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One of the most pervasive challenges in our health care system is allowing people to optimize their independence and continue living at home as they age and develop more complex health and social needs. These individuals often need long-term services and supports (LTSS), and their number is increasing. It’s estimated that the population of Americans in need of LTSS will rise to 27 million by 2050.
By David Blumenthal, MD, MPP, President, The Commonwealth Fund, and Tanya Shah, MBA, MPH, Assistant Vice President, Delivery System Reform, The Commonwealth Fund
The dialogue on caring for patients with complex needs has moved beyond a recognition that social factors like housing or nutrition have an outsize impact on health to practicalities. Now, health care providers are asking: what can we actually do to help?
Caring for the complex chronically ill — a population that makes up about 5 percent of patients and nearly 50 percent of health care spending — is remarkably challenging. It’s also essential, as the United States transitions to a health care system that is driven by value.
If you’ve seen how quickly a relatively mobile older adult can turn into a frail and bedbound patient — not because of a primary illness, but because of a lack of movement — then you can appreciate how dramatically different care is at Saint Joseph Mercy Health System in southeast Michigan, and Anne Arundel Medical Center in Annapolis, Maryland.
The program, known as Community Aging in Place — Advancing Better Living for Elders (CAPABLE), is a client-directed home-based intervention to increase mobility, functionality, and capacity to “age in place” for older adults.
Congress recently passed a federal budget incorporating the CHRONIC Care Act that capitalizes on and grows early successes in many of these programs.
Many studies have highlighted the importance of effective interprofessional care teams to improve health outcomes for people with complex needs. But many programs do not take advantage of the special training of social workers to meet these needs on their primary health care teams.
By Corey Waller, Better Care Playbook Faculty and Principal at Health Management Associates
I currently do some work as a locum tenens physician in the emergency department, filling in during staff shortages. In this capacity, I get to work in a few different hospital systems around the country. No matter which one I go to, I can count on the fundamental aspects of basic cardiac care to be delineated no matter where I am.
Effective complex care means first understanding the individual and the challenges they face in their day-to-day lives. Here are two stories of patients in the CareMore Touch program for people with institutional special needs.
In the following Q&A, Allison Hamblin, MSPH, Senior Vice President at the Center for Health Care Strategies, explains how she and her team populated the map.