Skip to main content

A Better Health System for Frail and Disabled Elders

http://www.life-panel.com/blog/

"The current 'care system' provides disjointed specialty services, ignores the challenges of living with disabilities, tolerates routine errors in medications and transitions, disdains individual preferences, and provides little support for paid or volunteer caregivers."

This quote is from an amazing and brilliant viewpoint by Dr. Joanne Lynn on how the US health system and Medicare are failing to meet the needs of frail and disabled elders.  As Dr.  Lynn notes, this is an issue that that is virtually ignored in the media, political discourse, and professional education.  The vast majority of persons who live into their 80's and 90's will live with a prolonged period of disability in which they will need help because of physical and cognitive problems.

Older people and their families facing the problems of late life disabilty are faced with a Medicare system that offers unlimited resources to spend on disjointed disease-focused medical care.  But older persons and their families also need supportive care.  This includes help with basic activities of daily living such as bathing and dressing, help with meals and managing money, and transportation assistance.  Medicare pays virtually nothing for these services that are often far more importand than the procedurally oriented care frail seniors get.

Lynn recommends 4 things that need to be done to assure better care for frail older persons
  1. Honest discussion:  We should stop deluding the public with the message that late life frailty is a preventable problem.  Of course good health habits should be encouraged.  But most who do all the right things will still have a period of disability when they reach advanced age.  Let's stop telling the public that exercising and eating blueberries will avoid this problem.  Let's instead talk about how to maintain good quality of life in elders with late life disability.  
  2. Better advance care planning based on each elders goals that targets care and services based on each elders individual needs.  (Maybe we can call these "life panels")
  3. Care delivery in the elder's home.  For disabled elders, just making it to a doctors office can be an insurmountable hurdle.
  4. A care system that embraces long term supportive services and medical care as equal partners.  As Lynn notes, "food, transportation, and direct personal services are often more important than disabetes management or chemotherapy."
Dr. Lynn has hit the ball out of the park with this wonderful Viewpoint--the two pages are full of wonderful insights.   

by: Ken Covinsky (@geri_doc)

Comments

Sara Perry said…
Just yesterday I was explaining the available options for health care for an elderly woman with advanced illness to her adult sons and daughters. They were incredulous, as most families are, when I tell them the facts.
In this case, their choices were paying out of pocket (`$18-22/hr) for home health aides to take care of their mother at home or sending her to long term care in a nursing home at about $8000-$10000 a month private pay with a month's fee paid up front.
"You mean Medicare doesn't pay for it? Her commercial health insurance doesn't pay for it? Her supplemental health insurance doesn't pay for it?"
As a hospice social worker, I have these conversations often. Our health care system is sadly lacking when it comes to helping our frail, disabled, ill elders to live everyday life (however long they have left to live).
I would love to see a health care system that provided much better options.
ken covinsky said…
Sara--thanks for your comment. The costs of managing frailty and disability are often a surprise to patients and families.

The need for coherent comprehensive care was another part of this article--Based on a care model proposed by Lynn and colleagues called Medicaring. This involves organizing care geographically and using ACO shared savings to support local monitoring and management -- and the essential supplemental social services.

More info can be found in this youtube video:
http://medicaring.org/2013/08/20/medicaring4life/
Betsy said…
Thanks for posting this article. I have been a long term caregiver for my mom, and now my mother-in-law. Our current system is based on nursing home care, which no one wants,or likes. I think the reason this has not changed is because a lot of folks are making a lot of money on the way it is, and do not want it to change. We could serve our elderly so much better by giving them services that would support them and their family caregivers to keep them at home or in the community, instead of isolating them in a nursing home. I also think it is not healthy for our children and young adults to not have their grandparents, or other elders out in and part of the community.
Patricia Munson said…
One issue with health care - everything is expensive. That is most probably the root cause of availing a limited coverage medical insurance. If you can't get the total package, at least get a taste of a piece - a principle that most families in low-income household applies to medical insurance.
albina N muro said…
Mobiheathnews has an interesting report on the possible impact of mobile health for lower income PWDs. I was a little confused as to who was going to pay for what. svenska apotek

Popular posts from this blog

Dying without Dialysis

There is a terrific article in this weeks Journal of Pain and Symptom Management by Fliss Murtagh of King's College in London about the epidemiology of symptoms for patients with advanced renal failure who die without dialysis.  This study is important because while we know that patients with advanced renal failure have a limited life expectancy and the average age of initiation of hemodialysis is increasing, we know little about the alternatives to hemodialysis.  Specifically, we know nothing about symptoms affecting quality of life among patients who elect not to start dialysis (so called "conservative management" - is this the best label?).  This article provides a terrific counterpoint to the article in last years NEJM showing that nursing home residents who initiated hemodialysis tended to die and decline in function (see GeriPal write up here). 

The study authors followed patients with the most advanced form of chronic kidney disease (the new name for renal failu…

Language Matters: Podcast with Brian Block and Anna DeForest

One of our first GeriPal posts was titled "Rant on Terminology," by Patrice Villars, NP.  In the spirit of looking back over our first 10 years, here is the opening paragraph to that post:

News Headlines read: Sen. Edward Kennedy loses battle with cancer. Really, he lost? I thought he died from a malignant brain tumor, an “aggressive” brain tumor. The median survival is less than a year for people for his particular tumor. Kennedy was diagnosed in May of 2008. He lived over 15 months after diagnosis. What a loser. He must not have fought hard enough. Huh? I thought he spent most of his life battling for social and health care reform in America. In this week's GeriPal podcast we take a deeper dive into this issue of language and medicine.  We are joined by guests Anna DeForest, MD, MFA, a resident in Neurology at Yale, and Brian Block, MD, a pulmonary critical care fellow at UCSF.  

Anna recently published a paper in the NEJM describing her reaction to hearing terms like, &…

The Dangers of Fleet Enemas

The dangers of oral sodium phosphate preparations are fairly well known in the medical community. In 2006 the FDA issued it’s first warning that patients taking oral sodium phosphate preparations are at risk for potential for acute kidney injury. Two years later, over-the-counter preparations of these drugs were voluntarily withdrawn by the manufacturers.  Those agents still available by prescription were given black box warnings mainly due to acute phosphate nephropathy that can result in renal failure, especially in older adults. Despite all this talk of oral preparations, little was mentioned about a sodium phosphate preparation that is still available over-the-counter – the Fleet enema.

Why Oral Sodium Phosphate Preparations Are Dangerous 

Before we go into the risks of Fleet enemas, lets spend just a couple sentences on why oral sodium phosphate preparations carry significant risks. First, oral sodium phosphate preparations can cause significant fluid shifts within the colon …