In an article published in November 3 edition of Journal of the American Medical Association (JAMA), Chad Boult, MD, MPH, MBA, professor of Health Policy and Management at the Johns Hopkins Bloomberg School of Public Health, calls for key improvements to primary care in order to improve the health of the nation's most costly patients—older adults with multiple chronic conditions. Boult and his co-author, G. Darryl Wieland, PhD, MPH, research director of Geriatrics Services at Palmetto Health Richland Hospital, Columbia, South Carolina, evaluated studies of new primary care models to determine the best way to improve care and outcomes for the more than 10 million older adults living with four or more chronic conditions.
"Today's primary care physicians are often overwhelmed by the complex needs of patients with multiple chronic health challenges, such as diabetes, high blood pressure, arthritis and more," said Boult. "Current medical training often does not prepare physicians to provide the comprehensive support that these patients require. Through our research, we identifed four processes that can improve how we care for these patients, and three models that include these critical processes."
Boult and Wieland reveiwed all peer-reviewed studies of comprehensive primary care models for older adults with multiple conditions published between 1999 and 2010. From this review, they identified four processes that are present in most successful models of primary care for these patients:
"Most of today's primary care does not include these four processes, so patients receive fragmented and inefficient care that is further undermined by a lack of family and community support, " said Wieland, research director of Geriatrics Services at Palmetto Health Richland Hospital. "However, new models of primary care that include these processes have improved health outcomes, and patient and physician satisfaction, and have in some cases lowered the cost of care."
Boult and Wieland identified three models of care that have the greatest potential to improve effectiveness and efficiency of complex primary health care. All three models include a team-based approach to primary care, and they provide many of the same services to complex older patients, beginning with a comprehensive assessment and an evidence-based care plan. All of these models include proactive monitoring and coaching, coordination of care across all sites of care, support of patient's transitions from acute to post-acute settings, and access to community-based agencies.
Of the three models, only PACE is currently reimbursable through Medicare and state Medicaid programs.
"While most of the programs noted here are not yet widely available, we are hopeful that new initiatives launched by the Patient Protection and Affordable Care Act of 2010 will provide new opportunities for primary care physicians to care for their chronically ill patients more effectively and efficiently," said Boult. "More research is needed to define the optimal methods for identifying the patients who will benefit most, for providing the essential clinical processes, for disseminating and expanding the reach of these models, and for paying for excellent chronic care."
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