GERIATRIC TEAMS IN MANAGED CARE ORGANIZATIONS

A Promising Strategy For Costs and Outcomes

 

Marsha Regenstein

Jack A. Meyer

Nancy Bagby

March 1998

 

Economic and Social Research Institute

1015 18th Street NW, Suite 210

Washington, DC 20036

Supported by The Pew Charitable Trusts
Executive Summary
With some 300 health plans now enrolling elderly Americans as part of Medicare’s risk-based program, there has never been a more crucial time to make certain that health maintenance organizations (HMOs) serving Medicare enrollees know how to provide the services that the elderly and disabled need. This study provides information on precisely how some Medicare plans are addressing the needs of their elderly enrollees.

The study reports that a particularly effective approach for providing quality care to elderly patients is through the use of interdisciplinary geriatric teams. What is clear from our analysis and investigation – through in-depth case studies and site visits to progressive managed care organizations – is that in many cases, interdisciplinary geriatric teams can provide care that is better suited to the needs of seniors than the care they obtain through traditional provider arrangements. Not only is team care beneficial for the elderly, but it is cost-effective as well.

Seniors are signing up in record numbers – enrollment doubled between 1993 and 1996 – to take advantage of the lower out-of-pocket costs and richer benefit packages that Medicare HMOs offer. But these organizations have had little experience treating seniors with higher rates of acute and chronic illness, higher rates of disability and more complex medical conditions. HMOs need to re-engineer their health care delivery systems to fit the needs of the elderly. One way to begin is to consider the use of interdisciplinary geriatric teams.

This study, conducted by the Economic and Social Research Institute and funded by The Pew Charitable Trusts, describes several models of interdisciplinary team care in managed care organizations that have risk contracts with Medicare. The report identifies ways that teams of health professionals can improve the quality of geriatric care within a managed care setting, and at the same time, provide that care cost-effectively. This is important, because Medicare spending grew at an average rate of 10.8 percent per year during the period 1990-1995. It is unlikely that merely moving millions more elderly into managed care plans will stem rising Medicare costs, but the use of geriatric teams could lead to cost-effective, high-quality care for older Americans.

Interdisciplinary geriatric teams generally include one or more physicians, nurse practitioners, and social workers. Nutritionists, speech, physical and occupational therapists, psychologists, and others usually participate on a case-by-case basis. These teams are designed to treat the whole person rather than simply the specific medical condition that may have led the person to seek treatment. Teams are concerned about an individual’s living situation, independent functioning, nutritional status and spouse or caregiver. They also focus on health promotion and disease prevention.

Our study of the team approach to geriatric care in Medicare HMOs yielded the following findings:
     
  1. Geriatric teams can provide care more efficiently than traditional provider arrangements. Studies indicate that the use of teams in managed care can lead to fewer hospitalizations and emergency room visits.

     

  2. Targeting patients for team care makes sense. HMOs successfully employing the team approach target the elderly patients they believe will benefit the most from this technique, such as the frail elderly, those considered at high risk for hospitalization, or those with deteriorating cognitive status.

     

  3. HMOs should maintain flexibility in the design of the team. There is no ideal model of team care. The best models adapt to meet the needs of the patients and the goals of the HMO.

     

  4. Geriatric personnel are in short supply so they should be used wisely. Some programs may need to use their geriatrics personnel to provide on-the-job training to those who are committed to the team approach but have not specialized in geriatrics.

     

  5. Some non-medical services can be crucial to overall health. Geriatric teams have long recognized that frail elderly need more than medical care to remain independent and possibly prevent disease or injury. Non-medical services include home safety visits to prevent falls and other injuries, nutritional assessments, social interventions, and communication about feelings of depression and isolation.

     

  6. The patient’s family should be involved from the start. Spouses and children are an integral part of the informal care network.

     

  7. Medication management is extremely important. Older people can take several different medications each day, and often there is confusion about taking the right medicine in the correct dosage at the appropriate time of the day. Teams routinely monitor medication use to eliminate unnecessary medications, select alternatives with fewer side-effects or alter certain combinations since the interactions could render the drugs ineffective or even harmful.

     

  8. Teams can coordinate care across different sites. Geriatric teams coordinate care of the elderly across a variety of sites, including care in the patient’s home, primary care settings, clinics for the frail elderly and in the hospital. Coordination is crucial since the elderly often have chronic, complex conditions.

 

Recommendations

Despite the obvious benefits of the team approach to care, few Medicare HMOs use this approach for their elderly enrollees. Since this coordinated approach can be a vital component to improving the overall health of an elderly patient, we offer the following recommendations designed to expand the number of sites employing teams.
     

     

  1. HCFA should require Medicare risk plans to develop policies and protocols for caring for the complex and chronic needs of older Americans.

     

  2. Clinicians serving elderly patients must recognize the benefits of interdisciplinary care.

     

  3. Employers should make certain that the plans they offer their elderly workers and retirees have policies in place to manage chronically ill elderly enrollees. Employers should consider giving preference to plans with geriatric teams in place.

     

  4. Federal and state governments, private payers, and consumer groups should develop better information about the costs and benefits of team care in Medicare risk plans.

     

  5. In health care, the marketplace is increasingly becoming the laboratory for experimentation. But the Medicare program is helping to finance these "experiments" with little knowledge about how well elderly Americans are faring, what types of programs are most likely to produce high-quality results, and what services are most appropriate for the most vulnerable beneficiaries. We should not merely shift chronically ill and disabled older Americans into health plans without assuring that such plans have developed comprehensive proposals for their care and well-being.