of the field.

Implications of translating research into practice: a medication management intervention.

Through programs such as the Administration on Aging's Evidence-Based Prevention Initiative, researchers and practitioners are developing translational research studies seeking to implement rigorously tested, evidence-based interventions in new practice settings and evaluate the continuing effectiveness of these interventions. One such translational study is the Community-Based Medications Management Intervention (CBM Intervention), a collaborative effort to implement a medication management screening and intervention protocol in community-based waiver care management programs. The overall goals of the CBM Intervention are to implement an evidence-based medication management intervention in a California Medicaid waiver care management program, and to evaluate the effect of client-, intervention-, and organizational-level characteristics on resolving identified medication problems. This article presents the need for improved medication management in a frail, community-dwelling, older adult population and describes the CBM Intervention as an example of translating an evidence-based practice beyond its original efficacy trial in a home healthcare program into a care management program. It discusses critical factors involved in translating research into practice using a translational research framework, Promoting Action on Research Implementation in Health Services (PARIHS). Our experience suggests that although implementing research into practice can positively impact client care, professional skill enhancement and organizational effectiveness, this is very challenging work requiring signification facilitation for successful outcomes.

Characteristics associated with home- and community-based service utilization for Medicare managed care consumers.

PURPOSE: We identified the types of home- and community-based services (HCBS) that high-risk older adults in Medicare managed care used, and we examined participant characteristics associated with service use in six areas: overall service use, four specific categories of HCBS, and referrals to insured medical services. DESIGN AND METHODS: We used service data from the Care Advocate Demonstration Program, a telephone-based care-management intervention that linked chronically ill older adults to HCBS. Two hundred and twenty-four high-risk older adults who were enrolled in a southern California-based Medicare managed care plan received an assessment, service referrals, and 12 months of telephone follow-up by master's level social service professionals. We used logistic regression to estimate the odds of using the HCBS categories and medical services. RESULTS: Results indicated that characteristics associated with service use varied extensively, depending on the service. Age, gender, social support, living situation, education, specific functional impairments, heart conditions, and sensory impairments at baseline significantly predicted utilization in the six different service models. IMPLICATIONS: Policy implications include the importance of individualized care-management assessments that direct targeted referrals to appropriate services. Findings support the need for individualized care-management assessment and service planning, suggesting that a "one size fits all" approach to HCBS will not meet the varied needs of diverse consumers.

Using interagency collaboration to serve older adults with chronic care needs: the Care Advocate Program.

This article describes the Care Advocate Program, an interagency collaborative effort that involved health care organizations, social service agencies, and an academic research center to improve chronic care service delivery to older adults. The article discusses existing barriers to effective chronic care delivery as well as concepts for successful collaboration. The article describes the multiple and often competing demands of stakeholders who undertake collaborative projects. It concludes with lessons learned when partners from different settings work together to design and implement a demonstration program.