Study Investigates Six Geriatric Service Models

It’s well-known that a relatively small percentage of chronically ill patients accounts for a disproportionate amount of health care spending. Now, a multicenter study led by Johns Hopkins researcher Bruce Leff might provide insights into how to cut Medicare costs while improving health care for older adults suffering from chronic health conditions.

Results of the study, published in the June issue of the journal Health Affairs, highlight the early efforts of the Medicare Innovations Collaborative, a program involving six health care–related organizations around the country that focused on the simultaneous implementation of six geriatric health care delivery models.

“We all agree that it is critical to improve health service delivery for older adults, especially those with complex chronic illnesses,” Leff said. “Understanding the issues around implementing and adopting effective health service delivery is critical to Medicare’s efforts to provide value-based care.”

The organizations in the study varied from a solo hospital (Crouse Hospital in Syracuse, N.Y.) to a group of hospitals that owns or operates nursing facilities, hospices and a home health agency (Lehigh Valley Health Network in Pennsylvania). Other participants were Aurora Health Care, Milwaukee; Carolinas HealthCare System, Charlotte, N.C.; Geisinger Health System, Danville, Pa.; and University Hospitals Case Medical Center, Cleveland.

Each of the participating organizations already had one of the models in place, and each was required to plan the additional implementation of one of the six different geriatric service models.

The models are Nurses Improving Care to Healthsystem Elders (NICHE), a patient-centered model to improve hospital care processes for older adults, with oversight by a nursing team; Acute Care for Elders (ACE), which concentrates on helping hospitalized older adults maintain or achieve functional independence in basic activities of daily life; the Hospital Elder Life Program (HELP), designed to prevent delirium among hospitalized older patients; Care Transitions Intervention Model (Care Trans.), which provides chronically ill patients with “transition coaches” who help them effectively move from hospital to home; the Palliative Care Consultation Model (Pall. Care), which focuses on averting unwanted medical interventions for adults with life-limiting illnesses; and Hospital at Home, a model developed by Leff at Johns Hopkins that provides acute hospital-level care in the home as a substitute for inpatient hospital admission.

“Over the years, many evidence-based models of geriatric care have been developed, but few have been widely implemented. Our study developed the theory that putting multiple geriatric models into a geriatric service line or ‘portfolio,’ and providing technical assistance to an adopting organization in a learning collaborative, would make these models attractive for adoption by health systems from both a clinical and economic standpoint,” Leff said.

The study showed that NICHE, which facilitates more-effective communication and collaboration in elderly care, was seen as a model on which organizations could build a foundation for improving a hospital’s culture of quality and safety for older adults. Other organizations found the Pall. Care model effective in delivering patient-centered care to those suffering from terminal illnesses and in reducing medical costs.

“Organizations learned from each other and reduced adoption time and costs through structured support and voluntary exchange, since the main goal of the collaborative was to help participants evaluate and implement the geriatric service models,” Leff said.

Leff points out that the study does have certain limitations, as there are no measures of traditional outcomes or post-implementation results, but clinical and financial outcomes will be reported in the near future. The success of this phase of the work is to demonstrate that multiple complex health service delivery models that improve quality of care can be implemented rapidly by health systems.

“We are hoping to turn the participating health systems involved in this study into expert centers to provide technical assistance to more health systems to adopt the models, and working to expand beyond the hospital to include post-acute and ambulatory areas,” Leff said.

Currently, 44 million beneficiaries—approximately 15 percent of the U.S. population—are enrolled in Medicare, and nearly 7.3 million people receive benefits because of disability status, according to the Centers for Medicare and Medicaid Services.

Funding for this study was provided by The Atlantic Philanthropies. Leff, under agreements between The Johns Hopkins University and Mobile Doctors 24/7 International, is entitled to fees for licensing and consulting services related to the Hospital at Home care model. Under institutional consulting agreements between The Johns Hopkins University and Clinically Home LLC, the university and Johns Hopkins Health System are entitled to fees for consulting services related to the Hospital at Home care model. Leff, who participated in the consulting services, receives a portion of the university fees. The terms of this arrangement are managed by The Johns Hopkins University in accordance with its conflict-of-interest policies. Hospital at Home is a registered U.S. service mark. Leff is a noncompensated board member and president of the American Academy of Home Care Medicine and a noncompensated member of the Board of Regents of the American College of Physicians.

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